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

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

We looked for evidence that patients were protected from abuse and avoidable harm.

The service had a strong, open culture, where safety was taken seriously. Staff reported and learnt from incidents and worked well with people and partners to keep care safe and consistent. Patients were supported in a way that protected them from harm and respected their needs and preferences. Staff managed risks well, including challenging behaviour, and followed good infection control and medicines practices. The environment and equipment supported safe care. However, not all staff were up to date with mandatory training, including safeguarding. Staffing levels and support for staff were not always sufficient, and team working was sometimes inconsistent.

This service scored 72 (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 how to report incidents and recorded them on an electronic incident record. They were aware of the different types of reportable incidents and reported all the incidents that they should. Between August and October 2025, there were no reported patient safety incidents that required formal review. However, the trust had undertaken a review of patient safety incidents prior to August 2025, identifying several key areas for improvement. These included risk formulation, physical health and medication safety, transitions and coordination of care and the quality of documentation.

The service had implemented a range of targeted actions to improve patient safety. For example, work was undertaken to strengthen patient risk formulation by enhancing the depth and quality of assessments. This included improved identification of key risk drivers and the development of more proactive and robust risk safety management plans.

Incidents were appropriately recorded, monitored and reviewed to support people’s safety. Service data from April 2025 to April 2026 showed that the highest number of reported incidents related to expected deaths 32, with a smaller number of unexpected deaths at 3. Other incident types were reported at low levels and included self-harm, overdose, self-neglect, and adult safeguarding concerns. These were recognised risks within the service. There was clear evidence of oversight, monitoring, and learning from incidents to help reduce the likelihood of recurrence and to promote the safety and wellbeing of people using the service.

Staff understood the duty of candour and demonstrated openness and transparency, providing patients and families with a full explanation when things went wrong.

Staff received feedback from both internal and external incident investigations. Service managers reviewed all incidents. They escalated more serious incidents to a more senior level for investigation. Information from investigations was shared with staff at team meetings. Any identified learning was used to improve patient safety and clinical practice.

Changes had been implemented in response to feedback from investigations. For example, the service reviewed an unexpected patient death from January 2025. As a result, staff introduced measures to ensure that any changes to medicines were communicated and actioned promptly with the pharmacy and general practitioner. Inpatient records are now transferred to relevant staff during transitions to ensure continuity of care.

The service’s referral and admissions processes ensured that all essential information about each patient was obtained to determine whether their needs could be safely met. Referrals to the service could be made by individuals themselves, general practitioners, or a range of health and social care professionals, including hospital staff, district nurses, social workers, occupational therapists, and care home staff. A significant proportion were received from psychiatric liaison teams in general hospitals.

Staff teams held daily allocation meetings to review all new referrals. During these meetings, the urgency of each referral was assessed. Referrals requiring an immediate response were escalated to the Older People’s Outreach Team. The Community Mental Health Teams (CMHTs) aimed to assess high-priority referrals within seven days and routine referrals within four weeks.

Staff at the service had developed strong partnerships with hospital wards for older people and local care homes. These links included weekly virtual multidisciplinary team meetings, and face-to-face visits to both the care homes and older people’s hospital wards. These partnerships helped to support effective planning and smooth transitions for people being admitted to or discharged from the service. For example, staff within the Memory Assessment Pathway Transfer of Care Group facilitate the careful discharged of individual patients. They support transitions onto commissioned services or into appropriate alternative groups and therapeutic interventions.

Staff knew how to make a safeguarding alert and did so when appropriate. Between 1 January 2026 to 1 April 2026, 5 multi agency referrals were made across the service. Staff reported that the primary safeguarding risks for patients were self-neglect and financial abuse. A review of the safeguarding data supported this view, with self-neglect accounting for 39% of all safeguarding referrals, making it the most frequently reported type of concern. Financial abuse was the second most common category, accounting for 14% of all safeguarding referrals during this period.

Staff completed training on safeguarding adults and children. Completion rates for basic and intermediate levels for training were mostly consistent with the Trust’s target of 85%. However, completion of level 3 training at the Older People’s Outreach Team was slightly lower at 71% for adults and 57% for children and young people.

Staff received advice and support on safeguarding patients from both the trust safeguarding team and the local authority safeguarding team. The trust safeguarding team offered safeguarding supervision. This primarily consisted of level 3, face-to-face case management supervision, which were delivered through virtual discussions and attendance at meetings to support staff.

The trust monitored engagement with safeguarding supervision over the last 12 months and identified a correlation between high safeguarding activity areas and more safeguarding contacts. This showed staff were recognising and reporting safeguarding concerns and that safeguarding supervision was working well.

Staff carried out an initial risk assessment when they received the referral and allocated the patient to a member of staff. We reviewed 26 patient’s care records, including their risk assessments and risk management plans. A comprehensive risk assessment was completed with the patient at the first appointment. For example, we observed a patient attending the memory service for the first time. Staff completing a risk management plan. The patients’ relatives were involved and contributed to the risk formulation.

Staff generally completed patients’ assessments in a person-centred way and reflected people’s individual circumstances. Patients were involved in understanding and managing risks to their safety. Risk assessments were detailed, informative, and of a good standard, clearly identifying current risks such as self-harm, harm to others, and vulnerability.

Staff reviewed risk assessments regularly and updated them to reflect changes in risk. Crisis and contingency plans were in place for some people to support them during periods of increased risk.

Staff responded promptly to any deterioration in a patient’s health or increase in a patient’s risk. When staff became aware that a patient’s situation was deteriorating, either the duty worker or the patient’s key worker took action to address this. This action could involve bringing forward a planned visit, arranging an urgent visit from a doctor, reviewing the patient in the multidisciplinary team meeting, or reviewing the patient’s formulation. If the patient required more intensive support, staff could refer the patient to the older people’s outreach team. If a patient needed an admission to hospital this was arranged by the team.

We visited 3 sites; Marrow House, Lyme Brook Centre and Harplands hospital and found all the services we visited were clean and well-maintained. The Older People’s Outreach Team at Harplands hospital had plans to move site over the coming weeks.

Staff carried personal alarms to help maintain safety when lone working. Interview rooms were not equipped with fixed alarm systems. Instead, portable desktop alarms were strategically positioned within the rooms to ensure safety.

Clinic rooms were clean. Clinical equipment was well-maintained. The Older People’s Outreach team had a medicines storage room only. Other the clinic rooms contained medication storage facilities and physical health monitoring equipment, such as electrocardiogram machines and blood pressure monitors. Records showed that this equipment was regularly serviced.

In March 2026, the overall vacancy rate for qualified staff was 0.58%. However, there were three vacancies at the Older People’s Outreach team, following the recent retirement of two members of staff. These posts had not yet been advertised. The vacancy rates were low across teams for therapy staff including occupational therapist and speech and language therapist at 1.42 whole time equivalent (WTE) posts. The vacancy rates for unqualified staff were 1.52 WTE posts. There were no vacancies at the City and County CMHT. The City and County Memory service had vacancies for one advanced nurse practitioner and one administrator.

Although the vacancy rates were low, some staff from the Older People’s Outreach Team told us they were always short staffed and overstretched, and care had become more task-focused due to time constraints. Some staff said there was limited supervision and support. One staff member said they regularly worked at home after work hours to complete patient records.

The City CMHT leader was on a three-month secondment from March to May 2026 at another service, with no back fill. We saw this team were experienced and worked effectively in the team leader’s absence.

The service operated with low levels of bank staff. The Older People’s Outreach Team required a total of 1,792.5 hours of which 62.5 hours were covered by bank staff. This amounted to 3% of the total hours shifts.

Staff turnover was low at 3%, which was well below the trust target of 10%, supporting continuity of care and safe service delivery.

Caseloads across teams were low. In the CMHTs keyworkers held caseloads of 20 to 26 patients.The Memory Service operated a multidisciplinary team-based model, with caseloads managed at team level rather than through individual key worker caseloads. The Older People’s Outreach team held a shared caseload of up to 17 patients with complex mental health needs. Leaders said work was being carried out to review caseload allocations.

In March 2026, staff were mostly up to date with mandatory training. Overall compliance ranged from 75% to 100% with a target compliance rate of 85%. The exception related to Data Security Awareness; the target compliance rate was 95%. Staff completed the Oliver McGowan mandatory training on learning disability and autism (parts 1 and 2). Training comprised of three components: e‑learning, part 1 and part 2. Compliance rates ranged from 65% to 100% for e-learning, 100% for part 1 and 47% to 100% for part 2. Some training data did not include a detailed breakdown of compliance by training type or service area.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading, and took prompt action where cleaning was required. Staff kept the sites clean and well maintained.

Staff followed infection prevention and control principles. We observed the appropriate use of disposable gloves, aprons, and hand sanitisers. In the clinic examination room, disposable wipes were available to maintain clean surfaces.

Infection prevention and control training was provided at levels 1 and 2. Infection control compliance at level 1 was 100%. In some areas, level 2 compliance fell below the trust target compliance rate of 85%.

An infection prevention control audit for 20 January 2026 showed that staff adhered to established infection control principles, including effective hand hygiene. Staff at County CMHT site scored 91% compliance. Improvements noted around controls for sharps including better labelling, waste management and environment cleanliness.

Staff at Marrow House City and County Memory Services remained compliant at 98%. Personal protective equipment compliance remained strong, with sharps standards implemented and standards for waste management and environmental cleanliness maintained.

During the assessment, small quantities of medicines were stored in clinic rooms at Marrow House and the Lyme Brook Centre for use by the CMHTs and the Memory Service. Staff managed and stored medicines appropriately. Clinic environments were clean, well maintained, and suitably furnished, supporting the safe delivery of care.

Within the staff team there were doctors and non-medical prescribers to prescribe medicines. A non‑medical prescriber (NMP) is a qualified healthcare professional who is not a doctor or dentist but has completed specialist training that allows them to prescribe medicines within their scope of practice.

Staff conducted a full assessment of patients, including both their physical and mental health, before prescribing medicines.

Staff reviewed the effects of medication on older adults’ physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance, especially when a patient was prescribed a high dose of antipsychotic medication. Staff changed the prescriptions when necessary.

Some patients were prescribed lithium and were reviewed every three months to ensure the medicine remained safe and effective. These reviews maintained safe lithium levels, monitored kidney and thyroid function, detected side effects early, and gave patients a chance to discuss their wellbeing and treatment.

Decisions regarding medicines were discussed within the multidisciplinary team, ensuring that prescribing was clinically appropriate and aligned with national guidance and best practice for older people. Where people had fluctuating or impaired capacity, staff completed timely capacity assessments and clearly recorded the rationale and outcomes in care records.

Staff ensured information was offered in an accessible and appropriate manner to support understanding and informed decision‑making. We saw examples of staff adjusting treatment plans to reflect patients’ preferences, therapeutic goals and individual circumstances.