North Staffordshire Combined Healthcare NHS Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

At our last assessment we rated this key question as outstanding. At this assessment the rating has changed to good. This meant people’s needs were met through good organisation and delivery.

The service was responsive to patients’ needs, placing individuals at the centre of their care and making decisions in partnership with them. Care was flexible and adapted promptly to changes in people’s needs, supported by an understanding of the diverse needs of individuals and the local community. Information was accurate, up to date and provided in accessible formats. Patients were encouraged to share feedback or raise concerns, and were supported to plan for important life changes, allowing them time to make informed decisions about their future. Leaders recognised delays in the Memory Service and were taking action, while governance systems effectively identified risks and supported fair access for most patients.

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 supported people to be actively involved in decisions about their care and treatment, in line with a person-centred approach. People were enabled to exercise choice and control over how they engaged with the service. For example, individuals could choose to receive one-to-one support with a key worker, decline this option, or participate in group-based support, depending on their preferences.

Staff described how care and support were delivered in a flexible and responsive way, with a planned sequence of appointments that were regularly reviewed. At each stage, staff considered the person’s changing needs, preferences and goals. They made recommendations based on clinical judgement, but these were discussed collaboratively with the person to ensure care and treatment reflected what mattered most to them. Staff told us they would vary their visits throughout the day to accommodate, patients, families and carers wishes. Staff identified low attendance at morning therapeutic sessions and sought feedback from patients to understand their preferences. In response, session times were moved to later in the morning to better align with patients’ routines. This change led to improved attendance and engagement, demonstrating a person-centred approach where staff listen to and act on patient feedback to tailor care and support to individual needs.

Where patients were discharged back to the general practitioner this was carried out in a person centred, respectful and empathic manner with contact names and numbers made available if further support was required.

The service provided a range of community mental health pathways including memory assessment, functional mental health care, crisis intervention, and dementia support. Referrals were accepted from multiple sources with triage systems in place to prioritise urgent need. Teams held daily meetings to discuss referrals and assign patients to a care pathway.

Appointments within the pathway were flexible and supported patient choice offering options for face to face, video consultation, group form or by telephone. City and County Memory Services were delivered by the same staff team at a single site, supporting joined up working and continuity of care for patients. The service worked collaboratively with primary care, acute hospitals, and social care to ensure timely, person-centred interventions. There was clear evidence of multidisciplinary working within the service, involving psychiatrists, community psychiatric nurses, occupational therapists, and psychologists.

Transitions between services, such as transfers from CMHTs to Memory services, were well managed and effectively coordinated, with clearly identified named key workers supporting continuity of care.

Staff made notifications to external bodies as needed, including safeguarding referrals to the Local Authority and statutory notifications to the Care Quality Commission (CQC).

The service was implementing the Accessible Information Standard. The service made sure that patients and their carers with a disability, had access to information that they could understand and any communication support they need to help them with their care journey. Information was provided in accessible formats, and appropriate communication support was arranged to promote equitable access to care.

Patients were provided with clear and accessible information about their treatment options, local services, and how to raise concerns or make a complaint. Information was tailored to meet the needs and preferences of the patient group.

Information was available in a range of formats to support accessibility. This included translated materials in community languages and alternative formats such as large print, and braille for people with visual impairments. Staff told us that appointment letters and care review information could be provided in patients’ preferred languages when requested.

The service signposted patients and carers to online health and wellbeing resources, including information available in easy read formats to support people with additional communication needs.

Interpreting services were used regularly to support effective communication with patients. Interpreters were accessed either face to face or via video, depending on patient preference and availability. Leaflets were available in languages commonly spoken by the local population.

The service had received a low volume of complaints. Between April 2025 and April 2026, the service received 3 complaints. Two for County CMHT and one for the Memory Service. There have been no further complaints received for this service since June 2025.

Leaders investigated complaints alongside incidents, safety reviews, and quality assurance activity. Themes included communication and engagement, continuity of care and follow-up, clarity and accuracy of clinical information, and practitioner-specific concerns.

The service took action in response to complaints including, escalation to clinical directors, direct feedback, reflective supervision, senior clinical oversight and case reallocations and second opinions.

When patients complained or raised concerns, they received feedback. This would be direct meetings or telephone calls with patients and families. Formal acknowledgement and apologies. Review and adjustment of care plans and medication. Increased monitoring and multidisciplinary support. Access to second opinions and alternative clinicians.

Staff knew how to handle complaints appropriately. Staff told us they felt able to speak to team leaders and service leaders without fear of retribution or discrimination. Managers said that they aimed to resolve complaints locally where possible and understood the formal complaints process, including referral to the Patient Advice and Liaison Service (PALS).

Staff received feedback on the outcomes of investigation into complaints and acted on the findings. Team leaders were responsible for sharing learning from complaints. Staff learned from complaints at team meetings, multidisciplinary discussions and reflective practice forums.

The service provided information to patients on how to raise concerns. Notice boards in patients waiting areas displayed information for patients and staff on how to raise concerns or provide feedback. This included contacting the Patients Experience Team, the trust Chief Executive directly or the Freedom to Speak Up Guardian. Information was available to feedback to the Care Quality Commission, as well as links to patient and staff feedback surveys. The service also signposted patients to advocacy services to support them in raising concerns.

Staff made reasonable adjustments to support patients’ individual needs and promote equitable access to services. For example, people with mobility difficulties were supported through the provision of accessible ramps at service sites, handrails, and accessible toilet facilities. An induction hearing loop system was also available to support individuals with hearing impairments.

Staff ensured patients received appropriate discharge planning and continuity of care. Within the Memory Service, patients discharged via the Transfer of Care (TOC) pathway were provided with structured discharge plans, including up-to-date information, relevant guidance, and details of ongoing support.

Referrals were managed promptly. Staff completed triage on the same day referrals were received, with no waiting times for triage. Staff reported this was supported through daily morning meetings where referrals were reviewed and triaged.

The service monitored referral-to-assessment times. Referrals were accepted, and the assessment process commenced within four weeks. The service measured performance based on the time between receipt of referral and the first patient-facing appointment. Data for the period 1 April 2025 to 31 March 2026 showed compliance rates between 98% and 100% across CMHTs and Outreach Teams.

For the Memory Service, access varied between localities, with referral-to-assessment compliance at 25% in the City and 75% in the County, although urgent and high-risk referrals were consistently prioritised and seen within target times. While overall referral-to-treatment performance remained high (96–99%), waiting times to diagnosis varied by condition and increased during the reporting period, with maximum waits extending to 37–48 weeks for assessment and 87–98 weeks for treatment. The service had taken action to improve equitable access, including enhanced triage processes, clear timelines for assessment, and use of digital reminders to reduce missed appointments.

Leaders said there were no formal waiting lists across services. However, staff within the County CMHT reported a short wait for psychology services. Staff within the County CMHT also reported challenges with delayed discharges. Some patients remained on caseloads for extended periods, in some cases for several years, due to a predominantly medical model approach to care.

The trust had appointed a member of staff to lead on work relating to the Patient and Carers Race Equality Framework. Work was ongoing to improve access, service quality and outcomes for patients and carers from under recognised groups. Staff had arranged events with local community groups to ensure that diverse communities were aware of the care, treatment and support that was available.

Staff compliance with Diversity and Inclusion training ranged from between 90% to 100%. The trust presented staff each year with Diversity and Inclusion awards. This award recognised staff and volunteers who had helped make services or workplaces more inclusive. This could include improving access for people from disadvantaged or minority groups or improving people’s experiences when using services.

Staff demonstrated a good understanding of groups who had historically under-accessed services and were therefore more likely to experience inequality in access, experience or outcomes. The service was working to build relationships with these groups to improve awareness, increase engagement and reduce barriers to access. For example, one clinician established a transcultural clinic to better meet the needs of older patients, including some second and third-generation individuals from the Asian subcontinent. The clinician used validated assessment tools available in Punjabi and Urdu.

We saw examples within care records of staff supporting patients their carers and families to plan for significant life changes, including the progression of illness, future care arrangements and the potential loss of capacity. Staff supported patients with information for example managing issues around driving, lasting power of attorney, financial support and attendance allowance. Staff signposted patients and carers to services in the community for example Alzheimer Society Advisors.

Service documentation reflected sensitive, respectful, and person-centred practice, with staff recognising the emotional impact of mental health difficulties on older adults and their families.