All inspections: Sheffield Health and Social Care NHS Foundation Trust

Sheffield Health and Social Care NHS Foundation Trust provides three acute inpatient wards for adults of working age and one psychiatric intensive care unit ward. Wards are located across two sites; The Longley Centre and The Michael Carlisle Centre.

The trust is registered to provide three regulated activities in relation to this core service;

Assessment or medical treatment for persons detained under the Mental Health Act 1983
Treatment of disease, disorder or injury
Diagnostic and screening procedures

We carried out this unannounced inspection because at our last inspection in May 2021 we rated the service as inadequate and issued the trust with a Section 29A warning notice indicating areas requiring significant improvement.

This was a full inspection of the service whereby we reviewed all the key lines of enquiry within all domains.

As part of this inspection we visited all four wards;

Dovedale Two ward – a 12 bed female acute ward located at The Michael Carlisle Centre
Stanage ward – a 16 bed male acute ward located at The Michael Carlisle Centre
Maple ward – a 17 bed mixed-sex acute ward located at The Longley Centre
Endcliffe ward – a 10 bed mixed-sex psychiatric intensive care unit ward located at The Longley Centre

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

Staff did not always assess and manage risks relating to patients’ physical health. Checks were not consistently completed on, and during, admission when patients had known physical health concerns.
Staff did not always ensure that the use of section 17 leave was safe and appropriate. We found occasions where staff did not record patient’s use of leave and their whereabouts to maintain safety.
Staff did not appropriately discharge their roles and responsibilities under the Mental Capacity Act 2005 and Mental Health Act 1983, as it was unclear how decisions were made regarding capacity and whether the principles of the Act were adhered to because it was not always appropriately documented.
Managers did not ensure that all staff received training, as bank and agency staff did not have to engage in the trust’s physical intervention training, and not all staff had received adequate levels of supervision.
Managers did not ensure that blanket restrictions on the wards were individually risk assessed and proportionate, and that their use was consistently applied. We were concerned about the restrictive nature of the care provided to patients admitted to beds in the health based place of safety suite.
Managers lacked oversight of some risks and concerns we found during the inspection. Governance processes were not always followed to ensure the safe running of the service. We found that there was no procedure or policy in place to guide safe staffing in the use of physical interventions, and the procedure in place for the management of beds in the health based place of safety used for acute admissions did not take into account the restrictive nature of the care of these patients.
Managers did not ensure that staff had access to shared learning in order to improve the service. Supervision rates were low, staff did not always have access to debrief following incidents and team meetings were not always planned, well attended and appropriately recorded.

However:

There had been some areas of improvement since the time of the last inspection and the service was compliant with the warning notice previously submitted.
The trust continued to make improvements to the ward environment, Burbage ward was closed for a full refurbishment and the temporary environment on Dovedale Two ward was an improvement. We found that the overall cleanliness and presentation of the wards was improved.
Mandatory training levels in the management of aggression and violence had improved since the last inspection and the majority of mandatory training had an improving compliance trajectory.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. 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 provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
Staff followed good practice with respect to safeguarding, treated patients with compassion and kindness and understood the individual needs of patients.

How we carried out the inspection

During the inspection we visited all four wards, looked at the quality of the environment and observed how staff were caring for patients. We spoke to 28 members of staff including ward managers, senior service managers, registered nurses, healthcare assistants, doctors, occupational therapists and psychologists. We spoke to 11 patients and 11 carers and family members of patients using the service. We reviewed a range of patient documents including care records, medication and physical health charts, and restraint and seclusion records. We attended five clinical meetings and reviewed a range of policies and procedures relating to the running of the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Patients were largely positive in their feedback about the service. Patients told us they felt safe and that staff treated them well and were supportive and caring. Patients could attend weekly multi-disciplinary meetings where they were encouraged to ask questions and offered advice and support around their treatment. Patients were largely positive about the food and activities available on the wards.

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.

We expect Health and Social Care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability or autistic people.

Our rating of this location went down. We rated it as inadequate because:

The service could not show how they met the principles of Right support, right care, right culture.
The service was not safe. Staff did not have the training and skills to care for people and respond to their needs. Medicines were not managed safely; there was no policy or protocol regarding people self-administering medicines or care plans for as needed medicines. Staff had not responded to safeguarding concerns and taken the necessary action to safeguard people from abuse.
The service was not effective. People did not receive person centred care; care plans were lengthy and people and those close to them were not involved in the development of their care. Staff did not have the specialist training to support people with a variety of needs. The multidisciplinary team was not effective, with a divide between the multidisciplinary team and nursing team. Patients did not receive outcome focussed care and treatment in line with national best practice. Communication was poor, staff providing the care were not up to date with the plans for each person at the service.
The service was not caring. We saw staff ignoring people’s request of basic needs of food and drink. Staff talked amongst themselves rather than engaging with people. Relatives were not involved in the care of their relatives.
The service was not responsive. Discharge planning was poor, and people had long lengths of stay. Relatives were not involved in the discharge planning for their relatives. Staff were not meeting the needs of people at the service, including those whose first language was not English. People were not supported to access meaningful activities and develop their skills in preparation for discharge.
The service was not well led. Governance processes had not ensured the delivery of safe and high-quality care. There was no ward manager in the service and the modern matron and general manager were new to their role. Meetings did not effect change; actions were not progressed following meetings. Staff did not feel supported in their role, they were not provided with the training and guidance to provide person centred, individually tailored care.

Due to the nature of our concerns, we have imposed conditions on the provider’s registration for this location which prevent the trust from admitting people to the service and require the trust to submit regular updates to CQC on the improvements made.

Culture

People experienced harm because of a lack of protection, they experienced abusive incidents, restraint and seclusion. People had poor relationships with staff which were not therapeutic. Care decisions did not prioritise people’s individual needs. People’s communication needs were not facilitated.

People did not receive person centred care; staff did not have access to the training to provide the knowledge and skills of how best to support people. People were bored and did not have access to meaningful activities including community access to develop their skills and prepare them for the future. People were in hospital for too long. Policies were not in place to progress people’s recovery. Including staff training in administering rescue medicine to people to enable them to access the community and people to be involved in self administration of medicines.

There was a lack of visible leadership, staff did not feel listened to, and management failed to act on known issues. People using the service did not see improvements in their care.

Background to inspection

The Assessment and Treatment Service (ATS) has seven beds and is commissioned to provide assessment and support to people with a learning disability or autistic people who are experiencing mental health needs and difficulties with behaviour where other services are not able to meet their needs and keep them safe. There were four people using the service at the time of the inspection.

The service has been registered with CQC since 2013. The service is registered to provide the regulated activities of:

Assessment or medical treatment for persons detained under the Mental Health Act 1983

Diagnostic and screening procedures

Treatment of disease, disorder or injury

There is a nominated individual at the trust with overall responsibility for the service.

The service was last inspected in October 2018 with a rating of good overall and requires improvement in safe. CQC issued requirement notices in relation to induction of staff, staff training in managing aggression and violence. Also, the review of incidents and sharing of lessons learnt. The service had not met all of the actions from the last inspection.

This inspection was an unannounced focused inspection of all the key questions, following concerns raised by the trust’s Director of Nursing in March 2021, staff and commissioners.

What people who use the service say

We spoke with two of the people at the service and observed the care being delivered to the other two people at the service using the Short Observation Framework for Inspection (SOFI) observation tool which is a structured way of observing staff interaction with people using the service.

People told us they were bored, they had been at the service too long and spent the majority of their time on their phone, listening to music or watching television. They said agency staff did not know them as well as permanent staff. Everyone was waiting to move to a new placement.

We observed negative engagement with another person at the service of staff not facilitating a request when they asked for a drink and staff talking and laughing amongst themselves rather than engaging with the person. Our observations showed positive engagement of staff playing football with one person at the service and responding to their request of accessing their iPad.

We spoke with five relatives. Four relatives were concerned about the care delivered to their relative, they did not feel that staff had the skills or knowledge to meet their needs and did not support their relative to progress and engage in activities they enjoy. Relatives did not feel involved in their relative's care and discharge planning, including multidisciplinary meetings. They did not get regular updates regarding their relative. When the had raised concerns, the service had not responded to them. Relatives told us that staff had been unprofessional and disrespectful regarding their relative, had not safeguarded them from improper treatment and did not support them with activities to develop their daily living skills in preparation for discharge. However, one relative felt involved in their relative's care and received regular updates from the service.

People were not always encouraged to give their feedback about the service. Weekly get together groups should take place to gain feedback from people at the service, however, minutes showed they took place 15 times in 24 weeks. Feedback was being collected individually at the time of the inspection as people found it difficult being in a group together, however we did not see evidence that their feedback was acted upon. One person said they found the ward environment very difficult especially sharing the space with other service users. Minutes showed limited discussion, several agenda items were blank with some actions not being achieved. However, the action of a DVD player was achieved.

Two people regularly completed the feedback form for the multidisciplinary team, prior to the meeting. Topics included activities, recovery goals, mood and feelings. Feedback forms showed that people did not know what their discharge plans were.

We did not re-rate this core service during this inspection. We found evidence that the service had improved.

Sheffield Health and Social Care Trust provides three acute mental health inpatient wards for adults of working age and one psychiatric intensive care unit. The wards can provide care and treatment for up to 64 patients. Services are provided at the Michael Carlisle Centre and Longley Centre as follows:

The Michael Carlisle Centre;

Burbage Ward – 19 bed mixed sex ward (Includes five detox beds)
Stanage Ward – 18 bed mixed sex ward

The Longley Centre;

Maple Ward – 17 bed mixed sex ward
Endcliffe psychiatric intensive care unit – 10 bed mixed sex ward

The service was able to admit patients who were detained for treatment under the Mental Health Act (1983), those with deprivation of liberty safeguards in place and informal patients. Most patients were detained under the Mental Health Act at the time our inspection, there were no patients with deprivation of liberty safeguards.

The inspection was undertaken between 25 August 2020 and 27 August 2020. We visited all four wards during this inspection as part of our focussed inspection of this service.

We conducted this focussed inspection due to serious issues raised at the last inspection in January 2020. At that inspection we issued enforcement action to the trust to tell them they must make improvements to improve the quality and safety of care.

We previously inspected the acute and psychiatric intensive care unit services in January 2020 and the service was rated as inadequate overall. We rated the service as inadequate in the safe and well led key questions and rated the service as ‘requires improvement’ in the caring, effective, and responsive key questions.

At the last inspection we issued warning notices. We found the trust to be in breach of regulations within the Health and Social Care Act (Regulated Activities) Regulations 2014 for the following reasons:

The trust must ensure that patients are cared for in environments which are private and dignified. This includes the removal of dormitory accommodation and ensuring the seclusion suites and CCTV cannot be overlooked and that patients’ access to toilet facilities is appropriate. (Regulation 10)
The trust must ensure that staff undertake physical health monitoring with all patients. This includes monitoring of long term health conditions, monitoring after the use of restrictive interventions, monitoring of the side effects of medication, and monitoring patients’ physical health needs in line with national guidance whilst undertaking inpatient detoxification. (Regulation 12)
The trust must ensure that it addresses the fire risk associated with patients smoking inside the wards. (Regulation 12)
The trust must ensure that the premises used for seclusion are suitable for the purpose of which they are being used, properly used, properly maintained and appropriately located for the purpose they were being used. They must be in line with the Mental Health Act Code of Practice. (Regulation 15).
The trust must ensure that staff report all incidents, including all incidents of rapid tranquilisation and restraint.
The trust must ensure that staff maintain an accurate and contemporaneous record of patient care including seclusion records in line with the Mental Health Act Code of Practice. (Regulation 17)
The trust must ensure that staff do not use non-approved restraint techniques including the use of mechanical restraint and in line with the trust’s own policy (Regulation 13)
The trust must ensure that it is able to meet the needs of all patients admitted to the ward and ensure that patients with complex needs which staff are unable to cater for are not admitted. (Regulation 9)
The trust must ensure that sufficient numbers of experienced and suitably qualified staff are available on all shifts, and that staff are able to manage the high acuity of the ward. (Regulation 18)
The trust must ensure that all staff complete mandatory training. (Regulation 18)

We reviewed each of these breaches of regulation as part of this inspection.

Since the last inspection we have received further information that has raised concerns about the ongoing safety of the service.

During this inspection, we inspected the core service and only the safe key question. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

Before the inspection visit, we reviewed information that we held about the service. During the visit, the inspection team:

looked around all four wards, including the external areas
looked at the seclusion room on each ward
checked all clinic rooms
reviewed a sample of seclusion records, restraint records and rapid tranquilisation records for patients
reviewed a sample of incident reports
reviewed a sample of patients’ physical health monitoring records
spoke with the ward manager, deputy ward manager or senior operational lead for each ward
spoke with nine patients and six carers
interviewed eleven other staff including pharmacists, nurses, a psychologist and support workers
looked in detail at the risk assessments of 16 patients
looked at policies, procedures and other documents relating to the running of the service.

We found that overall issues had improved since the last inspection. However, there were still some areas of concern where changes the trust had made required further embedding. This included issues relating to staffing, the environments, timely actions following incidents, physical health monitoring, restraint and privacy and dignity issues.

Sheffield Health and Social Care NHS Foundation Trust provides inpatient services for older people with mental health problems. The service is available to people over the age of 65 years old who have or may have a mental health illness and who live within the boundaries of NHS Sheffield Clinical Commissioning Group. The service is accessed primarily via the trust’s community mental health services for older people. The service also accepts referrals via adult and older people liaison psychiatry services and emergency referrals in consultation with the trust’s on-call registrar team.

The trust provides two wards for older people with mental health problems:

Dovedale ward is an 18 bedded ward for older men and women who require hospital care for acute functional mental health conditions. This may include the acute phase of a severe mental illness such as schizophrenia, bi-polar disorder or severe depressive disorder and for those with a dual diagnosis of severe mental illness and drug/alcohol, or learning disability, or people with personality disorder and acute mental health needs. The ward is based in the Michael Carlisle Centre in South-West Sheffield. Patients can be admitted voluntarily or detained on the ward under the Mental Health Act.
Ward G1 is a 20 bedded (funded for 16) ward for the assessment and treatment of older men and women with organic mental health conditions such as severe dementia and associated challenging or highly distressing behaviour. Ward G1 is divided up into two areas, G1a and G1b. The ward is based in Grenoside Grange Hospital in North Sheffield. The majority of patients are detained on the ward under the Mental Health Act.

We did an unannounced focused inspection of the wards for older people with mental health problems, this was because we issued a warning notice at our previous inspection in January 2020. The warning notice detailed that the trust must:

Improvestaff compliance with appraisals, supervisions and mandatory training.
Ensure that patients’ physical health needs weremetand medication side effects monitored.
Ensure that patients were cared for in environments which are private and dignified.
Ensure that systems and processes are in place which were operated effectively to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users in receiving these services.

We did not rate the core service at this inspection. We looked only at those areas detailed in the warning notice where we had significant concerns and wanted to check that the service had improved.

On the day of the inspection there were 11 patients on Dovedale ward, all detained under the Mental Health Act. There were 11 patients on G1 ward, of which ten patients were detained under the Mental Health Act and one patient was voluntary.

Prior to the inspection, we reviewed all the information we held about the service.

During the inspection visit, the inspection team:

spoke with both ward managers;
spoke with seven other staff members;
reviewed the risk management plans of 12 patients;
reviewed the observation records of 12 patients;
reviewed the seclusion records of six patients;
attended a staff safety huddle;
looked at a range of policies, procedures and other documents relating to the running of the service.

We found:

Since our last inspection, both wards had made improvements. Staff had implemented these improvements during the COVID-19 pandemic which affected both wards impacting on their substantive staffing levels.
The service provided safe care. Staff assessed and managed risks well and received the basic training to keep patients safe from avoidable harm. The wards supported patient’s privacy and dignity and no longer relied on dormitory accommodation. Staff monitored patients’ physical health and the effects of prescribed medications.
Managers ensured staff received training, supervision and appraisal.

Sheffield Health and Social Care NHS Foundation Trust provide a range of mental health, learning disability and substance misuse services to the people of Sheffield.

The trust has four teams that make up the crisis services and they operate one health-based place of safety, which can accommodate two people and a Psychiatric Decisions Unit which can accommodate up to 10 service users. This inspection focussed on the Psychiatric Decisions Unit based at the Longley Centre.

We carried out an unannounced focussed inspection of mental health crisis services and health-based places of safety because we took enforcement action by issuing a warning notice following our previous inspection in January 2020. We did not rate the core service at this inspection. We looked only at those areas detailed in the warning notice where we had identified significant concerns and wanted to check that the service had improved. Our inspection looked at specific areas of the safe, effective and well-led key questions.

During the inspection visit, the inspection team:

spoke with three patients who had recently used the service
spoke with the service operational manager
spoke with five other staff members including nurses and support workers
reviewed the risk management plans of four patients who had recently used the service
looked at a range of policies, procedures and other documents relating to the running of the service.

We found:

The trust had addressed the safety concerns identified in the warning notice issued following the last inspection by making improvements to the physical environment of the Psychiatric Decisions Unit, implementing processes to keep young people safe, and ensuring staff completed their mandatory training.
The trust now ensured staff received an annual appraisal and regular ongoing supervision.
Our findings from the other key questions demonstrated that governance processes had improved and operated effectively at team level to manage performance and risk well.

However:

There was low compliance with some mandatory training courses due to the impact of the COVID-19 pandemic.

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.

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.

However:

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.

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.

However:

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.

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

The ward environments were not always safe and clean. Although the wards had enough nurses and doctors, a large proportion were newly qualified. Demand on staff time, acuity and staffing levels remained a constant challenge. The service used agency staff who were not always suitably trained to the requirements of the wards.
Patients subject to restrictive interventions, such as seclusion or rapid tranquilisation, did not always receive appropriate monitoring or support. Two of the seclusion suites did not meet the requirements of the code of practice.
Staff did not always manage medicines safely and follow good practice guidance when managing safeguarding concerns.
Patient care plans were prescriptive and did not show how patients were involved in their care and treatment.
The service was over occupancy on beds and there was constant pressure on the system when someone required an inpatient bed.
The trust had not responded effectively to issues and risks which had been identified and governance processes did not always identify issues.

However,

Staff provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of 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 training, 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 and understood the individual needs of patients. They actively involved patients, families and carers in care decisions.
The service had a positive and proactive approach to least restrictive practice.
Staff assessed and managed risk well. Patients had a comprehensive assessment of their needs and staff completed care plan goals to meet these needs.

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

We issued a warning notice under Section 29A of the Health and Social Care Act in relation to this service. This limited the rating in this key question to inadequate.
The service did not provide safe care and treatment. Staff did not assess and manage risk to patients waiting for services. The service had low rates for mandatory training compliance in specific courses which meant the service did not have enough staff who knew the patients and received basic training to keep people safe from avoidable harm. The service did not always recognise and act on incidents which highlighted a risk to patient safety, such as allowing the admission of young people to shared accommodation with adults in the Psychiatric Decisions Unit. The service did not use serious incidents as a method of learning and act to make the required improvements to care.
The service did not consistently provide effective care and treatment. Managers did not consistently support staff with regular supervision. Not all staff had received training in the Mental Health Act, and the service did not audit its adherence to the Mental Capacity Act. The service did not have access to all the required specialist staff to meet the needs of patients because there was a lack of availability of Section 12 Doctors which caused delays in assessment.
The service was not consistently responsive to peoples’ needs. The design, layout, and furnishings of the Psychiatric Decisions Unit did not ensure that people using it could maintain their privacy and dignity. Care was not always available due to closures of the health based place of safety.
The service was not well-led. Our findings from the other key questions demonstrated that governance processes did not operate effectively at team level to manage performance and risk well. Leaders had not ensured there were structures, processes and systems of accountability for the performance of the service and to identify, understand, monitor, and reduce or eliminate risks. Staff did not know the trust’s vision and values and how they were applied in the work of their team.

However:

The physical environment of the health-based places of safety met the requirements of the Mental Health Act Code of Practice.
Staff from different disciplines worked together as a team to benefit patients.
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.
Leaders had the skills, knowledge and experience to perform their roles and staff felt respected and valued.
Staff felt able to raise concerns without fear of retribution and knew how to contact the trust’s freedom to speak up guardian.
The services met the needs of all patients who use the service – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural support.

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

The service did not provide safe care and treatment. Staff did not assess and manage risk to patients and themselves well. Staff did not complete and record patients’ observations in line with prescribed observation levels. The service had high rates of vacancies and sickness and low rates for mandatory training compliance in specific courses which meant the service did not have enough staff who knew the patients and received basic training to keep people safe from avoidable harm. Staff did not report incidents consistently and there was limited evidence of staff using incidents to improve practice.
The service did not consistently provide effective care and treatment. The range of treatment and care did not meet national guidance and best practice. Managers did not consistently support staff with regular supervision. Staff did not record consistently decisions made in patients’ best interests appropriately.
The service was not consistently responsive to peoples’ needs. The design, layout, and furnishings of Dovedale ward did not consistently support patients’ treatment, privacy and dignity. The service relied on dormitory accommodation to provide four of the eighteen beds on Dovedale ward which meant not all patients had their own bedroom with an en-suite bathroom.
The service was not well-led. Our findings from the other key questions demonstrated that governance processes did not operate effectively at team level to manage performance and risk well. Leaders had not ensured there were structures, processes and systems of accountability for the performance of the service and to identify, understand, monitor, and reduce or eliminate risks. Staff did not know the trust’s vision and values and how they were applied in the work of their team. Staff did not know how to use the whistle-blowing process and about the role of the Speak Up Guardian.

However:

Staff were caring. Staff were respectful, responsive and treated patients and families with compassion and kindness. Patients and carers were positive about the service. Staff involved patients and families in making decisions about their care and in shaping the future of the service.
The service was responsive to peoples’ needs.

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

Staff were struggling to deal with the volume of calls to the crisis service. The team had no way of knowing how many people had not been able to access the service. The service had a significant waiting list and the telephone system was not fit for purpose in that people could not always get through.
There was a significant delay in patients receiving a timely Mental Health Act assessment. At the time of the inspection there were 13 people awaiting a Mental Health Act assessment.
Staff were not always given the time to fully review triage/risk information before providing care, treatment, and support. Patients had to repeat information or answer the same questions during assessments.
Staff were providing a range of care and treatment interventions but this was not always documented in a written care plan.
Multidisciplinary team meetings at Netherthorpe House took place regularly but their effectiveness was limited. There was no clear focus and meetings were held at the same time that assessment appointments took place, which meant that some staff could not attend.
There was mixed staff morale across the teams. Some members of the single point of access/emotional wellbeing team did not feel valued or supported by the trust.

However:

The trust had responded to the last inspection and made improvements to the health-based place of safety. Staff were now completing risk assessments, and carrying out physical health checks and observations as required. There were monthly audits of the activity in the health-based place of safety. Joint liaison meetings were taking place with representatives for all agencies.
Although some staff did not feel valued, senior managers were aware of the issues in relation to the single point of access/emotional wellbeing service. Issues regarding the service were included on the risk register. Weekly meetings were taking place and plans for a crisis hub were being developed.
Staff carried out an initial triage for all new referrals. Any emergency referrals were offered an assessment within four hours and any routine assessments were allocated to the emotional well-being service. All records reviewed contained a risk assessment.
Staff were up to date with mandatory training and were receiving regular supervision and appraisals.
The issues with the telephone system had been escalated and the trust had put some mitigation in place to support the system.

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

The wards were bright, clean and well maintained.
Each ward had a ligature risk assessment.
Staff safeguarding training was at 95% and staff were aware of how to raise safeguarding concerns.
All patient care plans that we reviewed were personalised, holistic and recovery focused.
Multidisciplinary team meetings were patient focused.
The culture within the service was a very positive one with staff being complimentary toward the managerial staff.

However:

Dovedale ward’s records of emergency equipment being had gaps which showed that checks were inconsistent.
The walkway to the garden on Dovedale ward was slippery and could be dangerous for patients.
The rate of clinical supervision for staff was below the trust target.
Although good practice in relation to delayed discharges had been implemented across both wards, G1 ward had a disproportionate number of delayed discharges due to the nature of the patients.

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

The service buildings were clean, tidy, wheelchair accessible and staff carried out environmental risk assessments and health and safety tests were up to date.
Staff ensured that patients could provide feedback on the service they received. The feedback that we collected suggested that staff treated people with kindness, dignity and respect and were polite, caring and compassionate. The service ensured that patients had access to advocacy, signers, translators, spiritual support and speech and language therapists.
Staff responded quickly when patients’ health deteriorated, prioritised urgent referrals, encouraged patients to attend healthcare appointments and encouraged them to lead healthier lifestyles. Staff communicated with patients with communication issues using cue cards, easy read information and translators. They engaged with patients who failed to attend their appointments and supported patients in accessing education and work opportunities.
Staff were skilled and experienced, were appraised and had access to specialist training for their role. Staff knew about safeguarding, whistleblowing, the duty of candour and handling complaints. Staff reported incidents appropriately and told us that they could raise concerns without fear of reprisals.
Staff had a good understanding of the Mental Health Act and the Mental Capacity Act. We saw evidence in patients’ care records that staff had undertaken mental capacity assessments when this was indicated. Staff involved other professionals within and external to the team when appropriate and helped patients to make decisions on their own behalf.
Staff had carried out a range of clinical audits within the service between February 2017 and May 2018, including an audit in relation to the identification of carers and assessment of their needs. Staff were given opportunities to consider ideas for improving and innovating and participated in national audits.

However:

The clinic room was too small for patients to receive depot injections in a seated position at the Mental Health Recovery North service.
Staff at the Mental Health Recovery North service were not up to date with their mandatory training. Staff sickness absence rates were high at the Mental Health Recovery North and Home Treatment Team services which resulted in poor staff morale. Staff told us that their caseloads were high.
Staff at the Mental Health Recovery North service did not update patient care plans or risk assessments regularly.

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

Staff participated and worked with outside agencies to promote and deliver the Stop Over Medicating People with a Learning Disability (STOMP) initiative. This is aimed at reducing the use of anti-psychotic medication for people with learning disabilities.
Since our last inspection, the trust had undertaken work to build seclusion room and a new clinic room to improve patient care and experience. The service also met the King’s Fund ‘enhancing the healing environment’. The trust had implemented safety huddles within staff handover meetings to try to improve staff and patient safety and managers had introduced other measures to try to improve safety on the ward.
Staff understood their responsibilities and had sound understanding of the Mental Health Act, Mental Capacity Act and safeguarding. Patients had access to a full range of multi-disciplinary professions and care plans were comprehensive and recovery oriented.
All of the patient care and treatment records that we reviewed contained comprehensive assessments and holistic recovery oriented care plans.
Observations showed positive interactions between patients and staff. Feedback from patients was positive about how staff supported them. Patients felt involved in their care and treatment and all patient care and treatment records contained comprehensive and holistic care plans. Patients left positive discharge messages for others.
Staff understood the trust’s visions and values and how they applied to their work.

However:

Managers did not always have effective oversight of the service. At the time of our inspection, there were 71 incidents which required manager review. This is something we told the trust they should address following our last comprehensive inspection.
Not all staff had received an induction or completed all of their required training before starting work on shift. Three training courses fell below 75% compliance and only 56% of staff were receiving clinical supervision in line with trust policy.
Shortages of staff had an adverse impact on the quality of care. Support staff could not always attend multi-disciplinary meetings or be actively involved in other reviews of patients’ care and treatment. This problem was compounded by a high rate of sickness.
There were deficits in the induction and training of staff. Some staff had not completed induction or mandatory training before working shifts on the ward. There were thirteen shifts over a three-month period that did not include the minimum required number of staff who had completed training in managing violence and aggression and restraint. This posed a particular risk because the service was standalone without surrounding staff who could assist in an emergency.
Carers did not always feel that staff listened to them and not all staff received feedback on the outcome of complaints.

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

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.

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

A high number of posts for qualified nurses were unfilled and there was a reliance on bank and agency staff to maintain safer staffing numbers. Despite the use of bank and agency staff, there was not always the required number of staff on duty to undertake physical interventions safely.
Demand on staff time, acuity and staffing levels remained a constant challenge.
Staff did not always manage medications correctly.
Staff did not receive regular clinical supervision.
Patients subject to restrictive interventions, such as seclusion or rapid tranquilisation, did not always receive appropriate monitoring or support.
Safeguarding procedures for children visiting the service were not always robust.
The service was not always well led. The service did not effectively use its systems and processes to ensure actions were identified and change was implemented. Audits within the service were not regularly completed or effective at identifying issues.

However:

The service had a positive and proactive approach to least restrictive practice.
The service undertook comprehensive assessment of patients’ mental and physical health upon admission to hospital. Assessment and management of patient risk was thorough.
Staff received mandatory training and annual appraisal.
The trust promoted a culture that supported and valued staff. Staff across the service were committed to delivering the best quality care.
Patients and carers spoke positively about the service. Engagement by the trust was good.

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.

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

Staff did not provide information in alternative formats or languages. There were no information leaflets for patients whose first language was not English. Patients were not asked if they wanted to receive information in alternative languages or formats.
Patients did not have access to nurse call systems. None of the rooms within the service was fitted with nurse call systems and patients were not provided with any form of hand held or personal device. This meant that patients could not summon help if they needed it.
The service produced a ward booklet for patients, which provided patients with the rules, and restrictions in relation to smoking but staff did not follow these. The implementation of the policy relating to contraband items was delayed as the ward manager was not aware of any updates.

However:

Since our last inspection, work had been carried out to reduce ligature risks in the service. All the bathrooms in the service had been refitted with anti-ligature fittings. The doors in the service were in the process of being refitted with anti-barricade doors that had anti-ligature fittings.
Patients were able to access courses through a recovery college, which allowed them to learn about their illness or gain recognised qualifications.
Staff had a good understanding of the Mental Health Act, Mental Capacity Act and safeguarding.

We rated acute wards for adults of working age and psychiatric intensive care units as good because:

The wards had scored above the national average in all areas of the patient led assessment of the care environment.
The trust was trialling the use of an electronic tablet to record patient observations. This meant that clinical records accurately reflected the time that a patient was observed and what activity they were undertaking at the time.
The trust had effective systems for managing inpatient admissions and discharges. This meant they had managed to reduce the overall number of beds in the acute care pathway but could increase capacity as demand increased.
Because of good capacity and demand management of inpatient beds, no patient had been admitted to an acute admission bed outside of the Sheffield area in the last two years.
There were detailed and comprehensive care plans and risk assessments in place and these were being regularly reviewed. Patients told us they felt involved in their care planning and discussions about their progress.
There was access to multidisciplinary interventions which included medical, nursing, and psychological and occupational therapy. Care and treatment was evidence based and followed recommendations in national guidance.
Each of the wards had a sensory room. Patients who were upset or agitated could use this dedicated room. The rooms had comfortable relaxing cushions and chairs, muted lighting and soft music. The rooms gave patients somewhere safe to go where they could implement a range of strategies, based on mindfulness, to help them through their crisis.
Regular audits were being undertaken and improvements made based on the outcomes identified in those audits.

However:

Some of the ward environments were not safe. All of the bedrooms contained potential ligature anchor points. Stanage and Burbage Wards did not comply with guidance on the elimination of mixed-sex accommodation. The seclusion rooms on Burbage, Stanage and Maple Wards did not comply with the Mental Health Act code of practice.
The trust had identified mandatory training for staff but compliance with undertaking this training was below the trust target. Although improvements had been made in the preceding months, at the time of inspection, the wards were not achieving the trust target of 80% staff receiving regular supervision.

We rated wards for older people with mental health problems as good because:

Patients’ records contained comprehensive risk assessments, which staff regularly reviewed. These included falls and dysphagia risks. There was falls prevention equipment in both wards. The environment was clean and well maintained.

Multidisciplinary team meetings included all the professionals involved in the patient’s care. Patients could attend if they wished. Wards had psychologists who supported staff and patients, including formulation meetings. There was good access to dieticians, tissue viability nurses and continence nurses.

Mental Health Act documentation was in order. There was a good system in place to ensure the timely review and renewal of patients’ detention documentation. Patients were regularly informed of their rights. Decision specific mental capacity assessments were carried out and recorded.

Patients were at the heart of their care and treatment and staff clearly knew patients well. Staff involved patients, where possible, and carers in care planning. A new system had been developed to show where patients had been able to engage in the process. Carers and relatives were kept updated. Community meetings were inclusive.

There was a very good programme of meaningful activity. Innovative ways of communicating with patients had been developed. These included, utilising electronic technology, a ‘paro seal’, an interactive tablet and simulated presence therapy. Outside space was used to enable patients to take part in gardening and growing fruit and vegetables. Patients were involved in baking for themselves and others. There were breakfast groups and various discussion groups. Activities were tailored to individual patient needs. The local community and external organisations were involved with services. Staff were supported in developing new ways to engage with patients.

There were no complaints and a large amount of compliments.

Governance systems were robust at G1 ward, Grenoside Grange. There was a locally developed monitoring system which included, incident monitoring, training, supervision, length of stay and discharge.

Staff reported good morale across both wards and managers felt supported by senior managers. Staff had been involved in research and a new way of measuring outcomes for patients living with dementia had recently won an award.

However:

Dovedale ward at the Michael Carlisle Centre did not comply with guidance on eliminating mixed sex accommodation. Male patients were allocated bedrooms in areas of the ward designated as female areas. Female patients had to walk through the areas designated for male patients to access communal facilities.

G1 ward at Grenoside Grange had a seclusion room which did not comply with the Mental Health Act Code of Practice. There was no two-way intercom, no externally controlled heating and blind spots in the room.

Mandatory training compliance was not within trust targets.

On Dovedale ward patients' privacy and dignity was compromised due to there being clear glass on the doors leading from the public area of the hospital into the patient bedroom corridor. This meant that patients could be seen by members of the public walking by to other areas of the hospital. The trust rectified this on the day of our inspection.

The trust had responded to concerns we had raised at previous inspections, and we could see improvements in the service.
The service had no delayed discharges at the time of inspection, and no patients had been readmitted to the ward within 90 days of discharge. However, the average length of stay for patients was 326 days which is above the national average.

Staff were responsive to patients’ needs and treated them with dignity and respect at all times.

The use of positive behaviour support plans and techniques enabled staff to effectively understand, anticipate and meet patients’ needs, which reduced incidents and promoted patients’ wellbeing.

There were different types of therapy available for patients including enhancing daily living skills through active support, practising mindfulness techniques and adapted cognitive behavioural therapy.
A patient community group called ‘Rainbow’, met every two weeks looking at menus and what activities patients wanted to do. The trust told us that they also discussed patient experience and inclusion.
Staff told us that local managers and the senior managers from the learning disability directorate were supportive and worked as part of the team.
The trust provided counselling support for staff. They also offered group work to look at how to manage stress at work.
Learning from complaints and incidents was good at ward level. The multidisciplinary team discussed incidents, including restraint and staff looked at how they could improve their practice following an incident. Patients were also included in debrief sessions following incidents.
Staff had received training in positive behavioural support plans and had a good understanding of the patients’ plans. The use of individual positive behaviour support plans are considered best practice when supporting patients who may have challenges communicating and understanding what is happening.

However:

Staff did not consistently carry out two-stage assessments of patients’ capacity to make specific best interest decisions, in line with the Mental Capacity Code of Practice. However, staff did use all tools available to them such as pictorial leaflets and sign language specialists to support patients to make decisions about their care and treatment.
Medication was stored in and administered from the main office on the ward. This posed a risk to patients because staff could not monitor infection control. It also meant that they had to prepare medication for the patients in a busy environment and whilst we did not see any this could lead to errors.
The completion levels for the mandatory training for autism awareness, dementia awareness and Deprivation of Liberty Safeguards were below 54%. The trust had a training target of 75%.

Whilst the trust’s policy on aggression and violence did not stipulate how many trained staff were deployed on the ward, staff told us that they did not always feel safe with fewer than three staff trained by the RESPECT trainers. We saw that this had only happened on three occasions in the three months prior to our inspection visit.

We rated long stay/rehabilitation mental health wards for working age adults as requires improvement because:

We found that the trust could not always maintain safe staffing levels for the intensive rehabilitation service. The service had a high vacancy rate of 17% for qualified nurses and 27% for nursing assistants. The service had eight instances between February and October 2016 where one nurse was left to cover two or more units. One recent instance had left a member of staff lone working on a unit for five hours.
We identified several concerning issues in the intensive rehabilitation service. Average compliance with mandatory training was below the trust target. We found issues with safety in the prescribing, administration and monitoring of medication. Not all premises were clean. Cleaning records had gaps and did not accurately reflect the cleaning on the units.
The community enhancing recovery team had not responded appropriately to a patient who made disclosures to several members of staff. Managers had dealt with the safeguarding concern without consulting with the trust safeguarding team, making a report on the trust incident reporting system or documenting formally their response. The service did not provide any feedback to the patient.
The intensive rehabilitation service and the community enhancing recovery team did not have an effective governance system in place. The services were unable to respond quickly to requests for information from the inspection team. The intensive rehabilitation service did not have an effective quality assurance process to identify the impact of issues with medication management, recruitment of staff, training provision and the management of risks to staff and service users. The community enhancing recovery team did not have an effective system which documented safeguarding concerns. Neither the intensive rehabilitation service nor the community enhancing recovery team were compliant with the trust’s supervision policy.

However:

The intensive rehabilitation service had worked to address the issues with care planning identified in the previous inspection which meant that care planning had improved. Care plans were holistic and recovery-orientated with all plans focussed on achieving eventual discharge.
The community enhancing recovery team had a well-established partnership with South Yorkshire Housing Association. The partnership meant that 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
Almost all patient feedback was positive about both services. Patients in the intensive rehabilitation service told us that staff always had time for patients and that staff encouraged patients to push themselves in their recovery. Interactions between patients and staff in the community enhancing recovery team were respectful and friendly.
Staff in both the intensive rehabilitation service and the community enhancing recovery team had a good understanding of the trust vision and values. They were able to describe how these guided the work of the services.

We rated community based mental health services for adults of working age as good because:

The teams we visited included a full range of staff disciplines. Staff worked in a collaborative manner and were flexible in their approach across the different functions delivered in each location. This meant a patient’s treatment journey was seamless from referral to discharge.
The duty teams responded to urgent referrals without delays. They included staff across the different functions and in various disciplines. This meant that they were able to respond quickly to queries from GPs, patients and carers.
Staff across the teams were introducing new collaborative care plans for all patients. These plans included holistic and personalised interventions and were being used as a live document for all staff.
Managers shared lessons learnt from incidents and complaints through team meetings, emails and supervision. They facilitated staff development days and sessions within each function area and across full locality staff. These days enabled staff to share good practice and specialised knowledge. Staff felt supported and were able to develop any specialist areas of interest.
Staff were respectful and supportive in their interactions with patients. They considered the needs of families and carers and involved them in the patient’s care where this had been agreed.Patients co-produced their care plans and were empowered to maintain independence.
Staff were mostly happy in their roles. They felt involved and had opportunities for development.

However:

Staff had not completed mandatory training units required by the trust. This meant that they were not always confident or knowledgeable in carrying out the duties necessary for their roles. In particular, staff did not always embed capacity or consent consideration, or safeguarding discussions into their everyday practice.
The community teams all had waiting lists for a patient’s first appointment and the commencement of treatment. The waiting lists were up to nine weeks.Whilst staff ensured patients already in treatment received regular care plan and risk assessment reviews, patients on the waiting lists were not monitored. This meant that staff did not detect changing levels of risk for patients waiting to be seen.
Lone working protocols were mostly reliant on a buddy system. This meant that if the buddy was otherwise distracted, there were no other safety checks on a staff member’s welfare.
Not all patients’ needs were reflected in their care and treatment plans. In particular, patients’ needs around ongoing physical health monitoring and holistic recovery orientated objectives. The trust had recognised this and were implementing improvements. However, these improvements were still in their infancy and therefore not evident for all patients across the teams.
Managers had limited oversight of their team’s performance. They were unable to use the trust’s systems to extract information relating to their service and had developed localised systems which varied from information collated at trust level.

We rated mental health crisis services and health based places of safety requires improvement because

Arrangements were not robust to keep people safe at all services. Not everyone using the place of safety had a risk assessment in place, evidence of physical health checks or a record of their observation levels. There was no information within the liaison team about the mitigation required to ensure people’s safety in relation to identified ligature risks.
Robust governance structures were not in place within the out of hours service. The team did not have systems to routinely review and monitor service performance and capture feedback. The team felt disassociated from the wider trust. There was limited evidence of sharing learning from incidents amongst all teams.
Documentation within the place of safety was currently in paper format with mental health assessment paperwork held electronically. Paper records were not always complete and some records contained omissions such as times, dates and names.
Not all staff had completed necessary mandatory training. Staff supervision did not meet trust targets for the place of safety and liaison team. Formal supervisions had only recently been implemented in the out of hours team.
There was no single twenty four hour crisis provision in operation which meant people had to access different services for support. Some people using the out of hours service said there were delays and omissions in receiving call backs. The teaching hospital said wait times for people to be assessed in the emergency department by the out of hours team had improved but were still lengthy. People reported waits of several hours to be assessed in the place of safety.

However:

There was good feedback from people who had accessed the service. Most felt staff were kind, caring and supportive to their needs and carers spoke highly of the staff and service. We observed positive feedback between staff and people. Staff were respectful, listened, and worked collaboratively with people to determine what support they needed.

We saw good evidence of risk assessment and consideration of risks within the out of hours and liaison psychiatry teams. Staff undertook assessments of people’s needs which they used to signpost people on for longer term support. Handover systems allowed staff to share necessary information between teams.
There were effective working relationships between the teams who often supported the same people. There were also good working relationships with other agencies such as the police and the teaching hospital. Staff morale was good and staff spoke highly of their team colleagues’ passion and professionalism.

We rated community based mental health services for older people as good because:

The multidisciplinary approach to care was consistent and positive. Staff across the services managed risk effectively and reviewed patients’ risk regularly. They provided safe care and supported patients well.
Staff undertook a comprehensive assessment of the needs of patients and carers.They provided care and treatment that was effective, recovery focussed and met the needs of patients. Staff used best practice guidelines to deliver effective care and treatment.
Staff inspired confidence in patients and carers. Staff treated patients with kindness, dignity and compassion. Relationships were built on a mutual respect for each other.
The service had a co-ordinated approach to managing referrals and care pathways were clear and responsive to the needs of patients.
Complaints about the community based mental health service for older people were exceptionally low and compliments were high.
The needs of carers were consistently addressed by the service and this was supported by the role of carer liaison practitioner.

However:

Compliance with mandatory training was low.

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.

However:

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.

We rated forensic inpatient and secure wards as good because:

Staff treated patients with kindness and respect. Carers and most patients gave positive feedback about the care and treatment they received. Staff involved patients in meetings about their care and treatment.

Staff completed a comprehensive risk assessment prior to patients taking authorised leave. The wards had low incidents of restraint, seclusion and use of rapid tranquilisation.
Staff informed patients of their rights under the Mental Health Act at regular intervals and records contained valid consent to treatment documentation.
A multidisciplinary team was involved in ward rounds and bed management meetings to manage care and treatment to current and prospective patients collaboratively.
Staff felt supported by their managers and colleagues. All staff received regular supervision and appraisal.
Patients had access to advocacy involvement and an advocate led patient community meetings on the wards.

However:

Systems did not ensure that staff received mandatory training and sufficient staff to provide care and treatment on the wards. The overall training compliance rate was 57%. A number of shifts did not have enough staff to provide care and treatment.
Staff imposed a blanket restriction in relation to the searching of patients on return from unescorted leave. The assessment ward had an illogical restriction where staff denied patients access to the tea pantry on the assessment ward. Staff did not undertake an individual risk assessments when applying these restrictions.
The seclusion suite and its use did not comply with the Mental Health Act code of practice. Staff could not see patients in the toilet area of the seclusion suite. A door to the bathing area in the seclusion suite could be used by patients to harm themselves or others. Independent multidisciplinary team reviews did not always take place for episodes of seclusion in line with the Mental Health Act code of practice.
Ward environments had a number of ligature risks which included taps and door handles. Environmental risk assessments did not identify the precise locations of ligature risks and risk management plans contained limited information to explain how staff managed and mitigated identified risks.
Patients sometimes received their medication from the nurses' station on the rehabilitation ward and the clinic room door on the assessment ward. This did not promote privacy and dignity.
Patient involvement in care planning was limited and only one patient told us that they had a copy of their care plan.
Patients did not have a dedicated space to practice their religious and spiritual beliefs.
Activity timetables in place at the time of the inspection were dated months previously. Activities provided took place mainly between Monday to Friday each week. Some patients told us that they felt bored of the activities available.
The average waiting time from referral to assessment was 50 days for the assessment ward and 127 days for the rehabilitation ward.

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.

However:

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.

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.

We undertook an inspection of the Intensive support service between 27 and 30 October 2014. At this inspection we identified serious concerns that we escalated immediately with the trust. We asked the trust to put in place immediate actions to address these concerns. The trust provided CQC with an action plan before the end of the site visit period of the inspection.

At the national quality assurance group it was identified that to be proportionate CQC would need to re inspect the service before issuing the report. The CQC waited until the action plans had been completed and re inspect the service on 16 June 2015. At this inspection we found that the trust, senior management and the staff on the ward had made significant changes to the service being provided. This report identifies our findings at the time of the initial inspection and in bold our findings at the time of the follow up inspection to demonstrate what was found and the remedial action the trust has taken to address these concerns.

We found overall the quality of care provided by the intensive support service (ISS) at our initial inspection was inadequate.

We found that overall the quality of care provided by ISS had improved at our follow up visit and now required improvement.

Arrangements in place to ensure patient’s safety were unsatisfactory. Risk assessments had been completed to ensure the physical environment was safe and suitable. However where concerns had been identified these had not been actioned. We also found risks during our observations of the ward which had not been identified through the ward risk assessments or on the ward risk register.

Risk assessments had been completed. These were full and comprehensive including patient accessible areas, these also included assessments of ligature points. These were completed on 14 May 2015

One male patient was in a bedroom on the female side of the ward even though there was a vacant male room available. There was a female only lounge on the male side of the ward.

The accommodation has been designed to form two ‘wings’ with three individual, en-suite bedrooms (total six) and, two independent flats thereby supporting segregation. Each three bedded ‘wing’ has an allocated women-only lounge area.

Staff employed at the service did not have all the necessary skills and competencies to work with patients on the ward. For example staff had limited capability to communicate with patients who had little or no speech. We also observed staff had limited understanding of autism and this was demonstrated from their lack of awareness of the importance of visual prompts, engagement in meaningful activities and assessment of sensory impairments as well as implementation of coping strategies for patients who become anxious and distressed.

The service had recently identified and sourced autism and sensory needs training and were waiting for dates to be agreed. They had also identified two staff to undertake Makaton training to then cascade this training to other staff. The speech and language therapist had also undertaken some training immediately post inspection around communication with 15 staff.

Care plan evaluation and insight recording had also been completed Safeguarding information had been produced in an accessible format

Positive behaviour support (PBS) training had also been sourced and one staff was undertaking this in July 2015 accessed through the British institute of learning disabilities. Two further staff were undertaking the next steps in PBS and a further 19 were undertaking PBS next steps training.

Staff were unaware of this unannounced visit and we found that therapeutic activities for the patients were taking place

We found care planning and risk assessments were inadequate. Care plans were not holistic, personalised or recovery focused. The service did not embed best practices such as positive behaviour support, health action plans or Valuing People Now.

Work has been undertaken on training staff to write care plans by putting in place a framework for them to work to. Care plans and risk assessments had been updated and we found input from the patients, we reviewed all of the patients on the wards case notes. Positive behaviour support training was planned which would be delivered to the whole staff group. Dates for this further training for all staff had not been set.

Patients were poorly engaged in relation to consent to care and treatment. Patients were not involved in multi-disciplinary meetings despite their care and treatment being discussed.

We found that patients and their advocates and family were engaged in consent to care and treatment. This was recorded at their involvement in Multi-disciplinary meetings.

Although we did observe some positive interactions between staff and patients such as patients being spoken to discretely by staff, the majority of interactions were poor. We observed for a period of hours patients were left wandering corridors without any activities to engage in. Patients were ignored by staff when they stood at office windows for long periods of time or knocked on the office door.

We saw therapeutic activities taking place on the ward. Patients were engaged and staff interactions we observed were positive.

Care plans were not in accessible formats or person centred. They did not include goals, aspirations and coping strategies. There was an absence of advocacy and the service was not actively promoted on the ward.

Care plans were in an accessible format and we also saw that health action plans, hospital passports and health action plan summaries were in place. Discharge planning occurred at point of admission.

We looked at how discharge was planned and how recovery focused the service was. What we found was inadequate. Discharge was not planned at the point of admission which meant it was unclear what patient’s length of stay was likely to be. The ward environment did not optimise recovery because patients had limited access to facilities which promoted their independence and enabled them to learn new skills. Patients were unable to participate in basic tasks such as making a drink without staff supervision.

Discharge was now being discussed from the start of the admission and we saw evidence of this in all of the care notes. We also found that delayed discharges had been escalated to managers of services, health and social care commissioners and recorded within safeguarding procedures.

Most areas on the ward were now open to patients including two flats that included kitchens .

The intensive support service was poorly led. Staff were unclear about the organisation values and behaviours. There were staff vacancies, gaps in training, the ward office was disorganised with filing trays full of patient confidential information and an overall lack of oversight to the poor care patients received.

We found that the ward manager and her line manager had made significant progress since our inspection. The ward office was now ordered and all staff had identified drawers and no confidential information was visible from outside the office. All out of date information had been removed from the walls and new noticeboards had been put on display and included up to date information. There were also new signs which clearly displayed the menu, activities and which staff were on duty.

Following our inspection we requested an immediate plan from the provider detailing how improvements would be made.

There had been significant improvements made against the submitted plan since the time of our last 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

Download full inspection report for - PDF - (opens in new window)

Published 9 June 2015

All Inspections

Discharge was now being discussed from the start of the admission and we saw evidence of this in all of the care notes. We also found that delayed discharges had been escalated to managers of services, health and social care commissioners and recorded within safeguarding procedures.

Most areas on the ward were now open to patients including two flats that included kitchens .

Longley Meadows

Hurlfield

Woodland View

136 Warminster Road

Supported living Mansfield View

Supported living Wainwright Crescent

Aggregated rating for the adult social care services provided