Sheffield Health Partnership University NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment we rated this key question as Requires Improvement. At this assessment the rating has changed to Good.

Good: This meant people were safe and protected from avoidable harm.

Good: All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

During this assessment, we found up to date environmental and ligature risk assessments which highlighted areas of the wards that had an increased risk of ligatures as well as mitigations in place to manage those risks.

We found out of date individual risk assessments on Stanage ward and Burbage ward.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was 1 serious incident in the 12 months preceding our on-site assessment.

Staff told us that when they reported incidents, they received feedback in several ways including via team meetings, email, and during supervision. We found that staff had a good understanding of the duty of candour and gave patients and their families an apology and an explanation when things did not go correctly. Debriefs were carried out and support was offered to staff following serious incidents and staff told us that they felt this was beneficial and felt supportive.

Staff were able to tell us about changes made because of learning from incidents. For example, the introduction of daily safety huddles.

Staff we spoke to knew what incidents needed to be reported and how to report them. We found debriefs were offered to staff and patients post incident.

Feedback from relatives and patients evidenced that complaints were investigated, resolved and lessons learned from them were put in place when required.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff worked in partnership with different teams such as community teams and social workers to support the discharge process.

Ward rounds were attended by the trust’s community mental health teams, occupational therapy, pharmacy, discharge co-ordinators, social workers as well as medical and nursing staff members. which ensured there was a clear pathway for follow up care.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to raise a safeguarding alert, and did that when appropriate. At the time of our assessment, the compliance rate for safeguarding adults and children training within the service was 97%. Prevent training to help prevent terrorism, radicalisation, and extremism was facilitated by the trust, staff compliance at the time of this assessment was 94%.

Staff had a good understanding of safeguarding and the trust’s associated processes and procedures. Staff logged safeguarding concerns via the trust’s incident reporting system and RiO system, escalated any concerns to senior colleagues and staff also understood local authorities’ roles in safeguarding.

The trust had effective systems, policies, and processes in place to ensure that staff identified and reported concerns and care records that we reviewed included a section to capture any safeguarding concerns.

Staff within the service regularly reviewed restrictions and banned items. Patient voice meetings and mutual help meetings were held regularly to enable patients to openly discuss any restrictions and banned items with staff.

Mental Capacity Act

96% of staff had training in the Mental Capacity Act.

Staff we spoke with had a good understanding of the Mental Capacity Act, particularly the five statutory principles.

The trust had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Patients were supported to make decisions for themselves wherever possible. Where patients lacked capacity to make certain decisions, staff made decisions in the patient’s best interest, and this was evidenced in care plans and in records of capacity assessments and best interest meeting minutes.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 15 individual risk assessments during this assessment.

We found that 4 out of the 15 patient’s risk assessments were not completed on admission or updated.

In the previous 12-month period, there were 637 incidents of restraint, including the use of a safety pod. There were no incidents involving the use of prone restraint across all 4 wards.

There were 194 incidents that involved the use of rapid tranquilisation and 45 incidents that resulted in the use of seclusion across all 4 wards.

We did find that patients were included in developing least restrictive management plans to manage risks and the trust used the DRAM (Detailed Risk Assessment and Management plan) tool built into its care records system. We saw evidence in care records that patients, relatives, advocates and other agencies were involved in the development and ongoing reviews of risk management plans and care plans, and it was evident that these were reviewed in multi-disciplinary meetings.

Staff told us they made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only as a last resort to keep the patient or others safe.

Incidents and restraints were reviewed by managers and discussed within clinical governance meetings. Leaders discussed themes and regular occurring issues to try and understand why these had occurred and reduce the number of incidents of restraint where possible.

We spoke with 11 patients and 9 relatives who told us they felt safe on the wards. Patients were involved in weekly mutual help meetings and patient voice meetings, where they were asked about safety on the ward.

Patients had access to an independent advocacy service, this was provided by Sheffield Advocacy Hub and is commissioned by Sheffield City Council.

In addition to the statutory independent mental health advocacy service, patients from different ethnic backgrounds could seek advocacy support from a charitable organisation SACHMA (Sheffield African Caribbean Mental Health Association), that provided culturally sensitive services for patients. There were signs around the wards and wider site to inform people how to access advocacy services.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff involved patients in identifying potential risks within the ward environments. Patients were encouraged to comment on the quality of the environments in mutual help meetings and patient voice meetings. Staff used the meetings to consult with patients on restricted items, the safety of the environment and blanket restrictions.

Staff had access to assistance alarms and patients had access to nurse call systems on the wards. Clinic rooms were fully equipped with good access to emergency equipment and emergency drugs that staff checked regularly.

Staff carried out regular environmental checks. Any identified issues were escalated to the relevant specialist or senior member of staff for action and were discussed in safety huddles and handovers.

Staff were positioned around the wards to mitigate blind spots and unclear lines of sight in the absence of CCTV. There were rooms that were locked due to identified risks, but these could be opened on request and patients would be supervised.

Ligature cutters were clearly signposted, stored securely but were accessible to staff in the case of an emergency. There was a maintenance process in place for used cutters, which staff could demonstrate a clear understanding of. The wards had ligature risk assessments and ligature ‘heat maps’ available that identified ligature risks within the ward environment and what mitigation had been taken. Bedrooms throughout the wards had specialist, alarmed doors to identify any suspended ligature.

Burbage ward, Stanage ward and Dovedale 2 were single sex wards, Endcliffe ward is a mixed sex ward and complies with guidance on eliminating mixed-sex accommodation by providing female only spaces, ensuite bedrooms and separate male and female bedroom areas.

The seclusion room on Endcliffe allowed clear observation, 2-way communication and it had toilet facilities and a clock.

Patients had access to their own bedrooms with individual fob access and en-suite facilities, however not all bedrooms on Dovedale 2 ward had en-suite facilities.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received

effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Most patients and relatives that we spoke to said that the ward areas feel safe and that there are enough staff on the ward areas. 1 patient said that they had had escorted leave cancelled due to lack of staff availability. This Leave was subsequently rearranged.

Staff told us that staffing levels felt safe and there was enough staff to meet the needs of patients. Staff on Burbage told us that staffing levels had improved as well as morale over the last year. Staff said this was due to management changes and there had been a decrease in sickness levels and reduction in staff turnover.

Some patients told us that night shifts tended to be staffed by bank and agency staff, who did not interact as well with patients as regular staff. Patients told us they had observed bank and agency staff on the night shift to be asleep and at times using their personal mobile phones in patient areas. We raised this with the managers at the time of our assessment.

We reviewed staffing rotas for all 4 wards and found trust safe staffing levels were achieved most of the time.

Staff told us that the ward areas were rarely short staffed and if it did occur, it was due to unexpected absences such as sickness. They said shifts were often covered by the redeployment of staff from other wards as well as existing staff being flexible with shift patterns. Staff also told us that night shifts tended to be covered by bank agency staff.

We observed good levels of staffing during the assessment and there was enough staff to meet the needs of patients, including activities, engagement, and leave.

The mandatory training programme was comprehensive and met the needs of the patient group. The trust target for mandatory training compliance was 80%, at the time of this assessment this target was being achieved. The trust monitored training compliance and alerted staff when they needed to attend updates. Agency staff were not subject to the same training programme. Handovers, safety huddles and daily Psychologically Informed Partnership meetings were used to identify agency staff’s experience and training compliance as a way of deciding the best placement across the wards.

Staff used the Safewards tool, Positive Behaviour Support plans (PBS) and undertook the Oliver McGowan training package, Autism awareness training, Prevent training and clinical risk assessment training as part of the mandatory training program.

Managers had reported difficulty in uploading new supervision and appraisal data and accessing historical data since moving to the new RiO system.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Patients and relatives, we spoke to have no concerns regarding the cleanliness and hygiene within the service.

Staff we spoke with were aware of infection prevention and control requirements and policies. There was a nominated person on every shift for ensuring good infection prevention and control standards such as hand washing, use of personal protective equipment and adherence to the practice of bare below the elbows.

During our ward tours, we observed the communal areas and bedrooms to be clean and well maintained. There was furniture in the communal areas of Dovedale 2 that had visible signs of wear and tear. We found that although the wards were clean and cleaning rotas and checklists were up to date, the maintenance of the wards could be better.

The trust had systems and processes to ensure they managed the risk of infection. Domestic staff carried out regular cleaning of the wards and wider site. The training compliance for infection prevention and control was in line with the trust’s targets.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Patients were aware of their medicines and staff discussed these with them. Relatives told us that medications were discussed thoroughly, and any questions raised regarding medications can be discussed with the ward Doctors.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance. Staff knew what processes were in place for the supply of medicines.

Staff had access to advice from a pharmacist. The pharmacy department was available to support staff with managing medicine processes such as ordering and receiving medicines. A pharmacist attended any relevant ward rounds and discussed any medicine issues. Medicine management training was provided to all relevant staff across the 4 wards.

Medicines storage was locked and secure with access only to authorised staff. All clinic rooms seen were neat and tidy. Medicine room storage and refrigerator temperatures were recorded daily. Records evidenced that medicines were stored at the correct temperatures and staff knew what action to take if temperatures were outside of recommended ranges.

Processes were in place to ensure patients received their medicines as prescribed. A pharmacist conducted medicines management and medicines optimisation audits, including controlled drugs and the safe and secure handling of medicines. Controlled drugs (a controlled drug is a substance whose manufacture, possession, and use are regulated by the government.This regulation is typically implemented to prevent misuse and the potential harm related to the drug) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded in line with the trusts policy. Checks of controlled drugs showed that they were within date and stock balances were accurate on all 4 wards.

The service ensured patients behaviour was not controlled by excessive and inappropriate use of medicines.

Staff reviewed the effects of each patient’s medicines on their physical health according to the National Institute for Health and Care Excellence guidance.

The service worked towards achieving the aims of STOMP (stopping overmedication of people with a learning disability and autistic people).

There was a clear process in place for managing and reporting any errors or incidents involving medicines. Staff were able to talk through the process that would be followed if this occurred.