Sheffield Health Partnership University NHS Foundation Trust

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has changed to good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles; however, governance processes were not always operated effectively.

Leaders did not ensure that all care plans were holistic and included the patient’s voice and were updated when necessary.

Leaders didn’t ensure the timely reading of Section 132 rights under the Mental Health Act 1983.

Leaders did not ensure staff were competent in their knowledge of the trust policy for searching patients. We found staff searched all patients on return which was a blanket restriction and not in line with trust policy.

Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Teams had access to the information they needed to provide safe and effective care.

The service was in breach of regulation for Regulations 2014; 17(1)(2)(a) Assess, monitor and improve the quality and safety of the service provided in carrying on of the regulated activity (including the quality of the experience of service users in receiving those services.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Most staff told us they felt respected, supported, and valued.

Staff on Burbage ward told us that morale had improved, and the ward has a much more positive culture since new managers had been recruited onto the ward. Staff said away days organised by management had contributed to the improvement in morale and culture.

Managers provided staff with opportunities for development, and the provider promoted equality and diversity. Staff we spoke with had a passion and enthusiasm for their role, the culture of the service and the care and treatment they delivered to patients.

Staff on Stanage ward told us that they felt able to do their job to a high standard and that a positive culture that had been created.

The trust’s values were working together, being respectful and kind, being inclusive, and continuously improving. Staff on Dovedale 2 told us that they felt the leadership of the service was based on these values.

The service had a comprehensive training and development programme to ensure staff development, increase awareness of best practice and to ensure that staff understood and demonstrated the vision and values of the service. However, we found evidence that trust targets for supervision and appraisals were not being met.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge, and experience to perform their roles. They had a good understanding of the service and the needs of patients and their relatives.

Staff told us that senior leaders and managers were visible, supportive, and understood that the working environment could be challenging at times. Staff told us that there was adequate training for them to carry out their roles effectively.

Staff on Burbage told us that the new management structure on the ward had vastly improved staff morale and confidence. This was evidenced with improvement in sickness levels, staff turnover and recruitment.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

There was clear leadership at a local and senior level, however one member of staff told us they struggled to identify managers due to recent changes in personnel across Burbage, Stanage ward and Dovedale 2 ward.

Managers were visible during the day-to-day provision of care and treatment. Leaders were up to date with best practice and guidance and ensured that knowledge was shared across the whole team. Leaders ensured staff felt valued and supported.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up, and their voice would be heard.

Patient’s and relatives that we spoke to told us they had opportunities to discuss and offer feedback regarding the care that they receive and felt confident that feedback offered would be listened to.

Staff knew how to raise a concern and felt confident to do so. Staff said there was a positive and open culture, and they could always approach leaders if there was an issue.

The trust had a whistleblowing policy and procedure in place to ensure staff were aware of how to effectively raise a concern. Staff had access to this policy and procedure via the trust intranet. It gave staff information on who they could raise concerns to senior leaders and relevant bodies including the Care Quality Commission.

Staff had access to a freedom to speak up guardian and staff knew how to contact. Staff were able to raise concerns through a variety of feedback methods.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff were able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues.

Staff we spoke with felt managers were respectful of cultural diversity.

Staff informed us that there was a considerable amount of training surrounding equality and diversity. Staff understood and valued the importance of equality and diversity within the workplace. Staff also informed us that there were trust diversity leads and diversity network groups, such as the rainbow staff network group, ethnically diverse staff network group and disability staff network group within the trust that provide support to staff. Managers supported staff through supervision and team meetings.

We scored the service as 2. We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The trust had risk registers that identified items and areas of the clinical environment that presented an increased risk to patients. These risk registers were regularly reviewed by staff and senior management to mitigate any risk and avoid any unjustifiable blanket restrictions. Risk registers for all wards were provided to us when asked.

Managers did not ensure staff complied with the trust search policy, which resulted in a blanket restriction whereby staff searched all patients upon return from leave.This represents a breach of the Health and Social Care Act pilot 2008 (Regulated Activities) Regulations 2014;

Responsible managers were expected to review safeguarding risks on a regular basis, in line with the trust risk management strategy.

There were staff meetings, clinical audits, incident reviews and debriefs, and patient meetings called ‘Patient Voice’ meetings and ‘Mutual Help’ meetings as well as anonymous feedback boxes situated around the hospital, however; governance systems they had in place were not always effective in identifying issues.

Managers did not ensure the timely formulation or review of patient risk assessments and there were not sufficient audits to provide assurance and to alert staff to act on results when needed.

Leaders didn’t ensure the timely reading of Section 132 rights under the Mental Health Act 1983.

Staff had access to the equipment and information technology they needed to do their work. However, concerns were raised around access to the electronic documentation system for agency and bank staff due to lack of available smartcards across the wards. Staff also told us that there aren’t always enough laptops for staff to use, and they often become slow, battery life becomes compromised, and chargers aren’t always available.

A new electronic records system, RiO was recently adopted by the trust which allows the confidential input and storage of patient records.

Staff told us RiO wasn’t user friendly, with staff having difficulty navigating the system and inputting data, accessing information as well as other teething problems. However, most staff said that this is down to it being a new system rather than software issues.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Managers we spoke with described good working relationships with local teams, for example community mental health teams and culturally specific advocacy services.

The trust uses Care Opinion, which is a way for patients, relatives and professionals of health service bodies to share feedback, stories and experiences. The trust also implements the Friends and Family test tool that gives patients and relatives an opportunity to feedback to the trust regarding their experiences to drive improvements.

There are also governor’s meetings, led by corporate governance as well as monthly carers meetings, led by the engagement and experience team, all of which are open to patients and relatives to attend and offer feedback.

The trust also utilised Patient Led Assessments of the Care Environment (PLACE) visits, which involve patient input and are led by a public health specialist.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

We saw evidence of staff ‘away days’ that afforded staff the time to discuss opportunities for development and improvements to the care environments.

We found evidence that staff participate in a Section 17 leave improvement scheme which looked to improve patients access to Section 17 leave. There was also a culture of care programme which includes coaching for trusts to develop trauma informed, autism-informed and anti-racist approaches and how to apply them and to improve the overall patient experience which are led by the trust quality improvement team.

At the time of our assessment the trust was developing a new individual patient risk assessment and plan to implement the Personalised Assessment of Risk (PAR). This will replace the Detailed Risk Assessment and Management Plan (DRAM).

Support workers employed on the ward areas were expected to complete the Care Certificate, which is a set of 16 standards for health and social care support workforce that ensures that newly employed workers have the skills, knowledge and behaviours needed to provide compassionate, safe and high-quality care.

The trust implemented the triangle of care programme, which was a therapeutic alliance between patients, relatives and healthcare professionals to promote safety, well-being and recovery. The trust has been awarded a ‘star’ by the triangle of care board for their work with carers in inpatient mental health settings.