North Staffordshire Combined Healthcare NHS Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

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

People’s health, care and communication needs were assessed and reviewed to support good outcomes. Care was planned and delivered with people, focusing on what mattered to them. Staff worked well together and with other services to provide joined-up care. People were supported to stay healthy, be independent, and have choice and control. The service regularly reviewed care to make improvements and ensure positive, consistent outcomes. People’s rights around consent were understood and respected. Most staff received supervision and appraisals to support them in their roles and development.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed 26 patients’ care records. Overall care plans were personalised, holistic and recovery‑focused, and were developed collaboratively with the patient and their carers and families. Staff completed a comprehensive physical and mental health assessment at, or soon after, admission to the service, ensuring needs were identified promptly. Initial assessments took around 60 minutes and were usually completed by one practitioner. More complex multi-disciplinary assessments took longer to complete.

Most care plans clearly evidenced effective discharge planning for patients. Staff knew the patient well, and their needs were central to the care plan. However, one patient subject to a Community Treatment Order (CTO) who entered the service on 5 December 2025, did not have a documented discharge plan.

Care plans were reviewed regularly with the patient their family and carers and the care team to support consistency, understanding and effective management of needs.

Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and were delivered in line with, guidance from NICE. For example, cognitive stimulation therapy, brain health and wellbeing groups, Risks, progress and outcomes were routinely reviewed to keep care plans up to date. Psychiatrists’ consultants /doctors diagnosed mental health conditions, prescribed medication, and led care plans. Community psychiatric nurses visited patients at home or in clinics and checked mental health, medication and safety. Psychologists offered therapy, for example cognitive stimulation therapy in a group setting to help people improve thinking skills and overall wellbeing. Physiotherapists focused on improving people’s physical health alongside their mental health care by assessing mobility and strength, managing pain and medication side effects, and creating simple exercise plans to build fitness and independence. They also encouraged physical activity to support mental wellbeing, help reduce fall risks, and work with the wider team to ensure physical health is consistently considered in overall care. Occupational therapists supported patients with home and community safety assessments, cognitive rehabilitation and interventions. Healthcare support workers offered practical and emotional support with daily tasks and attended appointments at patients’ homes.

Consultants prescribed medicines in accordance with trust policies and national guidance. Prescribing was based on the patient’s presentation and physical health history. However, some staff at the County CMHT and Older People’s Outreach Team shared mixed views about the clinical approach. Some felt that medication sometimes be given priority, with less consistent consideration or discussion of alternative options, such as psychological or other therapeutic approaches where these might be suitable.

Staff received the necessary specialist training for their roles. Staff said they were encouraged to attend relevant role appropriate training for example Dementia Tier 1 and Tier 2 and Transforming care co-produced care planning training.

Staff told us they felt well supported by line managers and the multidisciplinary team. However, staff from the Older People’s Outreach team said that they did not consistently have access to senior staff for advice and escalation. They also highlighted difficulties in accessing regular supervision and appropriate support.

Leaders did not consistently provide staff with regular supervision. Trust policy stated that 85% staff should receive at least clinical or managerial supervision every eight weeks. The standard is for both to take place every 8–12 weeks and be recorded electronically. Staff had access to weekly peer support and regular reflective practice sessions. The compliance rate for the Older People’s Outreach Team was 71%. As this team comprises 7 staff members, this equated to approximately 1.5 WTE staff members who were not compliant at the time the data was captured. During the inspection, we reviewed a sample of 13 supervision records. Only three records showed the member of staff had received clinical supervision within the last eight weeks. Team leaders gave mixed responses when asked for staff supervision records. Some said they did not record supervision, while others could not easily find records or dates. This meant it was difficult for managers to know whether staff were receiving appropriate supervision.

Staff participated in clinical audits. The service conducted regular audits, for example dementia diagnosis, care plans, medicine management, and prescribing anti-psychotic medication for people with dementia.

Staff participated in quality improvement initiatives. We saw in the memory service a consultant had developed a virtual reality training film to help front line staff increase understanding and empathy of delirium. This was based on a patient’s own experience of delirium. This was accredited by Memory Services National Accreditation Programme (MSNAP).

Staff held multidisciplinary meetings each week. We observed staff working inclusively and collaboratively to manage patient’s needs. Meetings were chaired by representatives from different specialties to ensure impartiality. Meetings were well represented by different staff groups including consultant psychiatrist, psychologists, community psychiatric nurses, physiotherapy, occupational therapists, and the care home liaison team. However, staff from the Older People’s Outreach Team shared mixed views about the MDT’s approach. Some felt there was more focus on medical aspects with less attention to a broader, holistic approach. At times, this affected how the team worked together and coordinated care. Also, the Older People Outreach Team did not consistently evidence regular monthly meetings. Only one meeting was recorded between April 2025 and April 2026, with limited documented actions. This reduced assurance that staff were working together in a structured way to support ongoing service development and effectiveness.

The service had effective working relationships with teams outside the organisation for example, social services, general practitioners, third sector dementia care and alzheimers services. The service worked with the local football club to support older people to access community activities, access their premises for wellbeing activities, meetings and support networks.

The Memory Service offered a monthly neurology clinic, attended by a neurologist, alongside regular neurology and imaging meetings. This demonstrated effective working relationships with external teams and organisations to support patient care.

Staff consistently documented patients’ physical health checks, including monitoring of blood pressure, weight, falls risk, mobility, nutrition, diabetes, cardiovascular health, and medication side effects where relevant. Members of the inspection team observed a patient and their carers attending a clinical session, during which staff sensitively discussed diagnoses, treatment options, medication, and coping strategies.

Posters and leaflets in waiting rooms promoting services from external organisations, such as community day services, recall and reminiscence groups, local hubs, singing for the brain connection groups and chatty cafés. These services were aimed at supporting patients' wellbeing and social inclusion.

Information was available around promoting physical activity including walking groups, green activity, seated exercise, walking football and accessible cycling.

We saw notice boards providing carers with information about available services, including how to access carers' assessments, support groups, dementia awareness sessions, financial support, and respite options. This signposting was intended to promote carer wellbeing and support carers to sustain their caring role.

Staff used recognised, evidence-based rating scales to assess, record, and monitor people’s needs and outcomes. Tools included the Multidimensional Prognostic Index to assess frailty and inform care planning and prognostic discussions, and the Cohen–Mansfield Agitation Inventory to measure and monitor agitation in people living with dementia.

Staff also used the Rowland Universal Dementia Assessment Scale, a structured cognitive screening tool designed to reduce cultural and linguistic bias. In addition, the Addenbrooke’s Cognitive Examination (ACE-III) was used to support the identification of dementia and cognitive impairment. This tool had been validated for use in Urdu-speaking populations helping to ensure equitable and inclusive assessment. Occupational therapists used the Allen Cognitive Level Screen (ACLS), which is a simple test used to check how well a person can think and manage everyday tasks. The consistent use of validated assessment tools showed that staff monitored outcomes effectively and responded appropriately to patients’ changing needs.

Staff used a range of technology to support patients. For example, Kardio a blood pressure monitoring cuff device linked to a mobile phone app enabled staff to track patients’ blood pressure readings and associated symptoms.

The service provided information on medications and potential side effects and produced leaflets in community languages as well as easy-read formats. The trust also developed a system called Choice Medication to help patients make decisions about medication. Staff spoke highly of these systems and reported using them regularly to enhance patient care and outcomes.

For patients who might have impaired mental capacity, staff consistently assessed and recorded capacity to consent appropriately. There were clear records of formal capacity assessments or established consent arrangements recorded clearly within the electronic care records system.

Staff were aware of decision-making processes for patients who lacked capacity and of instances where family members held enduring powers of attorney for welfare or financial matters.

Staff took practical steps to enable patients to make their own decisions. They supported patients to make decisions by providing information in different formats. In some cases, staff took steps to improve communication, such as checking whether the patient had a hearing impairment and required signer. We saw staff explaining patients’ rights in a way that they could understand and repeated as necessary.