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Provider: Sheffield Health and Social Care NHS Foundation Trust Requires improvement

Read our previous full service inspection reports for Sheffield Health and Social Care NHS Foundation Trust, published on 9 June 2015.

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 19 August 2021

We carried out this unannounced inspection of the acute wards and psychiatric intensive care units, mental health wards for older people, and crisis and health-based places of safety because at our last inspection we rated them inadequate.

We inspected the well-led key question for the trust overall because at our last inspection we rated the trust as inadequate following which the trust was placed in special measures to help it improve.

At this inspection we rated two services as requires improvement, we continued to rate the acute wards and psychiatric intensive care units as inadequate because further improvement was required.

The trust was rated as requires improvement overall with a rating of good in the caring key question.

We did not inspect forensic wards or community based mental health services for adults of working age because we rated them requires improvement at our last inspection. We are monitoring the progress of improvements to these services and will re-inspect them as appropriate.

We did not inspect long stay rehabilitation wards, community substance misuse services or community mental health services for people with learning disabilities or autism and older people, because they were rated good or outstanding, and we did not have information that meant we needed to visit these services this time.

We did not inspect forensic wards or community based mental health services for adults of working age because we rated them requires improvement at our last inspection and the services had not had time to make the improvements necessary to meet legal requirements as set out in the action plan the trust sent us after the last inspection. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

Prior to this inspection, we inspected wards for people with learning disabilities and autism.

To support the trust, NHS England and Improvement have recently placed the trust into segment 4 of their Systems Oversight Framework and it will receive a package of support through the national Recovery Support Programme.

Our rating of the trust improved. We rated the trust as requires improvement because:

  • We rated safe, effective, responsive and well-led as requires improvement, and caring as good. In rating the trust, we took into account the current ratings of the six services not inspected this time. The adult social care services provided by the trust were not inspected this time, and their previous ratings were not aggregated into the trust’s overall rating.
  • One of the trust’s services had worsened since the last inspection, we rated inpatient services for people with learning disabilities or autism as inadequate. We took enforcement action following this inspection due to significant concerns identified.
  • Acute wards and the psychiatric intensive care unit had not improved enough for us to improve the rating of this service and it remained inadequate overall. We took enforcement action following this inspection due to significant concerns identified.
  • The trust had plans in place to continue to improve the safety and quality of their services supported by a strategy through to 2025. They had not yet had time to embed these plans and therefore whilst planned changes were evident, these were not yet in place at the time of the inspection as most initiatives were new or developing.
  • The accommodation in which the trust provided care continued to a present a significant risk to patients. There were a number of ligature anchor points and blind spots on the acute wards which did not have adequate mitigation in place to keep people safe. Areas of the acute wards and one of the older people’s wards were poorly maintained and patients had come to harm when using these services. The privacy and dignity of patients in seclusion on Burbage Ward was not protected, an issue identified on our last inspection. Staff working in community services told us that they had low morale because of the poorly maintained environments the trust asked them to work within.
  • Not all wards had enough staff who knew patients well and were able to care for them safely. The trust used a significant level of agency staff in order to maintain the safety of the wards who were not trained in the trust’s restraint techniques. Staff told us that this put them, and patients at risk because these staff were not always able to intervene when patients became distressed. There were a high number of vacancies for band five nurses. There remained gaps in medical cover and this meant that people’s reviews in seclusion and in the health-based places of safety were delayed.
  • Safeguarding and incident reporting remained a concern because incidents were not always reported and investigated correctly. The trust were not performing their statutory and delegated responsibilities well. Patients had not been safeguarded when they had experienced abuse or improper treatment on the acute wards and in the learning disability inpatient service. The trust had a rapid improvement plan in place for their safeguarding functions, but this had been removed as a risk on the trust’s board assurance framework.
  • There were high levels of the use of seclusion on the older people’s wards, and this was not always used as a last resort and in line with the Mental Health Act Code of Practice.
  • The trust was inconsistent in their approach to blanket restrictions and we found that on the acute wards and in the learning disability inpatient ward people’s rights and freedoms were sometimes restricted.
  • Rates of compliance with mandatory training had improved, however courses in immediate life support and restraint techniques (respect) where below the trust’s target. Not all wards had enough mitigations in place to ensure patients did not come to harm due to low levels of compliance with training.
  • The trust did not always provide effective care. People using services and their carers were not always involved in their care and treatment. Care plans were not personalised and people were not always involved in discussions about their care and treatment.
  • Since the last inspection, the trust had double the amount of supervision sessions offered to staff. However, compliance with supervision remained below the trust target.
  • There were pockets of closed cultures within the trust were staff had not provided kind, dignified and compassionate care. Leaders had not always recognised and acted quickly enough on the early warning signs in regard to closed cultures developing, and people using services had come to harm. The culture of the trust below the board and executive leadership team was not always positive. Staff told us that they did not always feel involved, had low morale in some teams and the staff survey and friends and family test outcomes indicated that staff would not recommend the trust as a place to work, or as a place for their relatives to receive care. Risks about the continued development of closed cultures were not entered on risk registers or the board assurance framework.
  • The trust was not consistently responsive. There were significant waiting times in community and specialist services and in the emotional wellbeing service. The trust did not have an accessible complaints policy available to the public and people did not always know how to complain. The trust did not use complaints to drive improvement in services.
  • The trust relied on digital systems which were not fit for purpose and did not support the provision of high-quality patient care. This remained a significant risk for the trust and patient records had been lost due to failures in the system. We were concerned about the pace at which the organisation were able to bring about improvement in its digital systems.
  • The trust required continued improvement in its approach to equality and diversity. The workplace race equality and disability standards had a number of key metrics where the trust had failed to meet their targets. Staff who were disabled or from a black minority ethnic background continued to be adversely affected in recruitment and selection, progression, disciplinary processes and felt more likely to experience bullying or harassment. The trust did not have an effective system in place to address the feedback raised by staff in relation to equality and diversity.
  • Senior leaders did not always ensure that they reported accurate assurance on areas of risk to the executive team. In learning disability services and in acute wards patients had come to harm and when this was brought to the attention of senior leaders it did not always result in reporting to the executive team and board for oversight and action.
  • There continued to be a high number of medicines administration errors and the trust had not made improvements in reducing the amount of errors being made over time.


  • The trust had made improvements since the time of the last inspection and the rating of well-led had improved from inadequate to requires improvement. The ratings of two of the four services we inspected had improved since the last inspection.
  • The trust leadership had improved since the last inspection, a number of new leaders had joined the executive and non-executive team and were leading the trusts improvement journey. The executive team and board had improved their oversight of and engagement with services including refreshed board visits to services with evidence of feedback from visits into board and committees.
  • There were a number of areas of concern at the last inspection which the trust had acted upon to reduce risk. The new leadership team had also identified a number of additional concerns and areas for improvement that had now been included in improvement plans going forward.
  • The safety of some services had improved. There had been significant improvement in the delivery of physical health care to patients which included a revised physical health strategy and ongoing monitoring of compliance with reporting.
  • The oversight of staffing had improved, and the trust had now ensured that high numbers of shifts were not being covered by newly qualified nurses. Daily staffing huddles had improved the oversight of leaders and allowed for the fluid deployment of staff into areas of the service which needed support.
  • There was improved oversight and involvement of the pharmacy team who provided support to staff within wards and services.
  • The trust had made some improvements to their estates include interim measures taken to improve accommodation whilst the trust worked to secure longer term improvement. This included the removal of dormitory accommodation and implementation of single sex accommodation on two of the three acute wards.
  • There had been no use of mechanical restraint by staff in the three months prior to the inspection and when this was used by external partners there was robust oversight and reporting. There was a falls management process in place on the older people’s inpatient wards.
  • During the inspections we observed staff providing, in most services, kind and compassionate care. People who used services and stakeholders told us about staff who were active listeners who provided good care.
  • The leadership of the trust had improved, leaders were working cohesively, and the restructures of some services and their leadership allowed clarity of responsibilities and improved oversight and ownership of risks.
  • Oversight of human resources had improved. The trust had oversight of disclosure and barring checks and oversight of staff professional registrations. The trust were able to evidence compliance with the fit and proper persons regulation. However, the response times for the grievance process required further improvement.
  • The trust’s oversight of risk had improved. The development of an integrated performance report allowed leaders and the board to have oversight of emerging risks and issues and allowed for clear action planning to reduce or mitigate risks.
  • The trust had invested in the development of the organisation, the board and the governors to ensure effective governance processes were in place.
  • The trust had improved engagement with staff, staff side, governors and stakeholders and system partners. We saw strengthened relationships with the voluntary sector. The trust had taken action to engage staff in conversations about racial discrimination and had action plans and pilot projects in place to make improvements.

How we carried out the inspection

During this inspection we;

  • worked with experts by experience who talked to service users and their carers about their experience of using these services.
  • visited all the acute wards and psychiatric intensive care unit
  • visited both older adult inpatient wards
  • visited the learning disability inpatient service at Firshill Rise
  • visited the psychiatric liaison service, single point of access and health based places of safety.
  • spoke with a variety of staff in face to face or virtual meetings including; health care assistants, nurses, doctors, allied health professionals, managers, the executive directors, non-executive directors and governors.
  • reviewed a number of records relating to the care and treatment of patients.
  • reviewed a variety of documents relating to the management of the trust and the services it delivers.
  • held four focus groups with; staff network groups, staff side and two open staff drop in calls.
  • reviewed a variety of information we already held about the trust.
  • sought feedback from a number of the trust’s stakeholders such as healthwatch, the local authority, NHS England and the CCG.

You can find further information about how we carry out our inspections on our website:

What people who use the service say

We spoke service users and their carers across the four services we visited and also spoke with staff and governors who were users of trust services. We also spoke with Healthwatch and advocacy services to obtain information about what people said to them about the trust’s services. Where people were unable to communicate with us verbally, we used observation tools to obtain insight into the care they were receiving.

People described staff working in services as respectful, compassionate and kind. They said that they were treated with dignity and respect. Patients and carers reported that the psychiatric liaison team were exceptionally ‘patient and understanding’ in their approach to providing support.

However, the majority of people we spoke with raised concerns about their involvement and engagement. People did not always understand their care plans and these had not been carried out collaboratively. Carers of people using the acute wards told us that they weren’t always kept update about their relative. Meetings designed to take place to allow people to give feedback about the services did not always take place. People told us that they did not know how to access advocacy support and some people and their relatives did not know how to make complaints.

Patients and their carers, relatives and advocates were not consistently invited to multi-disciplinary meetings with staff to discuss their care plans and be involved in their own recovery.

Feedback from stakeholders contained general themes around environmental cleanliness, waiting times in community services, access to the crisis services by telephone, and a lack of communication and engagement from some services with patients and their relatives.

During our observations of the care of people in the learning disability service, we observed care which was not always respectful and kind.

Inspection areas


Requires improvement

Updated 19 August 2021


Requires improvement

Updated 19 August 2021



Updated 19 August 2021


Requires improvement

Updated 19 August 2021


Requires improvement

Updated 19 August 2021

Checks on specific services

Wards for people with a learning disability or autism


Updated 15 July 2021

Wards for older people with mental health problems

Requires improvement

Updated 19 August 2021

Mental health crisis services and health-based places of safety

Requires improvement

Updated 19 August 2021

Acute wards for adults of working age and psychiatric intensive care units


Updated 19 August 2021

Forensic inpatient or secure wards

Requires improvement

Updated 30 April 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Not all risks were documented on the ligature risk audit and not all staff were up-to-date with all their mandatory training. The service did not monitor the numbers of staff on shift that had been trained in immediate life support. Minimum numbers of staff on the night shift on the rehabilitation ward were not always sufficient to ensure safety in an emergency.
  • Not all care plans were holistic or recovery orientated. Staff could not always find information easily on the electronic patient record as they recorded things in different places.
  • The trust did not collect enough information to monitor the service, like whether medical staff received supervision and appraisal and how many child safeguarding referrals the service made. The service did not monitor and audit adherence to the Mental Capacity Act
  • Staff did not always monitor the temperature of the food fridges and freezers in the occupational therapy kitchens and some liquid medicines were not stored in line with good practice.


  • The ward environments were safe and clean. The wards had enough nurses and doctors during the day and staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding adults.
  • Staff developed treatment plans informed by a comprehensive assessment. They provided a range of interventions suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in audit to evaluate the care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

Community-based mental health services for adults of working age

Requires improvement

Updated 30 April 2020

Our rating of this service went down. We rated it as requires improvement because:

  • The service did not always provide safe care. Not all clinical premises where patients were seen were safe and clean. Staff did not record the assessment and management of patient risk well. Staff had not completed and kept up to date with mandatory training.
  • Staff did not develop holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. Not all patients could access a Mental Health Act assessment in a timely manner. Staff had not received training on the Mental Health Act.
  • Staff did not always involve patients in care planning and risk assessment and did not seek their feedback on the quality of care provided. Staff did not always involve patients and give them access to their care plans.
  • The average waiting time for psychological treatments in the Mental Health Recovery Service South team was more than the Royal College of Psychiatrists recommendations of 18 weeks. The clinic room at the Mental Health Recovery Service South did not have a dignity curtain in place where patients received depot injections. Staff did not always follow up patients who missed appointments.
  • Telephone systems were not operating effectively to ensure that people are able to get through to the service they use by telephone easily. The information technology infrastructure did not work well. Governance systems were not always effective in identifying and acting on the concerns and risks within the service. Staff did not feel respected, supported or valued by senior management.


  • The service had enough staff, who knew the patients to keep them safe from avoidable harm. Staff responded promptly to sudden deterioration in a patient’s health when they were aware of changes. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • Staff ensured that patients had good access to physical healthcare and supported them to live healthier lives. Managers supported staff with appraisals and supervision. Managers provided an induction programme for new staff. Staff from different disciplines worked together as a team to benefit patients. Teams had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.
  • Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Patients could give feedback on the service and their treatment. Staff supported, informed and involved families or carers.
  • The service was easy to access. Staff assessed and treated patients who required urgent care promptly and patients who did not require urgent care did not wait too long to start treatment. The service met the needs of all patients – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support.
  • Leaders had the integrity, skills and abilities to run the service. The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Staff felt respected, supported and valued within their local teams and by their local leaders. The monthly governance report provided a wide range of oversight and managers were aware of many of the issues we identified.

Community-based mental health services for older people


Updated 5 October 2018

Our rating of this service went up. We rated it as outstanding because:

  • The environment was clean, tidy and well maintained. The building was bright and welcoming and there was clear signage for visitors.
  • Staff completed risk assessments for all patients and they were detailed and addressed risk and how to manage it appropriately.
  • Mandatory training for the team was all above 80%.
  • Staff received meaningful supervision and appraisal on a regular basis.
  • Assessments were comprehensive and completed in a timely way. Service users were seen quickly from being referred.
  • Staff were kind and caring towards service users and carers. Staff were highly praised by service users and they were observed to be empathic and sensitive.
  • Staff had reached out to harder to reach communities by attending groups for the South East Asian community, the Chinese community and the Somalian community. Here they spoke about mental health and the support that their team could offer.
  • There was a strong emphasis on maintaining patients’ links with the local community with lots of groups for older people and an active service user group who made decisions and gave feedback on proposed changes to the service.
  • There were strong links with external services such as care homes and GPs. Staff met regularly to discuss service users with complex needs.
  • The senior team had good oversight of staff performance including sickness, supervision and appraisal. Staff feedback about the support they received from managers was universally positive.

Long stay or rehabilitation mental health wards for working age adults


Updated 5 October 2018

Our rating of this service improved. We rated it as good because:

Community mental health services with learning disabilities or autism


Updated 30 March 2017

We rated community mental health services for people with learning disability or autism as good because:

  • Clients told us that they felt involved in their care and decisions made about their care and if they wanted a copy of their care plan they received one.

  • Clients told us that staff were interested in their well-being and reported that they were happy with the services that they received from teams. Clients told us that staff were polite, respectful and caring.

  • We observed staff interactions with clients and their carers. We saw that staff explained to clients the purpose of their visit.

  • Incidents were reported by staff and were handled appropriately. After each incident staff and clients were debriefed and a review of the detailed risk assessment and management plan took place.

  • The environments were accessible to clients who had difficulty with their mobility. Staff mostly saw clients in their own homes or other community venues.

  • Staff understood the lone working policy and everyone understood their responsibility to stay safe.

  • Staff completed assessments focussed on the involvement and intervention that the client required. They reflected the individual need of the client. Psychological therapies were available including cognitive behavioural therapy, dialectical behaviour therapy, and acceptance and commitment therapy.

  • The teams had developed pathways to other services, for example to employment, housing and palliative care to enable them to access the most appropriate services. Where more specific knowledge was required, staff signposted clients to other organisations that were more appropriate to advise and support.

  • Staff attended a number of meetings some monthly and some bi-monthly. These meetings allowed for the managers of the community teams to look at the service they were providing and the quality of the service. Professional meetings take place on a weekly basis at team level and a monthly basis at service level to allow for the development of various professions.

  • Staff reported they did not feel bullied or pressured in their role and they felt confident about taking any concerns, complaints or safeguarding to their line manager in order to keep clients safe.


  • The recording of mental capacity assessments was inconsistent, and did not always follow the Mental Capacity Act Code of Practice. Staff understanding about the Mental Capacity Act was varied and the Act was not always discussed by staff making plans for clients care.

Substance misuse services


Updated 30 March 2017

We rated substance misuse services as good because:

  • All areas were clean, well maintained and offered good facilities for the provision of services. Clients and staff told us they felt safe using the service. Services sharing locations had separate entrances for their clients.

  • Staff had good knowledge of safeguarding procedures and made appropriate referrals. There were beneficial links with the local authority safeguarding team who provided guidance and training to support the service.

  • Clients received care and treatment underpinned by best practice. Clinical staff demonstrated a good working knowledge of guidance and treatment options for drug and alcohol users. They received weekly continuous professional development and could access specialist training relevant to service delivery.

  • Partnership arrangements ensured a multidisciplinary approach. Staff had formed effective external working relationships with the local recovery community and mutual aid groups. This provided clients with further support and activities during and after their treatment with the service.

  • Clients spoke positively of the service; they felt involved in their treatment options and told us the staff team treated them with kindness and respect. We observed positive interactions between staff and clients in clinics and group sessions. Staff understood the needs of their clients and used this to build positive relationships with them.

  • Staff ensured that it was easy for people to access the service. Waiting times to access and begin treatment were better than national averages. People could attend for assessment at the opiate, non-opiate and alcohol services without an appointment. Staff were able to provide flexible appointment times.

  • The alcohol service had developed and updated an online screening tool for monitoring alcohol intake, which allowed health and social care professionals in Sheffield to make direct referrals into both the alcohol and the non opiate service.

  • Services provided a range of clinics and access to specialist staff to meet people’s needs and preferences, offering choice and continuity of care. This included home detoxification, wound care clinics, clinics for those using performance enhancing drugs and inpatient detoxification.


  • Staff in the opiate service did not use appropriate areas to activate urine tests and dispose of clinical waste. Instead, they used consulting rooms that were not fit for this purpose. This meant that staff and clients were exposed to an avoidable infection control risk.

  • Staff did not always update risk assessment records and management plans using the trust's recognised risk assessment tool following changes in a person’s circumstances or following a multi-disciplinary team review. Risk plans did not include agreed actions staff would take if a client missed an appointment or dropped out of treatment unexpectedly.

  • Clients did not always have care plans that were holistic, or recovery orientated. Some concentrated solely on appointment attendance and maintenance of treatment. Clinical staff did not routinely audit the quality of clients’ care records.

  • Services received over 500 telephone calls a day and had difficulty managing the volume of daily telephone calls. This meant that clients and professionals experienced delays when trying to contact the service.

  • Services were not able to monitor their team’s performance adequately at local level. Trust figures showed staff were not compliant with mandatory training and the recording of supervision compliance. There was a need to improve the mechanism for recording training and supervision sessions.