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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.

Reports


Inspection carried out on 30 May to 5 July 2018

During a routine inspection

Our rating of the trust went down. We rated it as requires improvement because:

  • We rated safe, and well-led as requires improvement and effective, caring and responsive as good.
  • We inspected eight core services on this inspection. The overall ratings for two of these core services went down to requires improvement and one core service remained rated as requires improvement. One core service improved to good and one core service improved to outstanding. We rated safe as requires improvement in five of the eight core services and inadequate in one core service we inspected. In rating the trust, we took into account the previous ratings of the core services not inspected this time.
  • The trust had recently undertaken a major reconfiguration of services at the same time as restructuring the management. The senior leadership of the trust had not recognised a deterioration in safety of some services during these changes. Also, the reconfiguration of community services had led to some patients having lengthy waits for services and staff were concerned about their ability to provide a safe and effective service. The single point of access was not able to manage or monitor the volume of calls to the service and people requiring a mental health assessment were not always assessed quickly.
  • Governance systems and processes had not ensured that staff were aware of or adhered to all policies and procedures or that they always reflected current national guidance and good practice. They had also not ensured that staff received regular clinical supervision. This was significantly lower than the trust target in most core services that we inspected.
  • Trust managers did not ensure that learning from the investigation of incidents was shared effectively across the trust.
  • There were not enough staff to provide safe care in three core services. This resulted in high caseloads in community teams, leave and activities being cancelled and a high use of agency and bank staff. This meant that one core service did not always have enough appropriately trained staff on duty.

However:

  • The leadership team were aware of the current challenges and were taking action to address them. The senior leadership team were visible and accessible to staff, patients and carers. Managers at all levels promoted a culture that supported and valued staff. Staff knew about the trust’s whistleblowing procedures and who the freedom to speak up guardian was and how to access their support.
  • The trust was actively involved in the local integrated care system and accountable care partnership. They had good relationships with stakeholders and partners, including the local clinical commissioning group, police force and local authority.
  • Mandatory training and staff appraisal rates were high and had significantly improved since our last inspection. However, this improvement had not been seen in two core services.
  • Patients and carers were positive about the care staff provided. Patients felt that staff helped them in a respectful, caring, and compassionate way and helped them to understand and manage their own condition, care, and treatment where appropriate. Carers felt they got the support they needed.
  • Staff, patients and carers were involved in planning and developing services and the trust had commissioned an independent review of the recently reconfigured community services in order to identify lessons learned and inform future changes.


CQC inspections of services

Service reports published 5 October 2018
Inspection carried out on 30 May to 5 July 2018 During an inspection of Wards for older people with mental health problems Download report PDF | 516.25 KB (opens in a new tab)Download report PDF | 2.31 MB (opens in a new tab)
Inspection carried out on 30 May to 5 July 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 516.25 KB (opens in a new tab)Download report PDF | 2.31 MB (opens in a new tab)
Inspection carried out on 30 May to 5 July 2018 During an inspection of Wards for people with a learning disability or autism Download report PDF | 516.25 KB (opens in a new tab)Download report PDF | 2.31 MB (opens in a new tab)
Inspection carried out on 30 May to 5 July 2018 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 516.25 KB (opens in a new tab)Download report PDF | 2.31 MB (opens in a new tab)
Inspection carried out on 30 May to 5 July 2018 During an inspection of Community-based mental health services for adults of working age Download report PDF | 516.25 KB (opens in a new tab)Download report PDF | 2.31 MB (opens in a new tab)
Inspection carried out on 30 May to 5 July 2018 During an inspection of Forensic inpatient or secure wards Download report PDF | 516.25 KB (opens in a new tab)Download report PDF | 2.31 MB (opens in a new tab)
Inspection carried out on 30 May to 5 July 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 516.25 KB (opens in a new tab)Download report PDF | 2.31 MB (opens in a new tab)
Inspection carried out on 30 May to 5 July 2018 During an inspection of Community-based mental health services for older people Download report PDF | 516.25 KB (opens in a new tab)Download report PDF | 2.31 MB (opens in a new tab)
See more service reports published 5 October 2018
Service reports published 30 March 2017
Inspection carried out on 14 - 18 November 2016 During an inspection of Community-based mental health services for older people Download report PDF | 352.37 KB (opens in a new tab)
Inspection carried out on 15 November to 18 November 2016 During an inspection of Community-based mental health services for adults of working age Download report PDF | 327.6 KB (opens in a new tab)
Inspection carried out on 14 to 17 November 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 378.92 KB (opens in a new tab)
Inspection carried out on 15 November – 16 November 2016, 30 November 2016 During an inspection of Forensic inpatient or secure wards Download report PDF | 370.83 KB (opens in a new tab)
Inspection carried out on 14 - 18 November 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 397.66 KB (opens in a new tab)
Inspection carried out on 14-17 November 2016 During an inspection of Wards for older people with mental health problems Download report PDF | 330.99 KB (opens in a new tab)
Inspection carried out on 14 – 18 November 2016 During an inspection of Substance misuse services Download report PDF | 342.7 KB (opens in a new tab)
Inspection carried out on 14 to 18 November 2016 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 322.6 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 454 KB (opens in a new tab)
Inspection carried out on 14 to 18 November 2016 During an inspection of Wards for people with a learning disability or autism Download report PDF | 322.55 KB (opens in a new tab)
See more service reports published 30 March 2017
Service reports published 5 October 2015
Inspection carried out on 27 -30 October 2014 and 16 June 2015 During an inspection of Wards for people with a learning disability or autism Download report PDF | 380.33 KB (opens in a new tab)
Inspection carried out on 14 -18 November 2016

During a routine inspection

At this inspection, carried out in November 2016 we changed the overall rating of the provider from requires improvement to good. We changed the overall rating for effective and responsive from requires improvement to good. However, the overall rating of the safe domain is unchanged.

We rated the following core services as good:

  • Forensic inpatient/secure wards.
  • Substance Misuse Services.
  • Community Based Mental Health Services for Adults of Working Age.
  • Wards for older people with mental health problems.
  • Community-based mental health services for older people.
  • Acute wards for adults of working age and psychiatric intensive care units.
  • Wards for people with learning disabilities or autism.
  • Community mental health services for people with a learning disability or autism.

We rated the following core services as requires improvement:

  • Long stay/rehabilitation mental health wards for working age adults.
  • Mental health crisis services and health-based places of safety.
  • Primary Medical Services

We rated Sheffield Health and Social Care NHS Foundation Trust (the trust) as good overall because

  • The trust had a clear vision and values which were supported by a set of strategic objectives which were developed with the involvement of patients, carers and staff. Most staff felt involved in changes and able to contribute to the continuous development of services. Staff could explain the trust’s values and observations showed that staff demonstrated these in practice. Staff knew who senior managers were. There were posters displayed to show who senior figures within the trust were and information to explain their roles. Staff told us that senior managers regularly spent time on the wards.

  • The leadership, knowledge and commitment of the non-executive directors of the trust was exceptional and the trust council of governors were knowledgeable and well informed and were clear about their role and responsibility to hold to account the non-executive directors of the trust.

  • Staff were supportive of each other, and told us they were proud of their teams.

  • The trust had excellent patient and public involvement and demonstrated a commitment to social inclusion. The trust was a host organisation for an employment scheme for adults with mental health problems, learning disabilities and complex needs. It paid the living wage to patients who have obtained employment within the trust. The opiate service recruited and trained ambassadors (people who had previously used the service) to support and inspire newer clients.

  • The trust demonstrated a caring ethos towards its patients and the community it served. Feedback from patients and carers regarding their care and treatment was mostly positive. Staff were professional, caring and supportive of patients and their carers in all the services we visited. Staff supported patients to use advocacy services and the wards and services we inspected had established good links with adult advocacy services. Observations of interactions between staff and patients showed that staff treated patients with respect, kindness and had a positive rapport. Staff knew patients and their needs in detail. Wards and community based services for older people with mental health problems had developed caring and innovative ways for patients to maintain relationships with loved ones.

  • Staff in most services, made holistic assessments of patients’ needs and care plans were developed with patients and carers, and multi-disciplinary teams worked together to support patients in their recovery. Staff received weekly continuous professional development suitable for their role. Nurses were encouraged to become non-medical prescribers and undertake training in psychosocial interventions to enhance their skills.

  • On wards for older people with mental health problems, there was a very good programme of meaningful activity.

  • The trust scored better than the England average overall for cleanliness, condition, appearance and maintenance, dementia friendly and disability in the 2016 Patient Led Assessment of the Care Environment data. The trust knew the population they provided services to and worked to ensure that services were accessible and that staff at all levels were representative of the communities they served.
  • The trust had worked hard to significantly reduce the number of patients with mental health problems who had to be cared for outside of the local area over the past two years.
  • The community enhancing recovery team had a well-established partnership with a local housing association. The partnership meant the trust was able to return patients from out of area placements to Sheffield with the team supporting patients to manage their own independent tenancies.
  • The trust had in place a policy which described how it would meet its responsibilities under the Counter Terrorism and Security Act 2015 and meet the health requirements of PREVENT.

However:

  • The trust did not ensure that all of the premises from which it provided patient care were safe. Staff had not undertaken environmental risk assessments, including identification of ligature risks and blind spots in all areas. The ligature risk assessment of the liaison psychiatry premises did not state what actions were required to mitigate all identified risks in areas accessible to people using the service. Seclusion rooms did not meet all the requirements of the Mental Health Act Code of Practice in relation to providing a safe environment for the management of patients presenting a risk to others. There was no policy or procedure to accommodate patients of the same sex in the same area. Bungalow 3 in the intensive rehabilitation service was not clean at the time of the inspection. In substance misuse services, staff did not always consider infection control procedures when using client rooms to activate drug screening tests.
  • At the time of the inspection, the percentage of staff completing mandatory training averaged 60% compared with the trust's mandatory training target of 75%. Trusts should ensure that staff maintain their skills knowledge and training to carry out their roles safely and effectively and are up to date with changes to best practice. The trust’s senior management team were aware of the poor compliance with mandatory training. They had started to deal with these issues and were introducing changes. However, poor compliance with mandatory training had the potential for a negative impact on patient care and safety.
  • Staff did not always manage or monitor the administration of medicines well. This included not always undertaking or recording issues relating to the management of medicines including physical observations after giving medication. In the long stay rehabilitation services, staff did not follow National Institute for Health and Care Excellence guidance (G10 ‘Violence and aggression: short-term management in mental health, health and community settings) when using rapid tranquilisation. On wards for people with learning disabilities, medicines were administered from the main ward office as the clinic room was located outside the main ward area.
  • At the health based place of safety, staff did not undertake people’s physical observations or keep these under review if necessary.

  • Qualified staffing cover was inconsistent in the long stay rehabilitation service. Staff in the community enhancing recovery team had not taken appropriate action as a result of a safeguarding concern.

  • Blanket restrictions were in place in the long stay rehabilitation services, wards for older people and forensic services. Patients on G1 ward at Grenoside did not have access to their bedrooms during the day.

  • In the community team for adults of working age, we found the service had waiting lists of up to nine weeks and there was no system of monitoring the risks of people who were on the waiting list. There were inconsistencies in the way in which lone working was managed in the community teams for adults of working age.

  • Risk assessment and management processes were not always robust. Staff did not always complete risk assessments for people using the place of safety. In substance misuse services, we found that over a third of clients did not have updated risk assessments or risk management plans.

  • Managers in some core services reported having limited oversight relating to their team’s performance. Robust governance structures were not in place in Community based mental health services for adults of working age, Substance misuse services, Community-based mental health services for older people, mental health crisis services and health-based places of safety and Wards for people with learning disabilities or autism.

  • The trust overall compliance for mandatory training on the Mental Capacity Act level one was 31% and Mental Capacity Act level two was 41%. Deprivation of Liberty Safeguards level two training across the trust was at 47%. Staff knowledge of the Mental Capacity Act and related Code of Practice was poor in some areas.

  • In the long stay/rehabilitation wards the service offered a number of activities, however, most of those activities were social activities and there were limited activities which focussed on rehabilitation.

Inspection carried out on 28 – 31 October 2014

During a routine inspection

We saw that the seclusion rooms on the acute wards and the 136 suite did not meet all of the requirements of the MHA Code of Practice in relation to providing a safe environment for the management of patients presenting as a risk to others. We identified a number of ligature points in all of the inpatient areas. There was evidence to show that ligature points were being managed by the trust in the low secure wards, the learning disabilities service, rehabilitation wards and the older people’s wards at Grenoside Grange. However It was not always clear that ligature risks were being fully mitigated in the acute admission and PICU wards. The inspection team also identified ligature risks that had not been identified by the trust on the acute inpatient wards Stanage and Burbage. We found there was inconsistent qualified staffing cover at the rehabilitation wards at Forest Close. Often there were two qualified staff working across three wards which left two unqualified staff on duty on one of the wards. There were also inconsistencies with regards to the level of junior doctor support across the wards. Staff working in the ward area told us that the junior doctors focussed on patient needs. This meant they spent less time on the wards where patients had less complex needs. The resource of staffing at night time to manage the out of hours and crisis demands meant that out of hours provision was not fully safe or responsive to people’s needs. We looked at compliance with Department of Health guidance on same sex accommodation (SSA) and the Mental Health Act (MHA) Code of Practice (CoP) throughout the inpatient services. We found compliance with SSA with the exception of the rehabilitation wards at 1a and 3 Forest Close. We identified the following concerns around medicines management:

  • In some acute wards physical observations following rapid tranquillisation were not always fully recorded.
  • In some treatment rooms on the acute adult and older people’s wards we found refrigerators were not always properly monitored by ward and pharmacy staff to make sure that medicines were always stored at the correct temperature.
  • In some acute adult and older people’s wards entries in the controlled drug register did not always include the signature of the witness observing administration and on the acute wards we found that sometimes the dose given was not recorded.
  • In the CMHTs there were concerns with nursing staff repackaging medicines which should only be carried out by pharmacy staff and the safe storage of medicines.
  • In the CMHTs there was no dedicated pharmacist input to support the safe and effective management of medicines.

However we saw that: Services had effective systems in place to capture clinical incidents and accidents and to learn lessons from them effectively.Overall staff had a good awareness of safeguarding procedures and knew how to raise alerts where necessary when they knew or suspected abuse was occurring.Data provided at trust level about training uptake showed significant gaps in mandatory training. Up to date lists of staff training uptake could not always be provided from some of the teams we visited. This system was not effective in monitoring the trusts training uptake. Gaps in training included:

  • Limited Mental Capacity Act (MCA) refresher training in acute services.
  • Levels of staff training around safeguarding adults were low on the Dovedale wards.
  • No training specific provided to staff working in the section 136 suite.

We saw some areas of poor practice around MDT working:

  • In the acute inpatient services patients were not usually invited into the MDT meeting but were instead offered time with any professional on an individual basis on request. This meant that it was not always clear that patients were fully participating in their care.
  • In the rehabilitation services we found some inconsistencies with the level of engagement some patients had with their multi-disciplinary team (MDT) meetings and a lack of proactive involvement of advocacy to support these patients to be more involved in their care reviews. The MDT notes we looked at did not always record who had attended the MDT reviews or the patients’ views.

We found some inpatient services did not always adhere to the Mental Health Act Code of Practice.

  • Staff were not completing the appropriate records to evidence adherence to the Mental Health Act.
  • Some records did not show that patients had been told about their rights under the Mental Health Act.
  • The recording of episodes of seclusion including the time the doctor attended seclusion and the cogent reasons if there is a delay in attendance.
  • The legal authorisations T2 (certificate of consent to treatment) and T3 (certificate of second opinion) for treatment were not kept with the medicines charts.
  • In rehabilitation services we found on some wards MHA documentation was not readily present and available for inspection for all detained patients.
  • In both acute inpatient and rehabilitation services we found that issues regarding adherence to the Mental Health Act (MHA) had been identified in previous MHA monitoring visits had not been addressed effectively.

We found the following areas in need of improvement around capacity to consent:

  • In the acute inpatient services there were issues with adherence to the Mental Health Act Code of Practice particularly around capacity to consent for treatment.
  • In the adult community teams it was not always recorded when the person had chosen for others not to be involved.
  • In rehabilitation services we found inconsistencies regarding the application of the Mental Capacity Act and Deprivation of Liberty safeguards across the wards. There was a lack of evidence to demonstrate that patients’ capacity to consent or dissent to treatment was assessed and documented.

However in the forensic service there were many examples of how the wards had integrated best practice within the care and treatment they provided to patients and their carers in line with the National Institute for Health and Clinical Excellence (NICE) and national guidance. In the forensic service 100% mandatory training achieved for all staff. Overall the trust was providing a caring service for patients. Throughout the inspection we saw examples of staff treating patients with kindness, dignity and compassion. The feedback received from patients was generally positive about their experiences of the care and treatment provided by staff. Staff were mostly knowledgeable about patients’ needs and showed commitment to provide patient led care. The services held a range of regular patient meetings and some carer meetings to support relatives and carers of patients on the wards. Patients were also facilitated to access external service user groups such as Service User Network (SUN:RISE) and Sheffield African Caribbean Mental Health Association (SACMHA). Patients had regular access to advocacy including specialist independent mental health advocacy (IMHA) for patients detained under the Mental Health Act. There were areas of good practice:

  • There were innovative service user involvement initiatives for patients using adult community mental health services
  • We found the CLDT was proactive in its approach to gaining feedback from patients and their families
  • Forensic services supported patients and their relatives to keep in contact with technology such as SKYPE.

However there were areas of poor practice:

  • In older peoples inpatient services, at Dovedale we saw patients were not consistently involved in care planning and at Grenoside patients were not involved in their life stories and person centred plans.
  • In rehabilitation services there was a lack of proactive involvement of advocacy to support these patients to be more involved in their care reviews.
  • At the section 136 suite there was no formal mechanism to obtain feedback from people detained under section 136.

The resource of staffing at night time to manage the out of hours and crisis demands meant that out of hours provision was not fully safe or responsive to people’s needs. There were no overall systems to record how the limitations on the out of hours service impacted on patient care to monitor its’ responsiveness. There were a number of pressures within the community mental health teams.Prior to our visit, the Trust had identified concerns regarding the management of new referrals in the CLDT because people had waited significant periods of time before being assessed by professionals within the service. The Trust had completed a full review of each patient in response to this and we could see evidence of improvements beginning to be made. In the rehabilitation services the service had identified that 23 patients did not require the in-patient hospital care they were currently receiving at 1, 2 and 3 Forest Close. Despite these figures no delayed discharges had been reported to the trust from Forest Close in the previous six months. The needs of some of these patients had changed over the years they had been at Forest Close with their physical health needs’ being more complex and requiring more nursing input than their mental health needs. It was not evident how the service had developed or planned services to effectively meet the changing needs’ of this patient group.

However we found that:Access, discharge, transfer of care and bed management was effectively managed throughout most inpatient and community services. Patients’ diversity and human rights were respected. Attempts were made to meet patients’ individual needs including cultural, language and religious needs. People’s individual, cultural and religious beliefs were taken into account and respected as demonstrated by the content of the care plans and observation at clinical meetings. We saw that complaints were well managed. The complaints within each service were looked into and responded to. Where complaints were not upheld, managers would still look at what could be learned or improved. We found evidence to show that managers had taken timely action in response to complaints which they had received. The trust had a strategy with the overall vision and values and most staff told us they understood the vision and direction of the trust and showed professional commitment to these values. There was a clear governance structure that included a number of committees that fed directly into the Board. Services were overseen by committed and experienced managers who oversaw the quality and clinical governance agenda. There were regular meetings for managers to consider issues of quality, safety and standards. Lines of communication from the board and senior managers to the frontline services were mostly effective, and staff were aware of key messages, initiatives and the priorities of the trust. Staff understood the management structure and where to seek additional support. The trust participated in external peer review and service accreditation. However there was variance in how staff across services learnt lessons from incidents, audits, complaints and feedback from patients. We saw that in some areas, local governance arrangements were good whilst in others they were not effective. Sheffield Health and Social Care NHS Foundation Trust are registered to provide adult social care service from six locations. These locations were inspected as part of the inspection process. Reports of the finding of these services have also been produced. The aggregated for these services are as follows.

Longley Meadows

Overall rating for this service -Requires improvement

Are services at this location safe? -Requires improvement

Are services at this location effective? -Good

Are services at this location caring?

-Good

Are services at this location responsive? - Requires improvement

Are services at this location well-led? -Requires improvement

Hurlfield

Overall rating for this service -Requires improvement

Are services at this location safe? -Requires improvement

Are services at this location effective? -Requires improvement

Are services at this location caring? -Requires improvement

Are services at this location responsive? -Good

Are services at this location well-led? -Requires improvement

Woodland View

Overall rating for this service -Inadequate

Are services at this location safe? -Inadequate

Are services at this location effective? - Inadequate

Are services at this location caring? -Requires improvement

Are services at this location responsive? -Requires improvement

Are services at this location well-led? -Requires improvement

136 Warminster Road

Overall rating for this service -Requires improvement

Are services at this location safe? -Requires improvement

Are services at this location effective? -Good

Are services at this location caring? -Good

Are services at this location responsive? -Requires improvement

Are services at this location well-led? -Requires improvement

Supported living Mansfield View

Overall rating for this service -Good

Are services at this location safe? -Requires improvement

Are services at this location effective? -Good

Are services at this location caring? -Good

Are services at this location responsive? -Good

Are services at this location well-led? -Good

Supported living Wainwright Crescent

Overall rating for this service -Requires improvement

Are services at this location safe? -Requires improvement

Are services at this location effective? -Requires improvement

Are services at this location caring? -Good

Are services at this location responsive? -Outstanding

Are services at this location well-led? -Requires improvement

Aggregated rating for the adult social care services provided

Overall adult social care rating - Requires improvement

Are adult social care services safe? - Requires improvement

Are adult social care services effective? - Requires improvement

Are adult social care services caring? - Requires improvement

Are adult social care services responsive? - Requires improvement

Are adult social care services well-led? - Requires improvement

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Reports under our old system of regulation (including those from before CQC was created)


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.