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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.

Reports


Inspection carried out on 5 to 28 May 2021

During a routine inspection

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.

However:

  • 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: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

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.


CQC inspections of services

Service reports published 19 August 2021
Inspection carried out on 5 to 28 May 2021 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 5 to 28 May 2021 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Inspection carried out on 5 to 28 May 2021 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
See more service reports published 19 August 2021
Service reports published 15 July 2021
Inspection carried out on 28 April 2021 to 10 May 2021 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Service reports published 22 October 2020
Inspection carried out on 25 Aug to 27 Aug 2020 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 25 Aug to 27 Aug 2020 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Inspection carried out on 25 Aug to 27 Aug 2020 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
See more service reports published 22 October 2020
Service reports published 30 April 2020
Inspection carried out on 7 January 2020 to 5 February 2020 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)
Inspection carried out on 7 January 2020 to 5 February 2020 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 7 January 2020 to 5 February 2020 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 7 January 2020 to 5 February 2020 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)
Inspection carried out on 7 January 2020 to 5 February 2020 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
See more service reports published 30 April 2020
Service reports published 5 October 2018
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 (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 (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 (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 (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 (opens in a new tab)
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 (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 (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 (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 (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 (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 (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 (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 (opens in a new tab)
Inspection carried out on 14 – 18 November 2016 During an inspection of Substance misuse services Download report PDF (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 (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 (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 (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 (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 (opens in a new tab)
Inspection carried out on 7 January 2020 to 5 February 2020

During a routine inspection

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

  • We rated safe and well led as inadequate, effective and responsive as requires improvement, and caring as good.
  • We rated three of the trust’s core services inadequate overall, and two of the trust’s services as requires improvement overall. In rating the trust overall, we considered the current ratings of the five services not inspected this time. The adult social care and primary medical services provided by the trust were not inspected this time, and their previous ratings were not aggregated into the trust’s overall rating. We rated well-led for the trust as inadequate.
  • At this inspection, three of the trust’s core services had worsened since the last inspection. Acute wards and psychiatric intensive care units had worsened from a rating of requires improvement to inadequate. Wards for older people with mental health problems had worsened from a rating of good to a rating of inadequate and crisis and health-based places of safety had worsened from a rating of requires improvement to inadequate. Community mental health services for adults of working age had worsened from a rating of good, to a rating of requires improvement. We had not seen the required improvements in forensic wards and this service had maintained a ratings of requires improvement.
  • The trust did not always provide consistently safe care. We identified issues during our inspections in relation to; staffing, mandatory training, safeguarding, the management of physical health, environmental safety, risk assessment processes and incident reporting and management.
  • The trust did not always provide effective care. The trust had failed to appropriately monitor and deliver staff supervision and appraisal, and there were not audits in place to monitor adherence to the Mental Capacity Act. Specialist staff were not in place to deliver the range of care and treatment required.
  • There were some pockets of culture within the organisation which was not caring and compassionate. This included that staff had used non-approved restraint techniques on one ward, and that care plans were not entirely person centred and recovery orientated.
  • The trust was not always responsive to the needs of patients. Areas of the trust estate were not fit for purpose. Dormitory accommodation remained in use and the seclusion areas were not all private, comfortable and dignified. Some community services held long waiting lists and complaints were not always managed in line with the trust’s own policy and in a timely way.
  • The delivery of high quality care was not assured by the governance of the trust. There were low levels of staff satisfaction and the trust did not prioritise the supervision, training and appraisal of staff. Leaders did not always understand, manage and mitigate the risks faced by front line services. The information that was used to monitor performance and make decisions was not of high quality which had a direct impact on the quality and delivery of services. The trust had not addressed all the areas identified for improvement at the last inspection. Where leaders were cited on issues and risks they had not acted with enough pace to make required improvements.

However:

  • We rated forensic inpatient wards as good in the effective, caring and responsive key questions. The caring key question was rated as good or outstanding across the trust other than in acute wards and psychiatric intensive care units (this considered the ratings of services not inspected this time).
  • The trust encouraged staff to learn lessons from incidents and worked from a multi-agency approach to manage safeguarding across the organisation.
  • When serious incidents had occurred, the trust had taken visible action to mitigate risks and had complied with action plans in making service improvements in line with regulation 28 reports.
  • Staff interactions we observed during the inspection we kind, compassionate and respectful. The leaders of the organisation acted within the values of the trust.
  • The trust had good working relationships with partner organisations and was an active member of the accountable care partnership. The trust focussed on providing care across the city of Sheffield to meet the needs of the community.
  • The trust encouraged patient and carer engagement and actively sought feedback on services to make improvements. They encouraged patients to become active partners in their care. The strategy for quality improvement was underpinned by patient and carer feedback and involvement.
  • The trust were aware of the diverse needs of the population they served and put services in place to meet these needs.
  • The trust continued to have a partnership in Uganda to share teaching and learning.
  • Leaders were passionate about improving the care they delivered and keen to make improvements. They had attempted to seek assurance on the quality of care delivered via a variety of audits and research and via working towards the accreditation of some services.
  • Leaders were aware of some areas requiring improvement and had begun to take action. They were working on; rebuilding relationships with staff, organisational development (including board and council of governors) development, improving the quality of data, and replacing the trust information technology systems. The trust were in the process of revising their strategy.
  • The trust had maintained a strong financial position and there were limited cost improvement plans.

On the basis of this report, the Chief Inspector of Hospitals is recommending the trust be placed into special measures.

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.

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.