North Staffordshire Combined Healthcare NHS Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained.

Good: This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew what incidents to report and how to report them. Staff and managers had good oversight of incidents across the service. We reviewed 3 completed safety reviews following incidents. They had been appropriately reviewed by managers and learning points identified. Managers reviewed serious incidents using the Patient Safety Incident Response Framework and monitored themes and trends, ensuring any learning was identified and implemented. Incidents were discussed and reviewed in handovers, multidisciplinary team meetings and clinical governance meetings.

In March 2025 there had been a death of a patient who had been open to the service. The patient had received an initial screening and was waiting for their face-to-face assessment, which according to the trust policy was due up to 72 hours after referral. The assessment was not allocated to a clinician for a further 5 days and the patient had subsequently died. Although there were no indications that the patient’s death was a result of the missed assessment, managers had identified learning points. All assessments were now allocated to a named clinician each shift and progress monitored through handovers. Any missed assessments were to be escalated to the shift lead who would ensure completion and reallocation as soon as possible.

There had not been any never events for this service in the 12 months prior to our assessment.

Managers told us that all incidents and complaints were investigated thoroughly with outcomes and feedback given to all involved. Staff were debriefed and offered post incident support.

Staff said learning from safety incidents was shared, and they implemented this learning into their work practices. Managers attended monthly learning lessons meetings to share insights from incidents, promote reflective practice, and support continuous learning and improvement across the service. Staff received lessons learnt through various forms such as team meetings, training, emails, staff intranet and handovers. Staff gave us examples of recent learning and changes made to the service following investigation and lessons learnt. For example, the front door to the crisis centre had been upgraded and was now locked and fitted with an intercom system following incidents of the door being damaged and broken with staff feeling vulnerable when people became aggressive or violent within the reception area. Security staff now sat within the reception area.

Staff understood the duty of candour and monitored when incidents met the threshold and were open and transparent to patients and families when things went wrong.

There were various ways patients could access the service; professional referral such as police or other healthcare professional, self-referral by calling the crisis number, NHS 111 service or they could walk-in to the crisis centre at Harplands hospital and wait to be seen. The service was available 24 hours a day, 7 days a week and dedicated phone lines were available so existing patients, the public, and people in a mental health crisis could make contact.

The service provided a single point of access and gatekeeping function for admission to mental health in-patient beds and facilitated early discharge and post hospital follow up. The team provided a bed management service for the mental health acute care pathway and attended patient flow meetings twice daily to ensure patients were admitted and discharged effectively and efficiently.

The referral process ensured that as much essential information about the patient was received to determine level of risk and how quickly an assessment was warranted. The trust targets for all emergency or urgent referrals to be assessed was within 4 hours and for non-urgent or routine assessments it was within 72 hours. The team used the UK Mental Health Triage Scale to determine the urgency of the response required, which was completed following a telephone consultation with either the professional or the patient, dependant on who was making the referral. Most patients were invited to be seen and assessed at the crisis centre, although staff were flexible and could attend which ever setting was most suitable and appropriate for the patient. The team monitored its response to referrals and assessments.

However, staff said not all of the 72-hour assessments had been completed within the target timeframe especially when they had a busy shift or high caseload. Managers had addressed this by ensuring that pending assessments were allocated to clinicians so they were not missed and these were monitored to ensure they were completed within the target timeframe. Pending assessments were also discussed at handovers.

The duty lead was responsible for co-ordinating the shift and monitored and allocated work including home visits and assessments. They had an overview of referrals received throughout the shift and prioritised those based on information available and risk.

Staff followed the ‘did not attend’ procedure and followed patients up who they had been unable to assess or review to ensure they were safe and to provide care and treatment. The trust followed the Right Care, Right Person national model and guidance.

Staff had access to patients’ previous electronic care notes, their GP care notes and when relevant, their acute care hospital records. Staff involved all the necessary healthcare, social care and third-party organisations to ensure patients had continuity of safe care, whilst with the service and post discharge.

Staff received safeguarding training. At the time of our assessment, staff were 88% compliant for safeguarding adults level 2, 93% for level 3 and 80% for safeguarding children level 3.

Staff we spoke with had good knowledge about safeguarding and any potential safeguarding concerns were discussed in handovers and multidisciplinary meetings.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. The trust had a nominated safeguarding lead and staff knew where to get advice and guidance from. We saw examples of staff reviewing safeguarding concerns within patient care notes and made referrals when necessary. Between 1 January 2025 to 31 March 2025, the service had made 7 adult safeguarding referrals and 4 child safeguarding referrals.

We reviewed 10 patient care records across the crisis and home treatment team and the health-based place of safety. Staff kept patients safe and involved them to manage risk. Staff knew patients’ needs well. Risk assessments were comprehensive and updated regularly, including after incidents. The risk assessment was completed after initial assessment and determined the level of risk the patient posed. Staff developed a safety plan detailing how to manage identified risks. Patients we spoke with said staff had communicated their treatment needs and they understood their plan of care. However, the majority of patients told us they had not received a copy of a care plan or safety plan.

Risk was discussed in handovers and multidisciplinary team meetings. Staff reviewed and monitored risk at each visit or interaction and could respond quickly when required.

In the health-based place of safety, the trust monitored the use of restraint and restrictive interventions and worked closely with staff to ensure they were appropriately trained and up to date with relevant practice and policy. Between 1 October 2024 and 31 March 2025, there had been 9 occurrences of restraint, 2 occasions when rapid tranquilisation was used and 1 instance of seclusion.

Information about the Patient Advice and Liaison Service (PALS) and independent advocacy was provided in the patient information leaflet if patients wished to access those services.

The environment at the crisis centre was safe, clean and well maintained. Ligature and environmental risk assessments were in place with appropriate actions where required. Staff completed regular checks and audits. The reception area was well placed so staff could observe the waiting area and security staff were present.

There were 4 assessment rooms; 1 was designated as a safe space primarily used for children. Each room had a staff call alarm and staff carried personal alarms. One of the rooms was equipped with physical health equipment and had a bed for physical examinations.

The health-based place of safety consisted of 2 assessment rooms, and 1 lounge area, fitted with CCTV cameras which could be observed in the staff office. Each room had a shower and toilet area with non-ligature fittings. The suite was clean, tidy, well maintained and appropriate for use.

The clinic room was fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Staff adhered to the lone working policy when attending visits in the community. Staff completed a lone working risk assessment as part of the initial assessment, to ensure staff safety.

In the summer of 2024, the service had undergone a significant transformation and the previously separate crisis assessment provision and home treatment team had merged. This had created a large team with new roles such as nurse practitioners and crisis call operatives. Existing staff were expected to work across the crisis assessment provision and the home treatment function and become skilled and proficient in both.

Managers had calculated the number and grade of nurses and healthcare assistants required. The day shift consisted of a minimum of 11 qualified staff, and 2 unqualified staff, the night shift consisted of 4 qualified and 2 unqualified. The team had recently introduced a twilight shift for crisis call operatives following analysis of the volume of calls received.

Vacancies at time of our assessment were for 1 occupational therapist, 4.6 senior qualified nurses and 4.24 qualified nurse. There were no vacancies for unqualified staff.

The service had required bank or agency staff to fill 1190 shifts in the 3 months prior to our assessment to cover vacancies, sickness and high acuity. Staff had filled 608 shifts but 582 shifts had remained unfilled. However, managers told us substantive staff often picked up the extra shifts. The service rarely used agency staff. They were used on 35 occasions in the 3 months prior to our assessment.

Newly qualified nurses received 12-month preceptorship programme for extra support and continued learning.

In the 12 months prior to our assessment, the average sickness rate for the service was 11%. This was above the trust target of 4.95%. Five staff were on long term sickness when we visited. In the 12 months prior to our assessment, the average turnover for the service was 12%. This was above the trust target of 10%.

Managers had recently reiterated the escalation process to staff. This had followed staff feedback that they felt when acuity was high they were understaffed and were concerned that the service was not safe and it hindered their ability to respond to risk. Managers had reviewed data to ensure capacity met demand and recruitment had filled some of the vacancies. Staff said staffing was sufficient, however, this was dependant on how many ‘walk ins’ arrived at the crisis centre for assessment as this could never be predicted.

When a person was in the health-based place of safety, the healthcare assistants from the home treatment team provided support. Staff received training in safety interventions such as observation, restraint and seclusion. However, staff were concerned that the new crisis call operative staff had not received training and were unable to provide support when required.

The team did not have a full-time consultant psychiatrist. They had cover for 2 days to cover the multidisciplinary team meeting and a limited number of patient reviews. The trust had attempted to recruit but had not been successful. They mitigated this with the 2 nurse practitioners, who could seek advice and support from other medical professionals when required.

The health-based place of safety and crisis centre had access to medical cover and a doctor could attend quickly in an emergency.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service.

Staff maintained equipment used to monitor patients’ physical health. It was calibrated regularly to ensure it worked effectively and kept clean.

The assessment rooms, waiting area and health-based place of safety was kept clean and tidy. Cleaning records were kept up to date.

Staff had completed mandatory training for infection prevention and control. In April 2025, 100% of staff had completed training in level 1 and 90% for level 2. Staff completed regular environmental audits and actions and mitigations were in place.

Staff followed good practice in medicines management. They followed systems and processes and safety stored, prescribed, dispensed, administered and recorded medicines in line with national guidance. The clinic room was clean and tidy, and staff had access to all appropriate equipment. At the time of our assessment, no patients had medicines administered by the team. Stock medicines were kept in the clinic and pharmacy support checked medicines weekly and ensured they were stored correctly. Pharmacy staff audited medicines management and staff had completed an action plan to ensure improvements were made.

There were 4 non-medical prescribers within the team. The 2 nurse practitioners did the majority of the required prescribing and medication reviews and had set up clinics to manage this. Many patients medicines were still managed by their GPs, and staff liaised closely with them to discuss any proposed changes or modifications. The consultant psychiatrist worked 2 days a week and had limited capacity to fully review all patients pharmacological needs.

The trust had shared care protocols in place with specialist services and GPs for prescribing and managing specific medicines.