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20171116 900885 Post-inspection Evidence appendix template v3 Page 1
Sheffield Health and Social Care NHS
Foundation Trust
Evidence appendix
Fulwood House Old Fulwood Road Sheffield South Yorkshire S10 3TH Tel: 01142716310 www.shsc.nhs.uk
Date of inspection visit:
30 May to 5 July 2018
Date of publication:
5 October 2018
This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.
Trust-wide leadership
Facts and data about this trust Sheffield Health and Social Care NHS Foundation Trust provide mental health, learning disability,
substance misuse, community rehabilitation, primary care, specialist services and adult social
care services.
It serves the 563,000 people of Sheffield. The trust employs 2,700 staff and provides services
from 42 community and inpatient sites with more than 150 beds across the city. It has an annual
budget of £128 million.
The trust was established in 2003 as Sheffield Care Trust and on 1 July 2008 became Sheffield
Health and Social Care NHS Foundation Trust. It works with one clinical commissioning group,
NHS Sheffield CCG. The trust has been registered with the CQC since 1 April 2010.
The trust provides primary medical services, mental health inpatient and community services and
adult social care.
The trust provides services that are commissioned by:
• NHS England
• Sheffield Clinical Commissioning Group
• Sheffield City Council
The trust provides the following services:
20171116 900885 Post-inspection Evidence appendix template v3 Page 2
• Acute mental health wards and psychiatric intensive care units for adults of working age
• Long stay rehabilitation mental health wards for adults of working age
• Forensic inpatient/secure wards
• Wards for older people with mental health problems
• Wards for people with learning disabilities or autism
• Community-based mental health services for people with learning disabilities or autism
• Community-based mental health services for older people
• Community-based mental health services for adults of working age
• Mental health crisis services and health-based places of safety
• Substance Misuse services
• Primary medical services
• Adult social care services
The CQC has previously inspected locations registered to Sheffield Health and Social Care NHS
Foundation Trust on 26 occasions. These inspections took place between October 2014 and
November 2016.
The trust had 11 locations registered with the CQC (on 8 June 2018). Registered location Code Local authority
Assessment and Treatment Service (ATS) TAHEC MH South Yorkshire and Bassetlaw Area Team
Clover City Practice TAHX4 PMS South Yorkshire and Bassetlaw Area Team
Forest Close TAHXM MH South Yorkshire and Bassetlaw Area Team
Forest Lodge TAHXN MH South Yorkshire and Bassetlaw Area Team
Fulwood House TAHXK MH South Yorkshire and Bassetlaw Area Team
Grenoside Grange TAHXP HSP South Yorkshire and Bassetlaw
Jordanthorpe Health Centre TAH54 PMS South Yorkshire and Bassetlaw Area Team
Michael Carlisle Centre TAHFC MH South Yorkshire and Bassetlaw Area Team
The Longley Centre TAHCC MH South Yorkshire and Bassetlaw Area Team
Wainwright Crescent TAHYR ASC North Central Hub 2
Woodland View TAH95 ASC Central East Midlands Hub 1
The trust had 157 inpatient beds across 12 wards, none of which were children’s mental health beds. The trust had no outpatient clinics a week and 450 community clinics a week.
Total number of inpatient beds 157
20171116 900885 Post-inspection Evidence appendix template v3 Page 3
Total number of inpatient wards 12
Total number of day case beds 0
Total number of children's beds (MH setting) 0
Total number of children's beds (CHS setting) 0
Total number of outpatient clinics a week 0
Total number of community clinics a week 450
20171116 900885 Post-inspection Evidence appendix template v3 Page 4
Is this organisation well-led?
Leadership
The trust board had the appropriate range of skills, knowledge and experience to perform its role.
The board comprised five executive directors, including the chief executive with career experience
in a healthcare setting and relevant qualifications as appropriate for their leadership roles. There
were also two non-voting directors and six non-executive directors, including the chair that
brought experience of business, finance, health and social care. Non-executive directors used the
knowledge and skills from their relevant backgrounds to provide appropriate challenge at board
meetings through robust questions and challenges. We saw that this was accepted and
responded to openly and positively by the executive team.
There was an open and patient focused culture. The senior leadership team displayed integrity in
their decision making and actions. The trust board engaged in regular board development
sessions. A recent session was used to develop the board assurance framework and future
sessions were planned to consider strategy and development. Non-executive directors had
undertaken joint development sessions with the trust’s governors.
The leadership team had comprehensive knowledge of the current priorities and challenges
across all sectors and were taking action to address them. They were aware of the trust’s
priorities and ambition for the coming years. However, there had been deterioration in services
since the last inspection, which the trust leadership team had not recognised and this resulted in
the reduction in the overall ratings for two of the ten core services at this inspection. The chair,
chief executive and other executive directors expressed concern regarding the trusts
management capacity to fulfil all of its projects and commitments going forward.
The executive board had 20% black and minority ethnic members and 20% of the executive
board were women.
The non-executive board had 17% black and minority ethnic members and 83% of the non-
executive board were women.
BME % Women %
Executive 20% 20%
Non-executive 17% 83%
Total 18% 55%
Directors, or equivalent, must be of good character, have the necessary competence, skills and
experience and be physically and mentally fit enough to fulfil the role. They must also be able to
supply information including a Disclosure and Barring Service check and a full employment
history. We reviewed the personnel records of the executive and non-executive directors who had
joined the trust since our last inspection. All were compliant with the requirements of the fit and
proper person regulation.
The executive team were supported by a senior leadership team which consisted of a full time
director and clinical director of operations and transformation accountable for all clinical
services. There were also three associate directors; two covering the care networks and one for
patient safety. The care network associate directors worked in partnership with designated clinical
20171116 900885 Post-inspection Evidence appendix template v3 Page 5
directors, to which there were five. There was a designed deputy director of nursing (operations)
reporting into the director and clinical director of operations, jointly accountable to the chief nurse.
The director of nursing was the executive lead for safeguarding adults and children and there was
a full-time safeguarding lead and a named nurse for safeguarding. Dedicated senior nurses were
in place and supported with physical health, resuscitation and infection prevention and control.
The director of nursing spoke positively regarding leadership that would be provided by the newly
introduced director role for allied health professionals and the director for psychological services
and therapies. She also spoke about the investment in in senior nursing roles and the clear
pathway for nurses in the trust and felt nurses were being valued by the trust.
Interim arrangements for the pharmacy service over the last 22 months had caused some impact
on staffing levels and reduced capacity to ensure policies and procedures were regularly
reviewed. This meant that staff were using out of date policies and guidelines relating to
medicines. The trust had recently appointed a new chief pharmacist who was accessible to all
staff. They were aware of the challenges to the quality and sustainability of the pharmacy service,
and plans were in place to address these. However, these plans had not yet had an impact on the
service.
The trust supported staff and offered training in a variety of leadership development initiatives at
all levels of the organisation. Leadership was an integral part of the workforce and organisational
development strategy. It had a delivery plan which set out objectives to deliver the leadership and
talent management strategy.
The trust offered skills training in management areas such as human resources and finance. It
was also formalising this into an induction programme for new managers. Managers had access to
tools for self-assessment and 360 feedback against the NHS Leadership Qualities Framework. An
in-house leadership development workshop provided preparation for appraisal conversations.
Leadership skills training was also available through short courses and electronic learning. In
addition, the trust could organise bespoke external provision where a learning need was identified
through appraisal.
Institute of Leadership and Management Accredited leadership qualifications were offered through
apprenticeship pathways at Level 3 and Level 5. These were delivered in partnership with other
local trusts and training providers. Apprenticeship pathways offered an opportunity to improve the
recruitment and retention of staff. These routes offered opportunities for leadership training at
different levels of the organisation including support staff team leaders.
Staff also had access to the accredited degree programmes such as NHS Leadership
programmes and graduate routes. The trust were a higher than average organisation for staff
accessing leadership programmes such as the Nye Bevan programme, specifically designed to
develop senior leaders and the Mary Seacole programme, a six month leadership development
programme which was designed by the NHS Leadership Academy.
The trust had a bespoke coaching service, which offered time with an accredited coach to
increase performance. Eight coaches were accredited to Institute of Leadership and Management
level five with a further four undertaking accreditation. On inspection,126 staff had received
coaching.
Other initiatives included leadership development workshops and leadership engagement network
events. In these events, the chief executive met with frontline leaders to converse, listen and
interact directly.
20171116 900885 Post-inspection Evidence appendix template v3 Page 6
Vision and strategy
The trust vision and values had been developed in consultation with patients, governors and staff. The vision was to improve the mental, physical and social wellbeing of the people in our communities. The vision was underpinned by values of:
• Respect – we listen to others, valuing their views and contributions.
• Compassion – we show empathy and kindness to others so they feel supported, understood and safe.
• Partnership – we engage with others on the basis of equality and collaborations.
• Accountability – we are open and transparent, acting with honesty and integrity, accepting responsibility for outcomes.
• Fairness – we ensure equal access to opportunity, support and service.
• Ambition – we are committed to making a difference.
The trust described these values as the guiding principles and behaviours for the way they do their work. These guiding principles were further supported by a number of specific aims, which were:
• Working with and advocating for the local population.
• Refocusing services towards prevention and early intervention.
• Continuous improvement of services.
• Locating services as close to peoples' homes as they can.
• Developing a confident and skilled workforce.
• Ensuring excellent and sustainable services.
The vision and values were very well embedded in the organisation. The senior executives referred to the trust vision and values throughout the inspection. Staff throughout the organisation were familiar with the values and their practice was valued driven. Staff recruitment and appraisals were centred on the trust values, thus ensuring that all staff were familiar with the trust values from the outset.
The trust had developed a strategy to enable it to achieve the vision and aims. This was approved by the trust board in June 2017. When developing the strategy, a range of engagement activities were undertaken to seek feedback and views from stakeholders. This included service user groups, staff and the council of governors. They also consulted with external partners to review and explore alignment across city wide plans and local needs. The strategic aims were:
• Quality & Safety Aim: We will provide high quality care and support as early as possible in order to improve physical, mental and social wellbeing.
• People Aim: We will promote a culture of collaboration, supporting people to work together to make a difference.
• Future Services Aim: We will develop excellent mental, physical and social wellbeing for the communities we serve through innovation, collaboration and sharing.
• Value for Money Aim: We will provide sustainable services through ensuring value for money, reducing waste and unproductive time for our staff.
The quality and safety aim had led to an improvement in the safety of only one of the core services inspected and the rating for the crisis and health based places of safety had seen its rating in the safe domain reduced to inadequate at this inspection.
20171116 900885 Post-inspection Evidence appendix template v3 Page 7
The trust had a strategy for meeting the physical healthcare needs of patients and had a lead nurse in place to support the implementation. The trust had also conducted a number of clinical audits in relation to physical health care with associated plans for improvements where these had been identified. However, there were inconsistencies in the standard of physical health care across the trust, for example in the acute wards for adults of working age and psychiatric intensive care units staff were ensuring that patients received a comprehensive physical health assessment on admission, but did not always undertake the required physical health monitoring following the administration of rapid tranquillisation.
The trust medicines optimisation strategy, which had been developed in partnership with senior pharmacy staff and other key stakeholders, was approved in April 2018. There was no mechanism in place to monitor progress against delivery of the strategy. However the newly appointed chief pharmacist was aware of this and had plans to improve monitoring in the future.
Culture
The trust had an open and honest culture. An example of this was demonstrated by the openness with which the executive team responded to staff and patient concerns. The chief executive was visible and accessible to staff and responded in person to discuss concerns raised by staff. He also offered face to face meetings with patients or carers who had made a formal complaint. Non-executive directors regularly visited frontline services.
Staff were aware of the trust’s whistleblowing policy and they knew who the trust’s freedom to speak up guardian was. The freedom to speak up guardian had regular meetings with the chief executive and we saw instances of where the freedom to speak up guardian had supported staff to raise concerns. Staff knew how to raise concerns and told us they could do this without fear of retribution. Managers had introduced externally facilitated team meetings to enable staff to express their concerns and suggest improvements.
In the 2017 NHS Staff Survey, the trust had better results than other similar trusts in four key areas:
Key finding Trust score Similar trusts
average
KF7 Percentage of staff able to contribute towards improvement at work 75% 73%
KF11 Percentage of staff appraised in last 12 months 95% 89%
KF16 Percentage of staff working extra hours 70% 72%
KF24 Percentage of staff / colleagues reporting most recent experience of
violence
94% 93%
In the 2017 NHS Staff Survey, the trust had worse results than other similar trusts in 23 key areas:
Key finding Trust score Similar trusts average
KF1 Staff recommendation of the organisation as a place to work or receive
treatment 3.47 3.67
KF2 Staff satisfaction with the quality of work and care they are able to
deliver 3.59 3.83
KF3 Percentage of staff agreeing that their role makes a difference to
patients / service users 82% 88%
20171116 900885 Post-inspection Evidence appendix template v3 Page 8
Key finding Trust score Similar trusts average
KF4 Staff motivation at work 3.71 3.91
KF5 Recognition and value of staff by managers and the organisation 3.44 3.59
KF6 Percentage of staff reporting good communication between senior
management and staff 31% 36%
KF8 Staff satisfaction with level of responsibility and involvement 3.80 3.88
KF10 Support from immediate managers 3.81 3.95
KF12 Quality of appraisals 2.92 3.22
KF13 Quality of non-mandatory training, learning and development 3.96 4.06
KF14 Staff satisfaction with resourcing and support 3.20 3.35
KF15 Percentage of staff satisfied with the opportunities for flexible working
patterns 56% 60%
KF17 Percentage of staff feeling unwell due to work related stress in the last
12 months 51% 42%
KF18 Percentage of staff attending work in the last 3 months despite feeling
unwell because they felt pressure from their manager, colleagues or
themselves
58% 53%
KF19 Organisation and management interest in and action on health and
wellbeing 3.66 3.77
KF20 Percentage of staff experiencing discrimination at work in the last 12
months 17% 14%
KF21 Percentage of staff believing that the organisation provides equal
opportunities for career progression or promotion 81% 85%
KF22 Percentage of staff experiencing physical violence frim patients,
relatives or the public in the last 12 months 24% 22%
KF25 Percentage of staff experiencing harassment, bullying or abuse from
patients, relatives or the public in the last 12 months 38% 32%
KF28 Percentage of staff witnessing potentially harmful errors, near misses
or incidents in last month 34% 27%
KF30 Fairness and effectiveness of procedures for reporting errors, near
misses and incidents 3.55 3.75
KF31 Staff confidence and security in reporting unsafe clinical practice 3.60 3.71
KF32 Effective use of patient / service user feedback 3.41 3.72
20171116 900885 Post-inspection Evidence appendix template v3 Page 9
The executive team were aware that the results of the staff survey were worse than in previous
years. The trust had recently undergone a large community service transformation and a
management restructure in a short period, which the chief executive described as an
unprecedented degree of change. The chief executive reflected that it had been a mistake to
undertake both projects so close together and that initial learning had been taken from that as well
as commissioning an external review.
Following the organisational changes, some staff felt their concerns regarding the re-configuration
of community services were not being heard and responded to. However, we found that the
executive team were aware of the concerns raised and had committed to listen to staff. Senior
managers had organised externally facilitated team meetings to ensure staff felt able to express
concerns and the chief executive has responded personally to concerns raised. Prior to the results
of the staff survey, they had also commissioned an externally facilitated review of the service
reconfiguration that would include patient safety, experience and staff views in the terms of
reference. In addition, the trust had held a learning from change event. The purpose of this was to
provide an opportunity to share experiences of change, to understand support needs throughout
the process, improve practice and update policy.
The executive team were visible and spent time in the services with patients and staff. These visits
formed part of the 15 Steps Challenge. The 15 Steps Challenge uses some of the principles of
mystery shopping and observational approaches. It aims to understand what service users and
carers experience when they first arrive in a mental healthcare setting. The chief executive spent
one day each month working as a support worker in different areas of the trust, he also used this
opportunity to listen to staff concerns. The deputy chief executive visited clinical areas outside of
office hours and on bank holidays. The medical director also ran patient assessment clinics within
the single point of access within the trust. During our interview with the director of nursing it was
clear that she had in depth knowledge of the staff and services in the trust.
Staff working in core services told us they felt supported by their managers and senior managers
were visible and approachable. Most staff, at all levels in the organisation felt respected,
supported and valued, however, staff morale within the crisis and health based place of safety
service was low. Staff demonstrated commitment, positivity and enthusiasm in their positions and
in the work they completed. Despite some staff feeing that recent organisational changes had a
negative impact, all were very passionate and cared about the service they provided.
The trust rewarded staff and volunteers through annual recognition and achievement awards.
There were also a number of initiatives in place to support staff. These included access to cheaper
loans for staff through a neighbouring organisation, salary sacrifice schemes for bicycles and cars
and staff rotation opportunities.
The trust worked with the trade unions and professional organisations. There were monthly
meetings attended by the deputy and chief executive to identify, discuss and where possible
resolve issues. Trade union representatives described the trust as very fair and approachable.
They were involved in policy development and consultation and had recently facilitated a
meaningful consultation workshop for members of the human resource department. The trust had
a redeployment policy in place and 80 percent of staff were redeployed successfully during the
reconfiguration of services and there had been no staff redundancies. The trust had received no
grievances from staff in relation to the process.
20171116 900885 Post-inspection Evidence appendix template v3 Page 10
Managers at all levels of the organisation provided examples of where poor performance had been
addressed in line with the trust’s disciplinary policy and procedure. We reviewed five disciplinaries,
all of which adhered to the trust’s disciplinary policy and procedure. Investigations were thorough,
and clearly explained outcome letters offered the staff member including the right of appeal
against any sanction, with staff being supported through the process by union or other
representatives. One case could have been dealt with in a more timely way, this was
acknowledged in the outcome letter and an apology given. Trade union representatives felt that
the trust treated staff fairly and would reschedule disciplinary meetings to enable the staff
members to be supported by an appropriate representative.
We reviewed two grievances against the trust, both adhered to the policy and investigations were
thorough. Neither case was upheld, however, in one case the investigation found that trust
procedures had not been followed.
The trust had policies and procedures in place to support clinical professional registration
verification and criminal records checking and disclosure and barring which were clear and easy to
understand. However, some of the terminology in the clinical professional registration verification
policy was out of date and the appendices in the criminal records checking and disclosure and
barring policy were in draft form. Although the trust had systems in place to monitor staff
compliance with these policies, it was acknowledged that it had not been monitored and managed
systematically since the member of staff who had dedicated responsibility for monitoring
compliance left 18 months ago. However, we did not find that staff were working without the
necessary registration and clearance.
The trust gained regular feedback from the Friends and Family Test, which was collated and analysed centrally and subsequently fed back at individual service level monthly for local action.
The Patient Friends and Family Test asks patients whether they would recommend the services they have used based on their experiences of care and treatment. The trust scored between 6% and 8% higher than the England average for patients recommending it as a place to receive care in all six months between November 2017 to April 2018.
February 2018 saw the highest percentage of patients who would recommend the trust as a place to receive care with 97%, however each month in the period scored 94% or above.
The trust scored lower than the England average in terms of the percentage of patients who would not recommend the trust as a place to receive care in all six months from November 2017 to April 2018.
Trust wide responses England averages
Total eligible
Total
responses
% that would
recommend
% that would
not recommend
England average
recommend
England
average not
recommend
November 2017
17982 190 94% 3% 87% 5%
December 2017
17024 127 94% 1% 88% 4%
January 2018
17689 153 95% 1% 88% 4%
February 2018
17584 144 97% 1% 89% 4%
March 2018
9688 124 95% 2% 89% 4%
April 9953 143 96% 1% 89% 4%
20171116 900885 Post-inspection Evidence appendix template v3 Page 11
2018
Last year the trust signed up to an enhanced feedback service with Care Opinion. It is a non-profit community interest company that provides a feedback platform for health and social care in an attempt to increase service user feedback regarding their services. The trust had 24 champions trained to manage, act upon and respond to service user feedback.
The trust also used other satisfaction questionnaires. These included the Quality & Dignity questionnaire, discharge questionnaires and microsystem improvement questionnaires. Additional opportunities for providing feedback were available such as through the trust website, focus, advocacy and participation groups.
Examples of changes and improvements as a result of patient and carer feedback included changes to the visiting hours in the older peoples wards, an increase in the activities available on the rehabilitation wards and changes to the format and font size of letters sent out to patients and carers in the community mental health services for older people with mental health problems.
The Staff Friends and Family Test asks staff members whether they would recommend the trust as a place to receive care and also as a place to work. Quarter 4 2016/2017 had the highest scores for staff recommending the trust as a place to receive care. Quarter 1 2017/2018 had the highest scores for staff recommending the trust as a place for work.
There is no reliable data to enable comparison with other individual trusts or all trusts in England.
The graphs below show the percentages of staff who would recommend the trust for work and for
care:
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 January 2018 1351.6 N/A
Total number of substantive staff leavers 1 February 2017 to 31 January 2018
129.6 N/A
Average WTE* leavers over 12 months (%) 1 February 2017 to 31 January 2018
8% 13%
20171116 900885 Post-inspection Evidence appendix template v3 Page 12
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31 January 2018 68 N/A
Total vacancies overall (%) At 31 January 2018 5% N/A
Total permanent staff sickness overall (%)
Most recent month (At 31 January 2018)
8% 5%
1 February 2017 to 31 January 2018
7% 5%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 January 2018 32 N/A
Establishment levels nursing assistants (WTE*) At 31 January 2018 433 N/A
Number of vacancies, qualified nurses (WTE*) At 31 January 2018 7% N/A
Number of vacancies nursing assistants (WTE*) At 31 January 2018 15 N/A
Qualified nurse vacancy rate At 31 January 2018 353 N/A
Nursing assistant vacancy rate At 31 January 2018
4% N/A
Bank and agency Use
Shifts bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 February 2017 to 31
January 2018 4977 (15%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses) 1 February 2017 to 31
January 2018 1629 (5%) N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses) 1 February 2017 to 31
January 2018 900 (3%) N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 February 2017 to 31
January 2018
21770
(37%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 February 2017 to 31
January 2018 5623 (9%) N/A
Shifts NOT filled by bank staff where there is sickness, absence or
vacancies (Nursing Assistants) 1 February 2017 to 31
January 2018 1760 (3%) N/A
*Whole-time Equivalent
Staff recruitment and retention was an ongoing challenge for the trust. In the acute wards for
adults of working age and psychiatric intensive care unit, although there was a high ratio of
qualified to unqualified staff on shift, vacancies for qualified nurses were high. There was a
reliance on bank and agency staff to maintain staffing numbers and there were not always the
required number of staff on duty to undertake physical interventions safely. Staff on the wards for
people with a learning disability or autism sometimes had to cancel activities and patient leave due
to there being insufficient staff.
Staff from the community-based mental health services for adults of working age told us that there
were not enough staff to provide an effective service to patients. The trust told us that these
concerns will be considered as part of the planned service review following reconfiguration, which
will be undertaken later this year. The associate director for planned and scheduled care had
developed a business case to increase staffing following feedback from staff and with supporting
evidence from ongoing service monitoring.
The director of nursing described a clear pathway for nurse development with the introduction of
new roles, including nurse associate and nurse consultant roles. She also recognised that the trust
20171116 900885 Post-inspection Evidence appendix template v3 Page 13
had many staff that were happy in their current roles and these were supported to harness those
within that role. The trust had introduced a preceptorship nurse rotation programme. The deputy
associate director within the crisis and emergency care networks led this initiative and began by
engaging new starters to configure a programme designed to develop their competency as a
nurse.
The trust had recently introduced a scheme whereby staff who work in high stress areas are given
opportunities to undertake secondments, when they were available to other areas of the trust,
such as risk management and safeguarding teams within corporate services. This allowed staff
time away from the stresses of high acuity services and enabled then to develop new skills and
knowledge. The safeguarding team told us they were proud that staff had asked to work with them
and recognised the benefit for the whole organisation through staff taking their knowledge back to
share and apply in operational services.
The board had recently approved a venture to support professions other than doctors to become
responsible clinicians under the Mental Health Act, the lead for this development was a newly
appointed director for psychological services and therapies.
The two highest causes of sickness within the trust were stress and musculoskeletal problems. In
an attempt to reduce absence levels, the trust had introduced a fast track referral to the Improving
access to Psychological Therapy services either within the trust or a partner organisation for any
member of staff. It had also introduced a physiotherapy service for staff, whether at work or absent
due to sickness, at no cost to the individual and without requiring a referral to the occupational
health department. The physiotherapy service also provided workshops across the organisation.
Staff could have a 45-minute consultation. Since the introduction of this initiative musculoskeletal
problems have reduced and are no longer in the top three causes of sickness absence.
The guardian of safe working hours had two hours per week dedicated time for the role. It was
reported as adequate time and this was used flexibly to attend meetings and forums to publicise
the role. This included the medical staffing committee, medical workforce planning committee, the
junior doctors and trust induction. Within the previous12 months, there had been 42 exception
reports. The themes from the reports were inpatient doctors reporting staying late to complete
work for medical emergencies at the end of the day and working more than the 50 percent of time
paid for in specific role on-call. However, the latter was difficult to quantify as there may have been
occasions when the doctor worked less than the 50 percent they were paid for. The trust had
made changes as a result of the themes identified. These changes included encouraging junior
doctors to discuss priorities with supervisors including handing work to others at the end of shift
and educating and supporting doctors to understand they do not have to stay late. A band 7
nursing role had been created on the inpatient wards, an aspect of the role was to identify and
coordinate work during the evenings. Consultants were encouraged to make contact with junior
doctors at handover to ensure they knew there was support available during their shifts. The trust
had not received any penalties in relation to safe working hours.
The trust had a strategy to promote and improve equality diversity and inclusion for black asian
and minority ethnic service users and staff. The trust board had also agreed Workforce Race
Equality Standard targets from 2016 – 2021. The Workforce Race Equality Standard action plan
was incorporated into the reporting against trust targets.
Diversity and inclusion was included within the human resources portfolio and there were
challenges regarding the engagement of operational services. Although, there were more service
objectives and priorities identified in the strategy, the priority was heavily based on the Workforce
Race Equality Standards and in increasing experience and representation in the senior positions
20171116 900885 Post-inspection Evidence appendix template v3 Page 14
within the trust. The executive directors were active participants in mentoring and received regular
updates, but were not used as the sole means to drive activity in this area.
We saw positive examples of development and opportunities in relation to the black and minority
ethnic priorities, including detailed data based discussions that drove equality impact assessments
and influenced change. There was also senior mentoring to support black and minority ethnic staff
development. The trust had a black and minority ethnic network with information and links to other
publications on the trust website. There were mixed views from the members of the network we
spoke with, but overall these were positive.
The trust’s programme to promote and improve equality, diversity and inclusion for black, asian
and minority ethnic staff won the ‘most effective use of diversity to strengthen governance,
recruitment or promotion’ category at the Healthcare People Management Association Excellence
in Human Resource Management awards 2017. The Healthcare People Management Association
Excellence Awards recognise and reward outstanding work in healthcare human resource
management. Forest Close long stay rehabilitation ward and the community enhancing recovery
team were finalists in the specialist mental health rehabilitation award. G1 and the Respect
training programme had been shortlisted as finalists for the mental health safety improvement
award and the liaison psychiatry service was shortlisted for the integration of physical and mental
health card award in the Positive Practice in Mental Health Awards 2018.
The trust’s Build, Modify, Expand project focused on mentoring staff at all levels across the trust.
The mentoring model involved five members of the board of directors who mentored members of
staff from black and minority ethnic backgrounds in senior positions. At the time of the inspection
the trust was establishing the third cohort, this had involved thirty to forty staff overall. These staff
in turn provided mentoring to members of staff from black and minority ethnic backgrounds in
more junior positions.
The trust relied on a project management approach to support the workforce race equality
standard agenda. This was due to end in the near future and could create a risk to the
organisation if the agenda is not fully embedded within the trust. It was not clear whether an
evaluation would take place. Although the trust had worked hard to promote improvements for the
black and minority ethnic staff group, there was little evidence of the same emphasis on disability,
it was described to us as being at the bottom of a mountain with little focus. The accessible
information standard was not being fulfilled and although there was a plan in place to address this,
there was not enough resource to implement the plan effectively. The intent was positive although
the lack of capacity presented a risk in driving the agenda forward.
As at 28 February 2018, the training compliance for trust wide services was 88% against the trust target of 80%. One training course provided by the trust (Respect Level 1) had compliance rates below the trust target and below 75% at 66%.The training compliance reported for the trust during this inspection was higher than the 77% reported for the previous year. Although there were significant improvements in the compliance with mandatory training since the last inspection staff on the wards for people with learning disabilities and autism and community based mental health services for adults of working age had not completed all elements of their mandatory training. Staff reported that they had access to and were well supported to attend conferences, access specialist training and were able to visit other services.
The trust’s target rate for appraisal compliance was 90%. As at 31 January 2018, the overall appraisal rates for non-medical staff was 96%.
20171116 900885 Post-inspection Evidence appendix template v3 Page 15
The core services failing to achieve the trust’s appraisal target were ‘MH - Substance Misuse’ with 89%.
Core Service Total number of
permanent non-
medical staff
requiring an
appraisal
Total number of
permanent non-
medical staff
who have had
an appraisal
Appraisa
l rate (%)
MH - Community mental health services for people with learning
disabilities or autism 39 39 100%
MH - Forensic inpatient 55 55 100%
Other 6 6 100%
MH - Long stay/rehabilitation mental health wards for working age
adults. 110 109 99%
MH - Wards for older people with mental health problems 84 83 99%
MH - Mental health crisis services and health-based places of
safety 93 91 98%
MH - Acute wards for adults of working age and psychiatric
intensive care units 181 175 97%
Other - ASC service 116 113 97%
MH - Community-based mental health services for adults of
working age 226 216 96%
MH - Community-based mental health services for older people 119 114 96%
MH - Other Specialist Services 311 300 96%
MH - Wards for people with learning disabilities or autism 28 26 93%
Other - PMS service 48 43 90%
MH - Substance Misuse 79 70 89%
Total 1495 1440 96%
Staff received a values based appraisal and the trust achieved its appraisal target rate. However,
both the chief executive and the director of human resources identified that there was scope for
improvement in the quality of appraisals; although there was no clear plan in place to address this.
The trust’s target rate for appraisal compliance was 90%. As at 31 January 2018, the overall appraisal rates for medical staff was 98%. This was a significant improvement since our last inspection. All of the ten core services achieved the trust’s target appraisal rate.
Core Service Total number of
permanent
medical staff
requiring an
appraisal
Total number of
permanent
medical staff
who have had
an appraisal
Appraisal
rate (%)
MH - Acute wards for adults of working age and psychiatric 5 5 100%
20171116 900885 Post-inspection Evidence appendix template v3 Page 16
Core Service Total number of
permanent
medical staff
requiring an
appraisal
Total number of
permanent
medical staff
who have had
an appraisal
Appraisal
rate (%)
intensive care units
MH - Community mental health services for people with learning
disabilities or autism 1 1 100%
MH - Community-based mental health services for older people. 11 11 100%
MH - Forensic inpatient 3 3 100%
MH - Long stay/rehabilitation mental health wards for working
age adults 2 2 100%
MH - Mental health crisis services and health-based places of
safety 8 8 100%
MH - Other Specialist Services 10 10 100%
MH - Substance Misuse 3 3 100%
MH - Wards for older people with mental health problems 3 3 100%
MH - Community-based mental health services for adults of
working age 11 10 91%
Total 57 56 98%
The trust had a target of 66% for staff receiving clinical supervision. Of concern was at 28 February 2018, the non-medical overall clinical supervision compliance rate was 64%. Six of the eight services in the table below did not meet the trusts target of 66%. The chief executive accepted that this was a governance issue of concern as the trust had not identified the issue prior to the inspection.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. Five of the eleven core services achieved the trust’s clinical supervision target.
Core Service Formal supervision
sessions each
identified member of
staff had in the period
Formal supervision
sessions each
identified member
should of staff have
received
Clinical supervision
rate (%)
MH - Mental health crisis services and health-
based places of safety 491 525 94%
MH - Community mental health services for
people with learning disabilities or autism 114 129 88%
MH - Long stay/rehabilitation mental health
wards for working age adults 281 321 88%
MH - substance misuse 158 184 86%
MH - Other Specialist Services 126 170 74%
MH - Community-based mental health services 342 579 59%
20171116 900885 Post-inspection Evidence appendix template v3 Page 17
Core Service Formal supervision
sessions each
identified member of
staff had in the period
Formal supervision
sessions each
identified member
should of staff have
received
Clinical supervision
rate (%)
for older people
MH - Wards for people with learning disabilities
or autism 45 81 56%
MH - Community-based mental health services
for adults of working age 155 287 54%
MH - Wards for older people with mental health
problems. 180 363 50%
MH - Forensic Inpatient 42 96 44%
MH - Acute wards for adults of working age
and psychiatric intensive care units. 249 685 36%
Total 2183 3420 64%
The trust was asked to comment on their targets for responding to complaints and current performance against these targets for the last 12 months.
In Days
Current
Performance
What is your internal target for responding to* complaints? 3 days 100%
What is your target for completing a complaint? 25 days 71%
If you have a slightly longer target for complex complaints please
indicate what that is here - -
* Responding to defined as initial contact made, not necessarily resolving issue but more than a confirmation of
receipt
**Completing defined as closing the complaint, having been resolved or decided no further action can be taken
Total Date range
Number of complaints resolved without formal process*** in the last
12 months 127
1 March 2017 to
28 February
2018
Number of complaints referred to the ombudsmen (PHSO) in the last
12 months 3
1 March 2017 to
28 February
2018
**Without formal process defined as a complaint that has been resolved without a formal complaint being made. For
example PALS resolved or via mediation/meetings/other actions
A complaints and comments policy was in place, which was clear and easily understood. The
policy identified that complaints should be acknowledged on the day of receipt and an
investigating officer to be identified within three working days. Investigation of the complaint should
be complete within 22 working days and a response provided from the chief executive within 25
working days.
The chief executive was the executive lead for complaints. There was also a non-executive lead.
The day to day responsibility was held by the head of corporate affairs. The total number of staff
dedicated to complaints was the head of corporate affairs supported by a corporate affairs officer
20171116 900885 Post-inspection Evidence appendix template v3 Page 18
and an administration assistant. The team was without one member of staff due to maternity leave
and attempts to cover this post temporarily had been unsuccessful. The team felt that they were
stretched and had difficulties with the workload, however, the lead for complaints acknowledged
the support they received directly from the chief executive.
The trust board had delegated the governance arrangements for complaints to the quality
assurance committee. The complaints/compliments quarterly reports were provided to the
committee, the head of corporate affairs attended the relevant meetings to speak to the report.
The reports were also tabled at the service user safety group meetings where the head of
corporate affairs attended on a quarterly basis to speak to the report.
The trust website contained information on the complaints process and explained how people
could make complaints. It also provided contact numbers for those wanting more information.
There was a dedicated complaints inbox and complaints literature was available on all trust sites.
All complainants were offered the opportunity to meet with the chief executive to discuss their
complaint.
The complaints policy outlined actions, which should be taken if a complaint raised concerns with
regard to an adult at risk and possible physical, financial, psychological or any other kind of abuse.
However, it was identified at interview that if a complaint had not been received from an inpatient
area, then safeguarding concerns would not be routinely considered. This may lead to a
vulnerable person not receiving the appropriate safeguards.
We reviewed four complaints files and found that there was no standard format and no contents or
checklist to identify whether all actions had been completed. All but one of the complaints we
reviewed were acknowledged within the appropriate timescale, however one complaint, although
thoroughly investigated took over six months to complete. One complaint was acknowledged
seven days after receipt and put on hold. The complaint was withdrawn five months after it was
raised, however there was little information in the file to demonstrate what investigation had taken
place up to the time it was withdrawn. Completed complaints all had clear action plans with dates
for completion. Outcome letters were open and transparent with an apology provided to the
complainant appropriately.
This trust received 651 compliments during the last 12 months from 1 March 2017 to 28 February
2018. ‘Wards for older people with mental health problems’ had the highest number of
compliments with 34%, followed by ‘Community-based mental health services for adults of working
age’ with 23%.
Governance
The trust had a clearly defined operating, performance and governance structure that connected frontline clinical services with the board. The structure was refreshed and formally approved by the executive directors group in March 2018 following a clinical directorate restructure. The previous governance structures had not provided assurance regarding the quality and safety of services. The executive team now believed that the new governance systems and processes were more robust than those previously in place and these systems were currently being embedded across the trust but it was too early to assess with confidence how well this was working. On this inspection, it was clear that these systems were not yet embedded across front line services because the latest policies and procedures were not always being implemented. Policies had been ratified by the trust but had not been introduced on the forensic/low secure wards. In acute wards for adults of working age patients were not being monitored in line with trust policy following the administration of rapid tranquillisation.
20171116 900885 Post-inspection Evidence appendix template v3 Page 19
There was a committee structure in place, with each committee chaired by a non-executive director with the appropriate skills and knowledge, reporting to the board. The committees were: • remuneration and nominations committee • audit committee • finance and investment committee • quality assurance committee • workforce, organisation and development committee. There was a reporting structure in place to manage the flow of information from directorate to executive management team and through to the board and relevant sub-committees. On a monthly basis, the director of operations provided a performance assurance report to the board that provided commentary to key exceptions, the plan to mitigate and timescale for update reporting to the board. This was supported via a performance dashboard derived from information reported by frontline teams. Clinical operations were represented on a variety of board sub-committees. Each directorate held monthly governance meetings in which wards and teams were represented. The service user safety group reported to the quality assurance committee and provided a forum for more detailed, deep dive discussions into particular thematic trends, the opportunity to share learning and practice and commission further work to support front line services. The structures and processes had not ensured that all breaches of Regulation identified at the last inspection had been addressed. In forensic wards work had not yet started to improve the seclusion room to meet the standard required in the Mental Health Act code of practice. Within the trust’s governance structure, there was a multi-disciplinary medicines optimisation committee, chaired by the chief pharmacist that reports to the service user safety group. The chief pharmacist is accountable to the medical director, and there was a clear line of sight to the Quality Assurance Committee at executive level. Medicines incidents were reviewed at a monthly medicines safety group meeting, however these were not always quorate as medical and risk department attendance was variable. The pharmacy service submitted a quarterly medicines safety report to the service user safety group. However, with the exception of reporting staff sickness, appraisal and compliance with mandatory training, there were no agreed performance measures to give assurance to the board about the performance of the pharmacy service. The pharmacy service outsourced their out of hours medicines supply to the local acute trust, however there was no formal contract or service level agreement in place to govern this relationship and ensure the quality of the service and performance of the contractor. Oversight of the Mental Health Act was provided through mental health legislation committee, the executive directors group and the quality assurance committee. There was an executive director Mental Health Act lead at board level through the director of nursing, but no non-executive director lead. The Mental Health legislation committee was a decision-making, monitoring and oversight sub-committee of the executive directors group, which met monthly. The committee monitored the use of the Mental Health Act in the trust, including key performance indicators and issues arising from the trust’s section 75 partnership with the local authority. It also received minutes from the associate hospital managers’ meetings. There were 19 associate hospital managers, which was sufficient for an organisation of its size, the ethnic mix was reflective of the area, and however, was not age representative as none were under the age of 55. There were robust systems in place in the Mental Health Act office, however these were in the process of being reviewed and formalised using a Microsystems approach.
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The trust provided its Board assurance framework. This detailed any risk scoring five or higher and gaps in the risk controls that affect strategic ambitions. The trust outlined four strategic aims:
1 – Quality and safety 2 - People 3 – Future services 4 – Value for money
There were arrangements for identifying and managing the risks facing the organisation. The trust
had a board assurance framework that was used to inform the trust board agenda and was
populated utilising the trust’s risk management system. The Audit Committee identified papers
presented to board committees, which provided assurance against the strategic and delivery
objectives within the strategic planning framework 2017-2020. This evidenced mitigation of the
strategic risks contained within the board assurance framework including highlighting the board
assurance framework risks for which no reports had been received.
The board assurance framework was reviewed twice a year by the internal audit department and
significant work had been undertaken to improve the framework. The framework was split and
was discussed at the relevant committees with the complete board assurance framework reviewed
in each committee on a quarterly basis. Both the board assurance framework and the trust risk
register were discussed in the audit committee. This provided assurance to the board that risks
were being appropriately identified and managed.
The corporate risk register is a mechanism to manage high level risks facing the organisation from
a strategic, clinical and business risk perspective. The high level strategic risks identified in the
corporate risk register were underpinned and informed by risk registers overseen at the local
operational level within directorates.
The corporate risk register was presented to the executive directors group on a monthly basis for
the review of all risks. In addition, the group received details of escalated risks from directorate risk
registers on a monthly basis in order to determine their appropriateness for inclusion on the
corporate risk register. Relevant risks were also presented to board committees on a quarterly
basis. Board committees were required to ensure that papers presented provided sufficient
assurance that risks were being managed.
Key:
High (15-20) Moderate (8-15) Low 3-6 Very Low (0-2)
The trust has provided a document detailing their highest profile risks. Each of these have a risk
score of 15 or higher.
ID Risk Type Details Risk level
(residual)
Last review
date
3679 Safety Risk of harm to service users via ligatures 15 7 February
2018
20171116 900885 Post-inspection Evidence appendix template v3 Page 21
Further high profile risks had been included on the register at the time of inspection. These related
to significant issues at the single point of access in relation to high call volumes thus resulting in
reputational damage and the inability to deliver timely triage and assessment at the single point of
access/crisis hub during times of higher demand.
Each team had its own risk register and staff in the organisation knew what the issues on their
team risk registers and how to escalate those risks to the directorate risk register. Team risk
registers were discussed in the monthly care network governance meetings. Pharmacy had a local
risk register in place, which was reviewed at monthly departmental meetings.
Risks were escalated to the directorate or corporate risk registers if they exceeded a set threshold.
We saw how risks had been escalated from team risk registers through to the corporate risk
register via the care networks risk registers. The risk to quality of care and patient safety during a
period of transition to the new model of service delivery for the adult recovery service throughout
2018 had also been added to the register. The risk was identified as moderate, but mitigation put
in place by the senior leadership team had not been effective in reducing risk. This had resulted in
a deterioration of the mental health crisis and health based places of safety core service, which we
found to be inadequate at this inspection.
Sheffield Health and Social Care NHS Foundation Trust has submitted details of five external reviews commenced or published in the last 12 months (1 March 2017 to 28 February 2018).
1. The trust was part of a pilot study by the Royal College of Psychiatrists regarding serious
incident investigations. An initial sharing event took place in October 2017, following which the Royal College of Psychiatrists published an occasional paper in March 2018 called 'Principles for full investigation of serious incidents involving patients under the care of mental health and intellectual disability provider organisations' which contains a set of principles for serious incident investigations.
2. On the 15 March 2018 the trust was a contributor to the Europides study into patient experience. Feedback has not yet been received.
3. CQC interviewed the trust as part of a case study regarding mental health trusts who had improved with regards to the CQC ratings. The trust’s rating had improved from 'requires improvement' to 'good'. The 'Driving Improvements' report has recently been published by the CQC.
4. The trust has been part of the CQC's whole system review in Sheffield relating to dementia care. Key outcomes are not yet known.
5. The trust participated in Healthwatch's review into the accessibility of services across different providers in Sheffield for people with hearing difficulties. Healthwatch's report has been published and the trust provided a response to Healthwatch. Recommendations made by Healthwatch relate to information on when and how to book British Sign Language interpreters, having information on complaints, concerns and advocacy being available in British Sign Language, communicating via two-way email and text messages and ensuring correspondence is written in an easy language.
Management of risk, issues and performance
Providers must report all serious incidents to the Strategic Executive Information System within
two working days of identifying an incident.
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Between 1 March 2017 and 28 February 2018, the trust reported 29 Strategic Executive
Information System incidents. The most common type of incident was apparent/actual/suspected
self-inflicted harm with 18. Ten of these incidents occurred in community-based mental health
services for adults of working age services.
Never events are serious incidents that are entirely preventable as guidance, or safety
recommendations providing strong systematic protective barriers, are available at a national level,
and should have been implemented by all healthcare providers. Sheffield Health and Social Care
NHS Foundation Trust reported no never events during this reporting period.
We asked the trust to provide us with the number of serious incidents from the same period on their incident reporting system. The number of the most severe incidents was broadly comparable with the number the trust reported to Strategic Executive Information System.
Type of incident reported on STEIS
MH
Acu
te / P
ICU
MH
Co
mm
unity A
dults o
f W
ork
ing A
ge
MH
Co
mm
unity for
Old
er
Peop
le
MH
Crisis
HB
PO
S
Oth
er
MH
Substa
nce M
isuse
Oth
er
PM
S s
erv
ice
Unknow
n
Tota
l
Apparent/actual/suspected self-inflicted harm 2 10 1 3 1 1 18
Medication incident 3 1 1 5
Apparent/actual/suspected homicide 1 1 2
Abuse/alleged abuse of adult patient by staff 1 1
Disruptive/ aggressive/ violent behaviour 1 1
Pending review 1 1
Diagnostic incident including delay 1 1
Total 3 14 2 1 3 1 1 4 29
The trust had an incident management policy and procedure that identified the responsibilities of
staff at all levels in relation to serious incidents. The head of clinical governance managed serious
incidents. They were supported by the clinical risk manager and lead nurse for investigations.
Serious incidents were investigated by clinicians working in operational services; each
investigation was undertaken by two people, one of which was a consultant psychiatrist and the
other a senior clinician. Investigators were trained in root cause analysis investigation. The clinical
risk manager delivered training to new investigators.
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During our inspection, we were informed that between nine and 12 months previously there had
been a backlog of serious incident reports due for submission to the clinical commissioning group.
The trust was breached for not meeting submission dates twice. At the factual accuracy stage the
trust submitted information to show that compliance for submission within the agreed timescales
was now at 84%. Clinicians involved in investigations negotiated the time with line managers;
however, it was acknowledged that clinicians were busy and it was not so easy to clear a
clinician’s diary in order to undertake investigations. The risk management team told us that they
supported operational services by stepping in to help clear the backlog, but could not demonstrate
any long-term plans to ensure that clinicians involved in investigations would be allocated
dedicated time to complete the investigation to meet agreed timescales.
The trust had systems in place to identify learning from incidents. The service user safety group
was responsible for ensuring that the incident management policy was effectively implemented
across the trust. The group had not ensured that all directorates had robust governance systems
in place to ensure that incidents were reported and that learning occurred at team and directorate
level. In wards for people with a learning disability and autism incidents were not reviewed quickly,
71 incidents had not been reviewed by the manager at the time of the inspection. This meant that
any learning from these incidents was not shared with staff in a timely way. Senior leaders and
managers described how learning was shared through directorate and team meetings. Staff
across the organisation told us of how they were provided with feedback following incidents within
their own teams.
However, governance systems and processes were not robust. Staff from a number of disciplines
and services reported that lessons learnt from incidents in other teams and services were not
routinely shared. This meant that safety issues which could have an impact across the trust may
not be addressed.
The Quality Assurance Committee was responsible for ensuring that incident management
processes were in place. The committee also requested assurance from the Service User Safety
Group that actions following serious incidents were effectively monitored and implemented. The
committee was also responsible for reporting on assurance to the trust board.
The local clinical commissioning group monitored the trust’s performance in the management of
serious incidents. This was completed through one to one meetings with the trust to review
progress against outstanding actions. An improvement was recognised in the trust’s timeliness in
submitting investigation reports. However, the timeliness of 72-hour reports and the trust’s
responsiveness to the commissioners’ comments following their review of reports remained an
issue.
Serious incidents were not always robustly investigated and reported. We reviewed five serious
incidents as part of our inspection and we found that two did not involve or liaise with other
agencies in the investigation, despite there being multi-agency involvement. We also found what
were described as root causes in the reports were often a list of the facts of the case rather than
an analysis of cause. Arrangements for shared learning were the same in each report reviewed,
with a standard statement that findings will be shared with teams directly involved and may be
shared with the wider directorate and that findings may be shared with the Service User Safety
Group.
The trust policy stated, service users, carers/families would be offered the opportunity to be
involved, and that where they did not wish to be involved in the actual investigation, once the
report and action plan were completed, they would be contacted again to advise them of the report
completion and to ascertain how they would like to receive feedback on the findings and a copy of
20171116 900885 Post-inspection Evidence appendix template v3 Page 24
the finalised report would be shared, or discussed, with them, where this was requested. We only
found evidence of patient or family involvement in two reports and in one case the final term of
reference stated that patient would be given opportunity to be involved in the investigation. There
was evidence of a letter being sent but no evidence of any further correspondence with patient or
family. In another report it was unclear whether conclusions were shared with the patient, even
though the original letter prior to investigation stated that this would happen. This was not
discussed within the report and there was no evidence of further communication with patient. Two
of the cases reviewed showed that the trust’s policy for duty of candour had not been followed.
Copies of serious incident action plans were not always maintained contemporaneously to reflect
the actions undertaken by the trust. We found that action plans in one of the reports were not
signed as completed within the timescale. However, we looked at this incident within the relevant
core service and found that staff were aware of the learning and the actions were complete. This
raised concerns that systems to support information reporting by the clinical governance and risk
management team may not be robust.
Safeguarding adults and children sat within the portfolio of the director of nursing, professions and
care standards. There was a lead doctor for safeguarding in place. There had been a complete
change of personnel within the safeguarding team within the last two years, the team now had a
safeguarding lead for adults and children from a social work background and a safeguarding
advisor with a nursing background; the team were supported by an administrator.
The annual work plans were linked to Safeguarding Children / Adult Boards priorities in the local
authority, the clinical commissioning group and police priorities. Quarterly meetings were attended
by the executive nurse or deputy chief nurse to this external board. The lead professionals
supported the functions of the local safeguarding children boards and safeguarding adult boards
by attending and contributing to the subgroups and the broader activities of those boards. This
included audit activity, serious case reviews and safeguarding adults’ referrals.
Safeguarding adults and children was reported quarterly to the quality assurance committee in the
trust by the deputy chief nurse. The trust had children and adults steering groups chaired by the
deputy chief nurse to ensure communication with clinical commissioning group, local authority and
safeguarding managers. This ensured joint work plans were progressing. The safeguarding team
attended and met with senior operational managers and safeguarding managers through different
routes. This included multi-disciplinary meetings, governance meetings and group or 1:1
supervision as well as being involved in complex case reviews. The mental health crisis service
and health based places of safety and the community based mental health services for adults of
working age had trained safeguarding managers who were responsible for overseeing the
safeguarding adults processes and outcomes within the team.
The safeguarding team were enthusiastic and knowledgeable and had a clear vision, they
believed that safeguarding should be city wide to enable early identification of at risk city areas
and so that intelligence could be gathered and safeguarding implemented sooner rather than later.
It was acknowledged that this was a challenge. However, an example of joint working included a
monthly city centre anti-social behaviour meeting, in which individuals at risk across the city were
discussed. An example of this had shown that this meeting had resulted in a referral to the trust’s
services and a plan for engagement to improve the individual’s mental health and circumstances;
a man who lived in extremely poor conditions and who had some evidence of mental illness led to
a referral to the trusts single point of access team. Some five months later the team continued to
have an active plan to engage with the man.
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The safeguarding team felt that the accountable care partnership enabled and supported joint
working. They had begun a piece of work with the local authority to develop an integrated city wide
performance report and communication. This was also to involve information from the local police
service.
Mandatory safeguarding training rates had a marked increase since our last inspection. The
safeguarding training package had been reviewed in the past year and updated to reflect new
emerging themes such as human trafficking, self-neglect, domestic abuse, female genital
mutilation and Prevent items. The team told us that safeguarding referrals had increased by 40
percent over the past year, with a significant increase in notifications of self-neglect.
Providers are encouraged to report patient safety incidents to the National Reporting and Learning
System at least once a month. They do not report staff incidents, health and safety incidents or
security incidents to National Reporting Learning System.
The highest reporting categories of incidents reported to the National Reporting Learning System
for this trust for the period 1 March 2017 to 28 February 2018 were patient accident, disruptive,
aggressive behaviour (includes patient-to-patient) and self-harming behaviour. These three
categories accounted for 2839 of the 4351 incidents reported. Self-harming behaviour accounted
for 24 of the 30 deaths reported.
Seventy eight percent of the total incidents reported were classed as no harm and 17% were
classed as low harm.
Incident type No harm Low harm Moderate Severe Death Total
Patient accident 1099 83 14 2 0 1198
Disruptive, aggressive
behaviour (includes patient-to-
patient)
944 148 33 1 0 1126
Self-harming behaviour 343 136 10 2 24 515
Medication 343 61 7 2 1 414
Access, admission, transfer,
discharge (including missing
patient)
88 131 53 0 0 272
Other 224 36 3 0 5 268
Treatment, procedure 146 45 7 1 0 199
Infrastructure (including staffing,
facilities, environment) 104 67 18 0 0 189
Implementation of care and
ongoing monitoring / review 10 22 10 0 0 42
Patient abuse (by staff / third
party) 32 4 4 0 0 40
Clinical assessment (including
diagnosis, scans, tests,
assessments)
19 12 4 1 0 36
Consent, communication,
confidentiality 19 2 3 0 0 24
Documentation (including
electronic & paper records, 9 3 1 0 0 13
20171116 900885 Post-inspection Evidence appendix template v3 Page 26
Incident type No harm Low harm Moderate Severe Death Total
identification and drug charts)
Medical device / equipment 8 1 0 0 0 9
Infection Control Incident 3 3 0 0 0 6
Total 3391 754 167 9 30 4351
Organisations that report more incidents usually have a better and more effective safety culture than trusts that report fewer incidents. A trust performing well would report a greater number of incidents over time but fewer of them would be higher severity incidents (those involving moderate or severe harm or death). Sheffield Health and Social Care NHS Foundation Trust reported more incidents from 1 March 2017 to 28 February 2018 compared with the previous 12 months.
Level of harm 1 March 2016 to 28 February
2017
1 March 2017 to 28 February
2018
No harm 3211 3391
Low 609 754
Moderate 125 167
Severe 8 9
Death 24 30
Total incidents 3977 4351
Staff were encouraged and knew how to report incidents on the trust’s incident management
system. All medicines incidents were reviewed by the acting Medicines Safety Officer.
Information Management
Leaders in the trust undertook the necessary information management roles. These included leaders allocated to be the Caldicott Guardian, Senior Information Risk Owner, Chief Clinical Information Officer and a Clinical Safety Officer. The trust also had a director of Information Management, Systems and Technology who was a chief information officer. The trust had ensured that the appropriate actions were taken in line with the General Data Protection Regulation introduction.
The trust’s information management systems were fit for purpose and provided the technical capability and infrastructure required at the time. The information systems in place were initially built by the trust 15 years previously. These had been maintained with additional capabilities and developments added on as required. The trust had identified that significant digital developments were required as the system was underpinned by dated technology and software and there had been some unplanned power outages, which could pose significant risks to performance and safety.
The trust had systems and processes to mitigate and manage potential risks to information management and information technology systems within the trust. This included the cyber threats and security breaches. Examples of these included: regular user and administrator password changes and the trust also sent out some pseudo phishing emails sent to staff. If staff responded to these, they provided education on security and risks. The trust also ensured that they received and acted upon communication from NHS Digital’s Care Computer Emergency Response Team.
20171116 900885 Post-inspection Evidence appendix template v3 Page 27
The team send external alerts to trusts and provided co-ordinated responses to try and deal with cyber security threats. The trust reported no cyber security incidents to date.
The trust had effective information governance arrangements in place. These included a data information governance board and a digital transformation board that oversaw the systems and processes around information management and the future digital strategy.
At the time of our inspection, the strategic outline case for digital integrated mental health care programme was in the process of going to board for approval. The trust had developed strong working links with local systems partnerships and digital programmes at a national level. In particular, the trust had been selected by NHS Digital to participate in a collaborative partnership with another trust in the NHS Mental Health Global Digital Exemplar Programme. This programme matched trust financial investment and is aimed at identifying digital systems and models that are effective and can be used more widely across NHS services. The strategic case had been through the appropriate governance processes prior to being discussed at board and had involved operational staff working in and managing frontline services. The board had requested further capacity impact consideration on operational staff prior to a decision being made.
Engagement
The trust held an annual members’ meeting, which provided an opportunity for members and the public to learn more about the trust, its services and to ask questions. Monthly open board of directors’ meetings were held and the papers and agendas for those meetings were published on the trust’s website. The website and other social media channels were used to engage with the public. Patients and carers were members of the service governance structures and actively participated in groups to contribute to planning and service improvement such as the inpatient forum, Service User Safety Group and restrictive interventions project group.
The main service user network (SUN:RISE) met monthly and followed a formal business agenda, but also had guest speakers invited which had included regular presentations on the planned changes to adult community mental health services. SUN:RAYS and SUN:LITES groups addressed topics, which were relevant to individual services.
The service user engagement group members held bi-monthly roadshows at varying sites across the trust, to collect both patient and staff views on improving service user experience. A particular emphasis was placed on working with and learning from harder to reach groups and external organisations such as: The Alzheimer’s Society, and the Sheffield African Caribbean Mental Health Association.
The trust had a council of governors that included publicly elected governors, elected staff governors and governors appointed to represent organisations regarded as the trust’s stakeholders or partners. They were provided with training on their appointment and had access to ‘govern well training’ and training in information technology was also available if required. The trust did not provide any ongoing training, but it was acknowledged they should.
Governors and staff participated in a number of community events, such as the Wellbeing Festival and Sheffield Mental Health Week to recruit and engage members from across the city. However, some governors we spoke with told us that support for attendance at these events had reduced. Feedback from the governors regarding engagement with the trust was mixed; some governors felt they were unable to challenge the non-executive directors as their questions were nearly always answered by executive directors. They also felt that the agenda for their meetings did not always include items they had requested. Whereas, others felt the trust provided opportunities to engage with meetings and committees.
Governors said they were well supported by the deputy board secretary and some spoke about an open culture among the trust board. However, some governors said they felt that they were not as engaged as they had been previously and that it was difficult to get answers to questions raised. Both the chief executive and the chair recognised that the relationship with some governors had
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deteriorated in recent months and had identified issues, which needed to be resolved to ensure the council of governors was able to fulfil its obligations.
The work of service users in the Reducing Restrictive Practice Group had been instrumental in the trust leading the way nationally in eliminating the use of face down restraint on in-patient wards. Figures released by NHS Benchmarking, showed that the trust had the lowest level of face-down restraint across England and Wales, and year on year the use of face-down (prone) restraint in the trust had reduced. In the past eighteen months there had been no use of face down restraint in the trust.
The trust was engaged with a number of partner organisations in order to develop and improve the service provided to its population. These included but were not limited to:
• A formal partnership agreement between the trust and Primary Care Sheffield to enable them to deliver effective primary medical services within general practices across Sheffield. Engagement and feedback took place via a joint executive board between the two organisations. An example of successful joint working was system wide work on the Older People's Pathway. This was a collaborative referral pathway located on the GP press portal for every GP in the city.
• The trust had a contract with Sheffield Flourish to support service users on their recovery journey. Projects included the Oasis garden project, which supported people into training and work, and the Brunsmeer Football programme, which addressed physical wellbeing and challenging stigma through football. Engagement and feedback with service users was built into the design of the projects.
• The trust had a range of contracts and partnership projects with South Yorkshire Housing Association, including a dementia care home, and the joint delivery of community enhanced recovery support with South Yorkshire Housing Association’s Living Well Team. This team aims to meet the needs of people with severe mental health problems returning to Sheffield from out of area placements to their own tenancies.
• The trust worked jointly with Rethink to establish a crisis house as an integral part of the acute care pathway.
The trust was an outward facing organisation, we saw how planning and decision-making was conducted not only for the benefit of the trusts current patient population, but also considered how they might benefit the whole population of the city of Sheffield. The trust had a strong position in the integrated care system and the chair described how a third of her time was spent working with stakeholders, which included membership of the accountable care partnership oversight and assurance group, the integrated care system governance sub group and health and wellbeing board. Other members of the executive team, including the chief executive and the director of human resources had roles within the integrated care system and accountable care partnership.
The trust had a good a working relationship with the local clinical commissioning group and although there had been previous difficulties, the relationship with the local authority was now described as good by the chief executive. This view was supported in feedback from the local authority who told us that senior managers were outward looking, innovative and open to new ways of working to meet the needs of stakeholders.
The trust had worked collaboratively with the local clinical commissioning group to improve and develop services to meet the needs of its patients and the Sheffield population in line with Mental Health Five Year Forward View. To support strategic planning and the implementation of transformation a tripartite arrangement had been developed to progress changes through a clear programme of work. A senior programme post was jointly funded between the trust, the clinical commissioning group and the local authority with significant progress being made with a joint memorandum of agreement and financial risk share being developed.
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There were service level agreements and memorandum of understanding with the local acute trust and children’s hospital trust to provide support over Mental Health Act documentation and provide advice. Multi-agency policies and protocols were in place for Mental Health Act issues and a multi-agency place of safety protocol had been developed.
Learning, continuous improvement and innovation
The executive lead for research and clinical audit was the medical director and they were supported by a director of research and development. A research champions network that met regularly with the director had been set up to promote research across the trust.
The trust worked closely with the Yorkshire and Humber Collaboration for Leadership in Applied Health Research and the Yorkshire and Humber Local Research Network and had strong links with academic partners, including the two universities in Sheffield.
The trust was involved in a research project with a local university entitled ‘Journeying through Dementia’. This was a research project where people with dementia worked alongside researchers to co-create a self-management programme for people with dementia.
The trust used the Join Dementia Research tool designed by the National Institute for Health Research in association with Alzheimer’s Research UK and the Alzheimer’s Society to match service users who have expressed an interest in research with appropriate studies.
At the end of 2017/18 there were 39 active clinical research projects underway in the trust; these included:
• A randomised controlled trial of an intervention to reduce or prevent weight gain in severe mental illness.
• A trial comparing the effectiveness of counselling for depression with cognitive behavioural therapy.
• A multi-centre trial of a self-help intervention to improve quality of life in Alzheimer’s disease.
• Support for the families and carers of service users with dementia.
• Interventions for service users with eating disorders.
• The effectiveness of services for mothers with mental illness.
• Co-morbidities between physical health and mental health.
• Pharmaceutical trials of new drugs for service users with dementia (including Alzheimer’s disease).
During 2017/18 the trust were involved five national clinical audits and four national confidential enquiries, these were as follows:
• Mental Health Clinical Outcome Review Programme
o Suicide in children and young people
o Suicide, homicide and sudden unexplained death
o The management and risk of patients with personality disorder prior to suicide and homicide
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• Learning Disability Mortality Review Programme (LeDeR Programme)
• National Core Diabetes Audit
• National Audit of Early Intervention Services
The trust participated in benchmarking audit through POMH-UK (Prescribing Observatory for Mental Health UK), these included:
• POMH Topic 17: Use of depot/long acting antipsychotics for relapse prevention
• POMH Topic 15: Prescribing valproate for bipolar disorder
Actions were developed following a high dose and combination antipsychotics audit to reduce the use of high dose and combinations, particularly on the acute mental health wards. The audit also identified an increase in the use of a single antipsychotic on forensic wards, but relatively high use of high dose and an increase in combination antipsychotics prescribed on the rehabilitation wards. Work was planned with rehabilitation wards to link monthly monitoring to multi-disciplinary reviews and team governance.
The trust conducted a range of local clinical audits, including an audit of physical investigations for admitted psychiatric patients, which led to an increased awareness of the physical health investigations standard operating procedure. Physical health monitoring in the early intervention service led to the services microsystems team leading the development of changes in team practice to drive the necessary improvements.
Wards and teams also undertook audits locally and we saw actions to improve following audits within clinical areas.
The Transforming Acute Care Programme implemented a new model of in-patient care for mental health service users with the result that far fewer Sheffield residents were being sent out of city for treatment and care. This was highly commended in the National Positive Practice Awards. The quality improvement team, which included an expert by experience who was appointed as an improvement coach to enhance the concept of co-production with service users and carers in all quality improvement activity, was highly commended in the quality improvement category. This reflected the quality improvement work supported by the microsystem improvement methodology that is championed across the trust.
Microsystem improvement involves engaging members from individual teams (the microsystem) to work collectively as an interdisciplinary group to improve the quality of care for patients as well as the workplace for staff who work there. A trained microsystem coach facilitated teams, through a structured improvement process, engaging and empowering front line staff, patients and carers to design and influence change from the front-line. At the time of our inspection there were 15 service users and family members who regularly participated in microsystems meetings. There were 35 members of staff who had been trained as a microsystem coach by the Sheffield Microsystem Coaching Academy, with 43 teams having used the approach to implement quality improvements.
Improvement stories and good practice were shared through internal directorate governance structures, the trusts intranet, the Sheffield Microsystem Coaching Academy website, local and national conferences and award ceremonies.
The trust holds an annual quality improvement event where staff and service users are invited to take part. Examples of influencing improvements include:
• Short Term Education Programme - three service users contributed to changes aiming to improve attendance rates and are subsequently involved in the review.
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• Intermediate Care Beds introduced a workbook to promote patient activation to their well-being.
• The Sheffield Community Brain Injury Rehabilitation Team identified a feedback station in their waiting area as a result of service user suggestion.
Other initiatives included leadership development workshops, and leadership engagement network events where the chief executive met with frontline leaders to converse, listen and interact on a direct level.
Historical data Projections
Financial Metrics Previous financial
year (2 years ago)
Last financial year
(2017)
This financial year Next financial year
(2019)
Income £128.216m £121.170m £120.371m £115.025m
Surplus (£0.139m) £1.529m £4.576m £1.502m
Full costs (£128.605m) (£122.580m) (£115.769m) (£113.630m)
Budget £1.234m £0.970m £1.529m £1.502m
NHS trusts can take part in accreditation schemes that recognise services’ compliance with standards of best practice. Accreditation usually lasts for a fixed time, after which the service must be reviewed.
The table below shows services across the trust awarded an accreditation (trust-wide only) and the relevant dates.
Accreditation scheme Core service Service accredited Comments and Date of accreditation /
review
AIMS - Rehab (Rehabilitation
wards)
Long stay /
rehabilitation
mental health
wards for working
age adults
Forest Close
At peer inspection stage
Quality Network for Perinatal
Mental Health Services
(QNPMH)
n/a Perinatal Mental
Health Services
At peer inspection stage
ECT Accreditation Scheme
(ECTAS)
n/a ECT Suite
September 2016 - 2019
Psychiatric Liaison
Accreditation Network (PLAN)
n/a Liaison Psychiatry
21st March 2017- 2020
Memory Services National
Accreditation Programme
(MSNAP)
n/a Sheffield Memory
Service
July 2015 - 2018. Accredited since
2010. Most recent reaccreditation
2017
Royal College of Psychiatry -
Home Treatment Accreditation
Standards (HTAS)
Specialist
community mental
health services for
adults
South West Home
Treatment Team
Accredited December 2016 - 2019
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The trust had a learning from deaths policy, which outlined staffs’ roles and responsibilities relating
to learning from deaths and promoted a culture of learning. Systems were in place to identify and
learn from all deaths, including unanticipated deaths. The trust was part of Northern Alliance (an
alliance of mental health trusts in Yorkshire, Cumbria and the North East) which formed following
the published outcome of the Mazars’ report into all deaths of service users who received mental
health or learning disability services at Southern Health NHS Foundation Trust in order to develop
a common approach to mortality across the region. Mortality was reviewed using information
reported through the trusts incident management system as well as deaths recorded through the
national death reporting mechanisms.
The trust had an established Mortality Review Group, which was chaired by the medical director,
and had robust systems in place to review all deaths of patients with mental health problems or a
learning disability against set criteria in line with the trust’s policy. The group met weekly and
considered all deaths that had been recorded as an incident on the trust’s risk management
system, together with sampling a number of deaths not recorded as an incident, but whose death
has been recorded through national death reporting processes. Each death was considered to
ascertain if sufficient information was known about the care provided leading up to the person’s
death, to enable the group to be satisfied and assured. Each case was closed only when the
mortality review group were satisfied with the response to the review and were assured that
contact with families had taken place to enable them to identify any concerns. Unexpected deaths
could also be subject to further review using the Structured Judgement Framework tools.
Structured judgement review methodology is used in practice within a large NHS region. It is
based upon the principle that trained clinicians use explicit statements to comment on the quality
of healthcare in a way that allows a judgement to be made that is reproducible. Unexpected
deaths, not thought to be from natural causes, may be subject to a review of care in line with the
trusts serious incident policy which may lead to a further investigation using root cause analysis
techniques.
The trust also participated in the Learning Disabilities Mortality Review programme, commissioned
by NHS England to ensure that the reviews of deaths lead to learning and improvement in
services for people with learning disabilities. The trust had reported eight deaths to the Learning
Disabilities Mortality Review programme during quarter 4 2017/18, but at the time of inspection
had not received any findings or lessons learned.
As required by NHS England national quality board the trust report their mortality to a public board
meeting on a quarterly basis through a mortality review paper produced by the mortality review
group and monthly via the safety dashboard, a tool developed by the Northern Alliance, which
recorded learning points arising from serious incident investigations that will potentially result in
changes in practice.
The trust were instrumental in developing the Sheffield case register to ensure that notification
was received regarding the death of any person with a learning disability in the city. The need was
identified due to the number of people with a learning disability accessing the local acute hospitals
trust who were not necessarily in contact with services at Sheffield Health and Social Care NHS
Foundation Trust. The register is now used city wide by organisations providing services to people
with a learning disability to record deaths and facilitate learning, which would otherwise not have
been shared. We saw an example of how an issue with posture management led to the
amendment of the assessment following a citywide audit of practice. Speech and language
therapists and physiotherapists are now working together, to use the same assessment tool.
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Mental health services Forensic inpatient/secure wards
Facts and data about this service
Sheffield Health and Social Care NHS Foundation Trust has two low secure forensic mental health inpatient wards. Each ward provides care and treatment for up to 11 patients. All the patients who receive care on these wards are detained under the Mental Health Act 1983. Forensic inpatient wards are located at Forest Lodge and are separated into assessment and rehabilitation wards.
Location site name Ward name Number of beds Patient group (male,
female, mixed)
Forest Lodge Assessment
Ward 11 Male
Forest Lodge Rehabilitation
Ward 11 Male
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Is the service safe?
Safe and clean care environments
Safety of the ward layout
Staff carried out regular risk assessments of the care environments. During a previous inspection a number of ligature risks had been highlighted. None of the wards presented a high level of ligature risk and both wards presented a lower risk due to the acuity of service users and remaining anchor points. The trust had identified the remaining ligature risks and renovation work was being carried out to further reduce these.
There were ligature risks on both wards within this core service. The trust had undertaken recent (from 1 April 2017 onwards) ligature risk assessments at one location. None of the wards had not had a ligature risk assessment in the last 12 months.
The trust had taken the following actions to mitigate ligature risks: Risk management of service users includes risk assessment, observations levels, and removal of items that may be used.
During our inspection, work was underway to replace all the doors in the service to ensure they did not provide anchor points. All doors were being replaced with anti-barricade doors and handles were anti-ligature alternatives. All bathrooms within the service had been renovated and replaced with anti-ligature fixtures. A ligature risk or a ligature point is anything which items could be secured onto for the purpose of strangulation or hanging.
Both wards were laid out in a way that prevented staff from observing all areas of the ward at all times. Neither ward had closed circuit television or mirrors to assist staff to see areas that were out of view. In order to reduce the risks on the assessment ward, a member of staff was assigned to observe the corridors.
The wards complied with eliminating mixed-sex accommodation. Over the 12-month period from 1 March 2017 to 28 February 2018 there were no mixed sex accommodation breaches within this core service.
Staff had easy access to alarms. Staff working on the wards were issued with personal infrared transmitter alarms and keys when they arrived. Alarms and keys were attached to a belt at all times which helped to ensure they would not get misplaced.
Patients did not have access to nurse call systems. None of the rooms within the service were fitted with nurse call systems and patients were not provided with any form of hand-held system. This meant that patients couldn’t summon help if they needed it.
Maintenance, cleanliness and infection control
All areas were clean, had good furnishings and were well maintained. The trust employed housekeeping staff to carry out cleaning activities on both wards. A cleaning schedule was in place for each ward which showed cleaning for the service was carried out in accordance with the schedule.
The most recent patient-led assessments of the care environment assessment was carried out in 2017. Forest Lodge scored higher than the similar trusts for all three of the applicable aspects overall. The scores achieved are shown in the table below:
Site name Core service(s)
provided
Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
Forest Lodge MH - Forensic 99.5% 97.3% - 92.1%
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Site name Core service(s)
provided
Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
inpatient
Trust overall 99.0% 97.8% 91.1% 91.8%
England average (Mental
health and learning
disabilities)
98.0% 95.2% 84.8% 86.3%
Staff adhered to infection control principles. There were adequate places for staff to wash their hands and alcohol hand gel was also available.
Seclusion room
The seclusion room did not comply with the requirements set out in the Mental Health Act code of practice. In our previous inspection of the service we identified that the seclusion room was not in accordance with the Mental Health Act code of practice as staff would not be able to see patients if they were to close the door to the toilet area. In order to mitigate the risk, the door to the toilet area was now left open at all times.
During this inspection we found that the door on the seclusion room toilet was now left open at all times and staff were required to watch patients throughout the time in the toilet. This was to prevent patients from harming themselves while using the facilities. However, we were concerned that this meant patient privacy and dignity was not protected.
The trust was made aware of our concerns at the time of the last inspection and a plan was put in place to have the seclusion room renovated. The trust was granted funding to have this work carried out the week before our inspection and it has now been agreed that work can commence in November 2018.
There was a seclusion mattress in place and patients were able to see a clock for orientation to time. There was two-way intercom in place however, communications were not clear and staff told us it was often difficult to hear what was being said.
Staff were positioned outside the seclusion room for the time it was in use, observing patients and carrying out physical health observations. Staff were able to see patients from a sitting or standing position with the use of mirrors through the observation hatch. Patients had access to a toilet and washing facilities in a room adjacent to the sleeping area.
Clinic room and equipment
Wards had access to resuscitation equipment and emergency drugs. Each ward had a clinic room which contained emergency bags and the equipment required by the Resuscitation Council for use in an emergency. Staff checked equipment regularly to ensure they were ready for use if required.
Clinic rooms did not always have sufficient space. The clinic room on the assessment ward was very small and there was no room for an examination couch. Staff had access to equipment to carry out physical health observations however examinations had to be carried out in patient bedrooms. We spoke with the ward manager about this and were told there had been no incidents because of this practice.
The clinic room on the rehabilitation ward was new and although a couch had been ordered this was not in place at the time of our inspection. All the medical equipment in the clinic rooms was clean, in date and calibration of equipment had been carried out.
Staff checked the temperatures in clinic rooms and medication fridges. Temperatures in clinic rooms were controlled with the use of air conditioning ensuring they were kept within the recommended ranges for the storage of medicines.
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Safe staffing
Nursing staff
The trust provided information on key staffing indicators. The table below shows information
submitted:
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 January 2018 53.8 N/A
Total number of substantive staff leavers 1 February 2017 to 31 January 2018
5.2 N/A
Average WTE* leavers over 12 months (%) 1 February 2017 to 31 January 2018
9% 13%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31March 2018 13 N/A
Total vacancies overall (%) At 31March 2018 20% N/A
Total permanent staff sickness overall (%)
Most recent month (At 31 January 2018)
6% 5%
1 February 2017 to 31 January 2018
5% 5%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 March 2018 22 N/A
Establishment levels nursing assistants (WTE*) At 31 March 2018 29 N/A
Number of vacancies, qualified nurses (WTE*) At 31 March 2018 1 N/A
Number of vacancies nursing assistants (WTE*) At 31 March 2018 11 N/A
Qualified nurse vacancy rate At 31 March 2018 5% N/A
Nursing assistant vacancy rate At 31 March 2018 38% N/A
Bank and agency Use
Shifts bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 March 2017 and 28
February 2018 455 (12%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses)
1 March 2017 and 28
February 2018 72 (2%) N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses)
1 March 2017 and 28
February 2018 80 (2%) N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 3008 (51%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 160 (<1%) N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants)
1 March 2017 and 28
February 2018 186 (<1%) N/A
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*Whole-time Equivalent
This core service reported an overall vacancy rate of 5% for registered nurses at 31 March 2018.
The vacancy rate for registered nurses was higher than the 0% reported at the last inspection.
This core service reported an overall vacancy rate of 38% for nursing assistants.
The vacancy rate for nursing assistants was higher than the 16% reported at the last inspection.
This core service has reported a vacancy rate for all staff of 20% as of 31 March 2018. This was higher than the rate (14%) reported at the last inspection (between 1 August 2016 and 31 July 2017).
Registered nurses Health care assistants Overall staff figures
Ward/Tea
m
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Forest
Lodge 1 22 5% 11 29 38% 13 65 20%
Core
service
total
1 22 5% 11 29 38% 13 65 20%
Trust
total 32 433 7% 15 353 4% 68 1339 5%
NB: All figures displayed are whole-time equivalents
The trust submitted data regarding covering shifts for registered nurses. This showed that between 1 November 2016 and 31 October 2017, that bank staff filled 10% and agency staff filled 3% of shifts to cover sickness, absence or vacancy for registered nurses.
Two percent of shifts were unable to be filled by either bank or agency staff.
Between 1 March 2017 and 28 February 2018, bank staff filled 12% of shifts to cover sickness, absence or vacancy for qualified nurses.
In the same period, agency staff covered 2% of shifts for qualified nurses. Five percent of shifts were unable to be filled by either bank or agency staff.
The table below shows the number of registered nurse shifts filled by bank and agency staff and the number of shifts which were not filled:
Ward/Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by
bank or agency staff
Assessment
Ward 1939 170 (9%) 16 (1%) 126 (6%)
Rehabilitation
Ward 1719 285 (17%) 56 (3%) 60 (3%)
Core service
total 3658 455 (12%) 72 (2%) 186 (5%)
Trust Total 32,394
4977
(15%)
7252
(22%)
900
(3%)
*Percentage of total shifts
Between 1 March 2017 and 28 February 2018, 51% of shifts were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.
In the same period, agency staff covered 9% of shifts. Three percent of shifts were unable to be filled by either bank or agency staff.
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Ward/Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by bank
or agency staff
Assessment
Ward 3607 2048 (57%) 145 (4%) 20 (1%)
Rehabilitation
Ward 2305 960 (42%) 15 (1%) 60 (3%)
Core service
total 5912 3008 (51%) 160 (3%) 80 (2%)
Trust Total 59,514
21,770
(37%)
5623
(9%)
1760
(3%)
* Percentage of total shifts
The trust provided information on staff turnover rates. This core service had 5.2 (9%) staff leavers between 1 March 2017 and 28 February 2018. This was lower than the 14% reported at the last inspection (between 1 August 2016 and 31 July 2017). This core service had 42 (equal to the average of 13%) staff leavers between 1 November 2016 and 31 October 2017.
Ward/Team Substantive staff
Substantive staff Leavers Average % staff leavers
Forest Lodge 53.8 5.2 9%
Core service total 53.8 5.2 9%
Trust Total 1351.6 129.6 8%
The annual sickness rate for this core service was 5% between 1 February 2017 and 31 January 2018.
The sickness rate for this core service was 7% between 1 November 2016 and 31 October 2017. The most recent month’s data submitted by the trust [October 2017] showed a sickness rate of 8%.
Sickness rates for this core service ranged between 6% in June 2017 and 9% in January 2017. The table below shows sickness rates for this core service:
Ward/Team Total % staff sickness
(at latest month)
Ave % permanent staff sickness
(over the past year)
Forest Lodge 6% 5%
Core service total 6% 5%
Trust Total 8% 7%
The below table covers staff fill rates for registered nurses and care staff between November and February 2018. The fill rates for the rehab ward were under 90% for care staff during day shifts in December 2017 and February 2018.
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> 125% < 90%
N – Nurse
C- care staff
The shift patterns for the service were;
• Early shift – 7am to 3pm
• Late shift – 1.30pm to 9.30pm
• Night shift – 9pm to 7.30am
Staffing levels were sufficient to meet the needs of patients. Staffing levels were worked out using a combination of professional judgement and workload calculations based on the Keith Hurst Tool and National Quality Boards.
During the day, there were two registered nurses and three health care support workers on the assessment ward and two registered nurses and two health care support workers on the rehabilitation ward. During the night, the assessment ward had one registered nurse and three health care support workers and the rehabilitation ward had one registered nurse and one health care support worker.
The ward manager told us that she was able to adjust the staffing levels according to the needs of the patients. However, the renovation work that had been carried out had also resulted in the need for additional staff during the day.
Although managers could increase staff numbers the trust reported that they had not been able to fill all shifts with bank and agency staff. Information provided showed that 186 (5%) shifts for registered nurses and 80 (2%) for health care support workers between 1 March 2017 and 28 February 2018 were not filled.
Wards had sufficient staff to carry out physical interventions. Forest Lodge operated a response system which ensured that were staff could get assistance quickly when needed. Staff told us that they were given help when needed however, some staff felt this could cause problems as it may leave the ward short staffed while they dealt with the incident.
Medical staff
There was adequate medical cover during the day and a doctor could attend the ward quickly in an emergency. We asked the trust for information regarding medical cover; however, medical locum information was not provided for this service. The trust informed us that this was because a locum had not been required at the service in the previous twelve months. The service had two consultants who equalled 1.7 whole time equivalent staff and a staff grade doctor who were on duty during the day.
During out of hours there was an on-call system in operation. Staff told us that there were occasional issues getting support from doctors as there was only one consultant to cover services throughout the Sheffield area. The trust told us that doctors were not expected to attend the ward
Day Night Day Night Day Night Day Night
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
November 2017 December 2017 January 2018 February 2018 Assessment 118.
1
97.9 106
.
105.
9
103.
5
99.
6
98.
9
100.
1
102.
8
108.
2
102.
5
103.
0
108.
4
91.
1
101.
8
102.
7
Rehabilitatio
n
96.9 100.
5
93.
3
108.
0
111.
0
86.
0
96.
8
102.
9
104.
0
95.1 96.8 97.7 101.
6
86.
3
107.
5
100
20171116 900885 Post-inspection Evidence appendix template v3 Page 40
and they were able to deal with some enquiries via telephone, although they did attend the ward to carry out seclusion reviews when required.
Mandatory training
The compliance for mandatory and statutory training courses at 28 February 2018 was 92%. Of the training courses listed one failed to achieve the trust target.
The training compliance reported for this core service during this inspection was higher than the 61% reported at the last inspection.
The table below shows the mandatory training compliance rates for this core service:
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service %
Trust target % Trustwide mandatory/ statutory training total %
Safeguarding Children (Level 2) 100% 80% 85%
Clinical Risk Assessment 100% 80% 91%
Equality and Diversity 98% 80% 95%
Fire Safety 2 years 98% 80% 96%
Hand Hygiene 98% 80% 94%
Health and Safety (Slips, Trips and
Falls) 98% 80% 97%
Safeguarding Adults (Level 2) 98% 80% 87%
Mental Capacity Act Level 1 97% 80% 94%
Safeguarding Children (Level 3) 96% 80% 91%
Respect Level 2 93% 80% 80%
Domestic Abuse Level 2 92% 80% 85%
Dementia Awareness (inc Privacy &
Dignity standards) 91% 80% 85%
Autism Awareness 90% 80% 88%
Mental Capacity Act Level 2 89% 80% 85%
Mental Health Act 88% 80% 83%
Medicine management training 87% 80% 87%
Immediate Life Support 85% 80% 88%
Adult Basic Life Support 84% 80% 81%
Information Governance 83% 80% 80%
Rapid Tranquilisation 81% 80% 88%
Respect Level 3 77% 80% 83%
Core Service Total % 92% 80% 88%
Assessing and managing risk to patients and staff
Assessment of patient risk
Staff completed an assessment of patient risk when they arrived on the ward. The core service used the historical clinical risk management 20 tool. This is a recognised risk assessment tool which is primarily used to assess the risk of violence and aggression.
We looked at eight patient care records and found six of these had an up to date risk assessment and these had also been regularly updated. Although the other two records had a risk assessment in place, these were not up to date.
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Other parts of these patients care records contained information in relation to identified risks. Staff that we spoke to had detailed knowledge of individual patients and risk.
Management of patient risk
Staff identified and addressed specific risk issues. Records contained evidence that when required staff had ensured that the relevant professionals had been involved to mitigate potential risks.
Staff maintained regular patient observations. Staff carried out searches of patients who had been out on unescorted leave. Searches were carried out to ensure that patients did not return from leave carrying items which were banned or restricted.
Restrictions that were in place were those expected for low secure wards. The service had a list of restricted items which included razors, mobile phones and shop bought medicine like paracetamol. In addition, there was a list of prohibited items which included weapons, cigarettes and tobacco products and illicit substances. The trust was in the process of reviewing its policies, including the policy in relation to restrictive practices.
The service was set on a smoke free site and patients were supported to stop smoking with the use of nicotine replacements.
Use of restrictive interventions
Staff understood the Mental Capacity Act definition of restraint and worked within it. The service used the RESPECT model of restrictive intervention. Staff told us physical restraint was only used as a last resort and only after de-escalation had been unsuccessful.
We were told by staff that there had been a period during the last 12 months where there had been a significant increase in violence on the assessment ward. Information submitted by the trust showed there were incidents in relation to physical aggression and violence towards staff where staff had sustained injury. These incidents were related to one patient who was subsequently moved to another service. However, the trust had not been required to report any RIDDOR related incidents in relation to this. RIDDOR is the reporting of injuries, incidents and dangerous occurrences regulations.
Patients that had been subject to restraint told us they understood why they had been restrained.
There have been no instances of mechanical restraint over the reporting period.
This core service had 11 incidents of restraint (on eight different service users) and 17 incidents of seclusion between 1 March 2017 and 28 February 2018. The service rarely used rapid tranquilisation. During the period from 1 March 2017 to 28 February 2018 the trust told us the service had only used rapid tranquilisation on two occasions. We checked the records in relation to these events and found observations had been carried out and records completed to reflect this. The below table focuses on the last 12 months’ worth of data: 1 March 2017 and 28 February 2018.
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
Forest Lodge 17 11 8 0 (0%) 2 (18%)
Core service
total 17 11 8 0 (0%) 2 (18%)
Information from the trust showed there had been no long-term segregation in the service between
the dates of 1 March 2017 and 28 February 2018.
Staff used the seclusion room on the assessment ward to seclude patients. We reviewed the
seclusion records for the last three occurrences of seclusion on the ward and found that records
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were comprehensive and up to date. Records showed a clear reason for patients to be placed in
seclusion and gave details of what was needed to end the seclusion event.
Staff kept paper based observation records while patients were secluded and these were scanned
and uploaded when seclusion ended. Observation records we reviewed were clearly noted with
patient observations every five minutes. Staff were aware of their responsibilities in relation to
patient observations during the time they were in seclusion.
Safeguarding
A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional.
Each authority has its own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.
This core service made no safeguarding referrals between 1 February 2017 and 31 January 2018.
Staff working in the service were trained in safeguarding adults and children. Training compliance rates were above the trust target rate of 80%. Staff were able to give examples of potential signs of abuse and how they could report safeguarding concerns.
The service had a process in place to safely allow children to visit. Staff working on the wards were aware of this process and ensure that it was followed at all times. Prior to visiting patients staff carried out checks to ensure that the patient wasn’t prevented from seeing the young person and the young person wasn’t at risk. Visits from children were carried out in the visitor’s room and appropriate restrictions were carried out to ensure the safety of the child. This may include supervision by a staff member or other appropriate adult.
Sheffield Health and Social Care NHS Foundation Trust has submitted details of zero serious case reviews commenced or published in the last 12 months (1 March 2017 and 28 February 2018) that relate to this core service.
Staff access to essential information
The trust used an electronic patient records system. The ward manager told us that Sheffield Health and Social Care was a paperless trust and therefore all records were electronic. The system used, Insight, was a bespoke package used throughout the trust.
All permanent and bank staff could access computer records. During our inspection, we did not receive assurance that agency staff working on Forensic wards had access to the electronic system. This meant that some documents had to be printed if agency staff were required to work on the wards. However, at the factual accuracy stage, the trust stated that there were procedures in place for agency staff to access a temporary log in for the records system. Seclusion records were paper based and transferred to the electronic care record following the end of seclusion.
Medicines management
Staff kept medication records up to date and completed these correctly. Medication charts were completed electronically and this allowed for accurate stock control.
Medication charts contained information regarding patients’ prescribed medicines and known allergies. Each of the clinic rooms contained an up to date British National Formulary which ensured that staff had up to date information about medicines.
Stock medicines were kept on each of the wards. We found these were correctly stored and all medicines were within their expiration dates. The hospital pharmacy team attended the wards
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regularly to ensure that stock levels were correct and none of the medicines needed to be replaced.
Staff carried out physical health monitoring in line with guidance to ensure that prescribed medicines with known side effects, like clozapine and lithium did not have a negative effect on patient’s physical health.
Track record on safety
Providers must report all serious incidents to the Strategic Information Executive System (STEIS) within two working days of an incident being identified.
Between 1 March 2017 and 28 February 2018 there were no STEIS incidents reported by this core service.
The number of serious incidents reported during this inspection was the same as what was reported at the last inspection.
Reporting incidents and learning from when things go wrong
The trust used an electronic incident reporting system. Staff who regularly worked for the trust could access the trust system and report incidents. Agency staff were unable to access this system and any incidents needed to be recorded by another staff member.
Post incident reviews and debriefs took place for staff and patients. Managers discussed incidents during team meetings, clinical supervisions, and individual one to ones. Staff also took part in weekly meetings which allowed them to reflect on the events of the week.
Staff were aware of their responsibilities under the duty of candour. The trust provided us with information relating to audits. Internal auditors, 360 Assurance, had carried out a recent audit and the trust had been rated as giving ‘significant assurance’ that reportable events would be reported.
Staff working in the service had received training in the Duty of Candour. Training included the statutory duty and individual responsibilities in relation to the Duty of Candour.
If there were lessons learned following an incident, staff were given information via several methods. This included, meetings, clinical supervisions and appraisals.
The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths.
In the last two years, there have been zero ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.
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Is the service effective?
Assessment of needs and planning of care
Admissions to the service were planned. Prior to admission an access assessment was carried out by a consultant psychiatrist and discussed with commissioners. Once a patient was admitted to the ward, nursing staff carried out a comprehensive assessment. The admission assessment covered a variety of things including, physical description, Mental Health Act status, mental and physical health history and current medication. Physical health examinations were carried out on all patients admitted to the service.
We looked at the care records for eight patients who used the service and found that of these six contained a completed care plan and four had been regularly reviewed. Two of the patient records we looked at did not contain a completed care plan. Care plans we reviewed were holistic, personalised and recovery oriented. Care plans outlined the support patients required to meet their mental and physical health needs and included needs identified during the initial assessment. Risk factors were identified in care plans and actions included to mitigate risks.
Best practice in treatment and care
There were a range of suitable care and treatment interventions for patients. This included psychological therapies, medication and education. Education formed a large part of the activity timetable which meant that patients who did not wish to pursue educational routes were restricted in their options.
Patients had access to physical healthcare when needed. Staff arranged for patients to see their own preferred specialists or ensured that they were registered with a local service. This included dentists, podiatrists and opticians. Patients with existing physical health problems were referred to local services where they were able to see a suitable specialist. Where this was not possible arrangements were made for them to be seen by the appropriate specialist at the hospital.
Staff used ratings scales to measure severity and outcomes. We saw the service used the health of the nation outcome scale and malnutrition universal screening tool.
The core service was pursuing a plan to allow patients independent access to the internet. Staff had been working with patients and formulating appropriate risk management strategies to enable this.
The provider told us this core service participated in the following clinical audits as part of their clinical audit programme in the 12 months leading up to the submission of the provider information return.
Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
Collaboration
with Primary
Care Clinicians
Service users
on CPA
Provider
wide Clinical on-going
Changes made following
previous audit round:
provide guidance to staff
on annual reviews of care.
Changes to care plan form.
Creation of a 'clinical
review for GP' IT system
solution.
Record keeping
audit 2016/2017 Trust wide
Provider
wide Clinical on-going
From data collected so far:
Further clarity provided to
staff on use of
abbreviations - to be
incorporated into the
relevant policy.
Audit of risk Trust wide Provider Clinical audit March 2017 Local action plans to
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assessments
2016/2017
wide address identified issues.
Audit tool to be revised to
give clearer results.
Re-audit to be undertaken
in 2017/18.
Audit of risk
assessments
2017/2018
Trust wide Provider
wide Clinical audit ongoing Await findings
Audits of care
plans Trust wide
Provider
wide Clinical audit
January
2018
Agreed need for frequent
small-scale audits.
Findings being shared with
teams.
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG43
Transition from
children’s to
adults’ services
for young
people using
health or social
care services
Trust wide Provider
wide Clinical audit June 2017
Findings fed into
Commissioning for Quality
and Innovation and other
related joint work with child
and adolescent mental
health services to improve
transitions
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG13
Workplace
health:
management
practices
Trust wide Provider
wide Clinical audit
September
2017
Review practices against
guidance as necessary in
future
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG58
Coexisting
severe mental
illness and
substance
misuse:
community
health and
social care
services
Trust wide Provider
wide Clinical audit
December
2017
Action plan under
development
Staff we spoke with told us they participated in local audits, including infection control audits, clinic room checks and health and safety audits. Concerns were highlighted and an action plan was drawn up which staff were required to complete. We saw evidence of actions being carried out following audits.
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Skilled staff to deliver care
The service had access to a range of specialists required to meet the needs of patients. The multi-disciplinary team consisted of doctors, nurses, health care support workers, psychologists and occupational therapist.
Staff working on the ward were required to complete the trust induction process. This included bank staff.
We asked the trust for information in relation to the completion of staff appraisals.
The trust’s target rate for appraisal compliance is 90%. As at February 2018, the overall appraisal rates for non-medical staff within this core service was 100%.
The rate of appraisal compliance for non-medical staff reported during this inspection was the same as what was reported at the last inspection.
The table below shows the number of non-medical staff who received an appraisal in the last 12 months:
Ward name
Total number of
permanent non-medical
staff requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an appraisal
% appraisals
Forest Lodge 55 55 100%
Core service total 55 55 100%
Trust wide 1495 1440 96%
The trust’s target rate for appraisal compliance is 90%. As at February 2018, the overall appraisal rates for medical staff within this core service was 100%.
The rate of appraisal compliance for non-medical staff reported during this inspection was the same as what was reported at the last inspection. The table below shows the number of permanent medical staff who have received an appraisal in the last 12 months:
Ward name
Total number of
permanent medical staff
requiring an appraisal
Total number of
permanent medical
staff who have had
an appraisal
%
appraisals
Forest Lodge 3 3 100%
Core service total 3 3 100%
Trust wide 57 56 98%
The trust’s target for clinical supervision is 66%.
Between 1 March 2017 and 28 February 2018, the rate across all teams in this core service was 44%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. The rate of clinical supervision reported during this inspection was lower than the 60% reported at the last inspection.
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Ward name Clinical supervision
sessions required
Clinical
supervision
sessions delivered
Clinical
supervision rate
(%)
Forest Lodge 96 42 44%
Core service total 96 42 44%
Trust Total 3420 2183 64%
Staff had regular supervisions, both individually and as a group. However, this included management supervisions. Figures submitted by the trust showed that the number of clinical supervisions carried out was 44%, which was below the trust target of 66%. Supervisions and appraisals were recorded and contained details of discussions and the staff members performance.
Information provided by the trust showed that clinical supervision for medical staff was 300%. This meant that medical staff had three times the number of clinical supervisions required by the trust.
Multi-disciplinary and interagency team work
The multi-disciplinary team worked closely to provide the best outcome for the patient. Weekly multi-disciplinary team meetings were held which all staff were required to attend. There were hand overs at the start of each shift and these were used to pass on important information regarding patient.
Staff communicated with care co-ordinators regarding patients and their progress. Care co-ordinators and social workers were invited to attend meetings regarding patients care and treatment.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
As of 28 February 2018, 88% of the workforce in this core service had received training in the Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient and all community staff and renewed every three years.
The training compliance reported during this inspection was lower than the 94% reported at the last inspection.
The majority of staff we spoke with told us they had received training in the Mental Health Act and the code of practice, although one staff member told us they didn’t recall having the training.
Staff had a good working knowledge of the Act and the associated code of practice. Staff told us they were able to access help and support via the trust Mental Health Act office but were also aware that information was available via the trust intranet.
Staff told us patients had access to Independent Mental Health Advocates and they visited the service regularly. Patients we spoke with confirmed they knew about the availability of advocates and some told us they used an advocate.
Staff explained patient rights under the Mental Health Act. Patient’s rights were explained to them when they were admitted to the ward and regularly after that. One staff member told us patients had their rights explained after there were changes in their care and treatment or if their legal status changed. Another staff member told us patients had their rights explained to them every three months.
Section 17 leave forms were completed correctly and were up to date. Section 17 forms show the amount of time patients are able to spend outside the hospital and if there are any conditions to
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this leave. For example, if they required a member of staff to escort them and if their leave was within the hospital grounds or if they could leave the site.
During our inspection we looked at the medication charts for all patients in the service. We found all charts had a valid T2 or T3 form in place. A T2 form is used when a patient has the capacity to make decisions about their treatment and they have given their consent for treatment. A T3 is used if the patient either does not consent to treatment, or does not have the capacity to make decisions about their treatment. In these cases, a request for a second opinion approved doctor must be submitted via the CQC to review the treatment plan and discuss it with the patient.
The trust completed weekly audits to ensure that patients had their rights explained to them. However, there were no other audits being carried out in relation to the Mental Health Act or Mental Health Act documentation.
Meetings were held prior to discharge to arrange care and support. When patients could be discharged multi-disciplinary team, meetings were held to discuss the section 117 aftercare needs of the patient. Section 117 aftercare is support that is available to patients who have previously been detained under certain sections of the Mental Health Act.
Good practice in applying the Mental Capacity Act
As of 28 February 2018, 97% of the workforce in this core service had received training in the
Mental Capacity Act Level 1 and 89% of the workforce had Mental Capacity Act Level 2. The trust
stated that this training is mandatory for all core services for inpatient and all community staff and
renewed every three years.
The training compliance reported during this inspection was higher than the 27% (Mental capacity act level 1) and 47% (Mental capacity act level 2) reported at the last inspection.
All the staff we spoke with demonstrated a good working knowledge of the Mental Capacity Act and were able to name the statutory principles.
The trust had a policy which related to the Mental Capacity Act and included information on the deprivation of liberty safeguards. Staff were able to access the policy and information regarding the Mental Capacity Act via the trust intranet.
Care records we looked at showed evidence of capacity assessments being completed and consent being sought for treatment. Where patients lacked capacity, we saw evidence of decisions being made in patients’ best interests.
All the patients who receive care and treatment in secure forensic mental health wards are detained under the Mental Health Act. Therefore, there were no deprivation of liberty safeguards applications made within the last 12 months for this core service.
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Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
Staff treated patients with kindness, dignity and respect. We observed staff interacting with patients and saw that staff treated patients respectfully at all times.
Patients we spoke with told us that staff were helpful and treated them well. However, patients told us that agency staff did not help them and they felt the ward was ran better when the permanent staff were working.
Staff were seen speaking with patients, talking to them about their plans for the day and what they had done the previous day.
Care plans showed evidence that staff had spoken to patients about their care and had helped them to understand their treatment.
Patients told us they felt able to raise concerns with staff and that these would be taken seriously.
The 2017 Patient-Led Assessments of The Care Environment (PLACE) score for privacy, dignity and wellbeing at this core service location scored higher than similar organisations.
Site name Core service(s) provided Privacy, dignity
and wellbeing
Forest Lodge Forensic secure 100%
Trust overall 97%
England average (mental health
and learning disabilities) 91%
Involvement in care
Involvement of patients
New patients were given information about the service before they arrived. Patients were provided with a welcome book which gave them information about the service. This included a list of restricted items, meal times, visiting times, information on how to make a complaint and expectations regarding behaviour on the ward and toward others.
Care plans and risk assessments showed limited evidence of patient involvement. Although patients attended meetings to discuss care, care plans did not always reflect this. We looked at the care records of eight patients and found four showed no evidence of patient involvement. The other four care plans we looked at showed evidence that patients had discussed their care with staff and care plans had been agreed. The manager and deputy manager both told us the service was to start collaborative care planning the week following our inspection.
Wards had regular community meetings which patients could use to discuss concerns, share their views and feedback on issues which mattered to them. We saw evidence in the form of ‘you said, we did’ boards, that the trust had listened to, and acted upon comments from patients.
The service had booklets available for patients. These included, ‘Who will be involved in my care’, ‘Clinical psychology’ and ‘occupational therapy’. The booklets gave patients information regarding the work of clinical psychologists and occupational therapists as well as telling them about the role of other members of the multi-disciplinary team. However, patients we spoke with did not recall receiving any of these booklets and there was no record of patients receiving these.
Involvement of families and carers
Patients could make a choice about the involvement of family in their care. Patients we spoke with told us that their relatives were made welcome in the service. Care records showed that staff had recorded the views of patients, families and carers as appropriate.
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Is the service responsive?
Access and discharge
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Bed management
The trust provided information regarding average bed occupancies for two wards in this core service between 1 March 2017 and 28 February 2018.
The table below shows the average range in bed occupancy for the ward across a 12-month period:
Ward name Average bed occupancy range (1 March 2017 and 28
February 2018) (current inspection)
Forest Lodge Assessment 73.6%-109.1%
Forest Lodge Rehab 87.7%-100.3%
The trust provided information for average length of stay for the period 1 March 2017 and 28 February 2018.
We are unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the period that was covered.
Ward name Average length of stay range (1 March 2017 and 28
February 2018) (current inspection)
Forest Lodge Assessment 93-1582
Forest Lodge Rehab 499-1038
This core service reported one out of area placement between 1 March 2017 and 28 February 2018.
As of 28 February 2018, this core service had no ongoing out of area placements.
This core service reported zero readmissions within 28 days between 1 March 2017 and 28 February 2018.
Discharge and transfers of care
Between 1 March 2017 and 28 February 2018, there were 15 discharges within this core service. This amounts to 2% of the total discharges from the trust overall (804).
There were no delayed discharges between 1 March 2017 and 28 February 2018.
Referral to assessment and treatment times was not provided for this service.
Prior to admission, the consultant carried out an assessment. There were clear treatment pathways in place and staff were aware of these and how they helped to support patients if their mental health deteriorated.
Although the wards had different purposes, discharge was possible from any of these. When staff felt patients were ready for discharge they were usually transferred to the rehabilitation ward, however, this was not always the case and staying on the assessment ward did not prevent discharge.
Some of the patients in the service were not able to be given leave or discharged from hospital without appropriate authority from the Ministry of Justice. Where this was the case, we found proper authority had been sought prior to discharge.
Facilities that promote comfort, dignity and privacy
All patients had their own bedrooms; however, only one room across the two wards had en-suite facilities. Patients were able to personalise their bedrooms and could take personal belongings in to the hospital, as long as there was nothing on the prohibited items list. Patients were able to lock personal items in their bedrooms and were also provided with a locker.
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Patient bedrooms had viewing windows fitted into the doors. Viewing windows had integrated blinds with could be opened and closed as needed. Patients were able to open and close blinds from inside their rooms. Staff used a key if they needed to see inside. This meant they met national standards for secure services.
Staff on the assessment ward told us they did not carry out a traditional medicine round. Patients were given the choice of where they wanted to have their medication. Some patients preferred to have their medication in their room, some in the clinic room and others were happy to have their medicine in the communal area of the ward. Although this meant some patients’ privacy could not be guaranteed, they were able to ensure patients were comfortable about taking the required medication.
Patients had access to space and facilities. Patients on both wards had access to secure garden space, pool table and computers. However, the patients on the rehabilitation ward did not have access to exercise equipment due to the ongoing works.
Access to the gardens on the assessment ward was via a locked door. Patients were only able to access the garden with staff authority and a member of staff was required to be in the garden with them. If more than one person wanted to access the garden another staff member of staff was also required. Patients on the rehabilitation ward were given unrestricted access to outdoor space.
Patients on both wards were able to access hot food and drinks, although patients were not able to prepare their own hot drinks due to the size of the kitchen on each ward.
The 2017 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at the location scored lower than similar trusts.
Site name Core service(s) provided Ward food
Forest Lodge Forensic Inpatient 87.4%
Trust overall 96%
England average (mental health and learning disabilities) 92%
Patients’ engagement with the wider community
Staff ensured that patients had access to education opportunities. The service offered patients access to their recovery college which provided them with the ability to gain qualifications, learn about their illness and learn about other things they were interested in. The prospectus included things like music appreciation, GCSE English and maths and substance misuse and mental health. Courses were running at Forest Lodge which meant all patients could take advantage of them.
Staff supported patients to maintain relationships with family and friends. Patients were able to see family and friends in the visiting room at the service. All visits were by previous arrangement and if patients did not have the ability to leave the hospital visits were carried out in the visitor’s room.
Staff ensured that patients had appropriate spiritual support. The service did not have a dedicated multi-faith room however, the visitors room could be used if it was available. Patients were also able to access spiritual support through the trust’s chaplaincy service.
Meeting the needs of all people who use the service
Patients were able to access sports, leisure and education based activities, however, the majority of these were part of the service recovery college. Weekend activities were limited on both wards.
Appropriate adjustments were not always made when required. The trust had a library of information which had been translated into multiple languages. At the time of our inspection we found that patients who did not have English as a first language had not been provided with information in another language. Although interpreters had been arranged, patients did not always
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have important documents translated. For example, we found that the patient had their rights explained to them by a member of staff using their first language however, this was not recorded on their care plan and the document they had been asked to sign was in English. In addition, we found that the patient did not have a communication care plan in place and did not have a copy of their care plan.
Although the wards and visitors room were on the ground floor, the service was not accessible to disabled visitors. There was no ramp at the service entrance and doors had not been widened to allow for wheelchair access.
The ward manager told us the service was unable to take patients who had mobility concerns. Although bathrooms had recently been refitted and contained grab rails to assist patients, none of the bedrooms were suitable for patients in wheelchairs. Any patients that had mobility needs and required low secure services had to be placed in services out of the area.
Equality and diversity was promoted on the ward. There was a zero-tolerance attitude to abuse in the form or discrimination. Some staff told us they had been subject to racist abuse by a patient. Staff told us that although they ignored this behaviour, the ward manager ensured that incidents were reported and the patient was told the behaviour was unacceptable. This ensured that both patients and staff were aware of the trust policy in relation to discrimination and abuse. Patients we spoke with told us that they had not experienced any discrimination while on the ward.
Listening to and learning from concerns and complaints
Patients we spoke with told us they knew how to make a complaint. We were told by patients that
they would speak to staff or make a complaint with the help of advocates.
We asked the provider for information on complaints and compliments the core service received.
This core service received two complaints between 1 March 2017 and 28 February 2018.
Ward
name
Total
Complaint
s
Fully
upheld
Partially
upheld
Not
upheld
Referred to
Ombudsman
Upheld by
Ombudsman
Assessm
ent ward 2 0 0 2 0 0
This core service received zero compliments during the last 12 months from 1 March 2017 and 28
February 2018.
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Is the service well led?
Leadership
Leaders had the skills, experience and knowledge to carry out their roles. The trust recruitment process was comprehensive and job adverts contained all essential information.
Senior managers were aware of incidents and concerns related to the services they managed and ensured that they were kept informed of investigations that were being carried out.
Vision and strategy
Staff were aware of the trust’s vision and all were able to tell us some of the trust’s values. Trust values were part of the appraisal process and staff were measured on their day to day performance in relation to these.
Local managers felt supported by senior managers. Senior managers did not visit the service often; however, the service director spent a lot of time there helping with the service recovery college.
Culture
The majority of staff told us they felt supported in their roles. Most of the staff we spoke with told us they were happy and enjoyed their work. However, we were also told that staff had experienced incidents of violence and had been subject to several episodes of verbal abuse. Staff told us they felt things had improved recently and particularly since a new deputy ward manager had been appointed.
Staff told us about incidents that had occurred on the ward and the support they had received from managers, both within the service and also from more senior management.
Staff felt able to raise concerns without fear of retribution. Staff were aware of the trust whistleblowing policy and knew about the trust freedom to speak up guardian. Staff told us The freedom to speak up guardian had visited the service the week before our inspection and staff told us they had used that visit to raise concerns about the service. These were to be investigated.
Poor performance was addressed using trust policies and procedures. The ward manager told us staff performance was reviewed during supervision and appraisals. If there were concerns regarding staff performance these were usually addressed as part of the supervision and appraisal process, dependent on what the concern was.
We asked the provider for details of any incidents which had resulted in staff being investigated. During the reporting period, there was one case where staff were moved to a different ward while under investigation.
Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these should be noted.
Ward name Suspended Under
supervision
Ward move Total
Forest Lodge 1 0 0 1
Core service total 1 0 0 1
Staff achievements were recognised through a trust award scheme.
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Governance
Mandatory training levels were high with all but one above the trust target level. Staff had regular supervisions however they did not receive the required number of clinical supervisions necessary for their roles.
There were usually enough staff to meet the needs of the patients and the acuity of the ward environment however, the staffing tool used was for acute wards and was not always appropriate for low secure wards.
The service was clean and tidy and there were systems and procedures in place to ensure staff completed tasks relating to this. A team of housekeepers were employed and were responsible for ensuring cleanliness. Ward restrictions were appropriate to the security of the service. Additional restrictions were in place for some patients following the completion of risk assessments.
Renovation work had been completed on all bathrooms in the service to ensure these were now ligature free. Doors within the service were in the process of being replace with anti-barricade doors. All bedroom doors had viewing panels to promote patient privacy.
Senior managers were aware of issues within the core service through a variety of meetings. There were regular meetings in place for patients, core service staff and managers. Minutes of these meetings were taken and made available to appropriate audiences.
The service had introduced a recovery college for patients where they could access education opportunities. This included participation in sports, learning about their illnesses or working towards a recognised qualification. However, patients who did not wish to enrol were provided with only limited activities.
The trust had reviewed a number of policies prior to our inspection. However, although these had been ratified, the majority of staff on the wards were not aware of the new policies and there was no implementation plan in place for the service.
The trust provided evidence of changes which had been implemented following incidents. Staff we spoke with told us they were informed of lessons learned and investigation outcomes.
Staff took part in clinical audits which were conducted at a local level. These included Mental Health Act, clinic room and fridge temperatures, mattress and pillow audits and infection control audits. Audits were carried out to ensure the quality and continued improvement of the service.
Management of risk, issues and performance
Managers were able to add items to the trust risk register. The ward manager knew how to escalate concerns and was aware of the trust governance structure.
Regular checks were carried out to ensure the building was safe. Environmental risk assessments were regularly carried out and used to identify potential risks to staff and patients. Areas of concern and potential risk were identified and steps were taken to minimise risks. We looked at the risk register for the core service and found there was one entry which was assessed as high and regarded the environment of the core service. This risk was the seclusion room which had been identified as unsuitable.
Information management
The trust used systems to collect data from wards and used it to assist managers with the reviewing of key performance indicators.
Permanent and bank staff could access the records they needed with the use of computer systems. The trust used a bespoke computer package which included care records, policies and guidance. If agency staff were required to work on the ward, information would need to be printed as they did not have access to computerised records.
Engagement
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The trust has an intranet system which provided staff with information and news from around the trust as well as having up to date information on trust policies and procedures. There was also a website which allowed public access to information, including trust policies, contact information, trust directors and wards.
Patients and their families were asked for their feedback on the service via questionnaires. There was also a comments box in one of the communal areas between the wards. The service had a ‘you said, we did’ board in the service to ensure patients and their families were aware of changes that were carried out.
Learning, continuous improvement and innovation
NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.
There were no accreditations for this core service.
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Long stay/rehabilitation mental health wards for working age adults
Facts and data about this service
Location site name Ward name Number of beds Patient group (male,
female, mixed)
Forest Close Forest Close,
Bungalow 1a 14 Male
Forest Close Forest Close,
Bungalow 1 8 Female
Forest Close Forest Close,
Bungalow 2 8 Female
Forest Close is an in-patient rehabilitation service provided by Sheffield Health and Social Care
NHS Foundation Trust. The service is based in Middlewood, North-West Sheffield. It is composed
of three wards and an additional unit called the learning and recreation hub, which is a therapy
and activity centre. (At our previous inspection in 2016, this unit was called bungalow three).
Forest Close provides long-term and rehabilitation care for people with severe and enduring
mental health needs who require support to reach their optimum level of recovery. The service
accepts all adults aged 18 years and over, irrespective of gender, ethnicity, sexuality, culture or
physical abilities. There was no upper age limit for the service.
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Is the service safe?
Safe and clean care environments
We checked all three ward environments and the learning and recreational hub, as well as the
documentation relating to the environments to consider if they were safe and clean.
Safety of the ward layout
All three wards and the learning and recreational hub settings were safe. Staff completed annual
environmental risk assessments for each ward and the learning and recreational hub. Staff
monitored all ward areas via a secure entry system and checked identification before allowing
people onto the ward. All areas displayed a notice informing everyone about items that should not
be brought on the wards for safety reasons such as weapons and cigarette lighters.
All visitors signed a visitor’s book to comply with security and fire procedures. All staff received
mandatory fire training every two years and the service training compliance was higher than the
trust target. All areas had the fire equipment they needed. Staff checked fire equipment regularly
and completed patients’ personal evacuation plans. Staff knew about the fire safety procedures for
their areas and carried out fire drills to test out their procedures in the event of fire.
All staff carried personal alarms that they checked regularly to make sure they worked. During the
inspection, staff issued inspectors with personal alarms and explained how to use them in an
emergency. The alarm system across all three wards was integrated that meant staff from other
wards were alerted when an alarm sounded. At the learning and recreational hub the alarms were
not integrated into the ward system. This was an area for improvement identified at our previous
inspection in 2016. We told the trust it must mitigate the risk of harm to staff and patients using this
area. At this inspection, we found that staff had taken other action in response to our concerns.
Staff carried out individual patient risk assessments and always accompanied patients in this area.
The absence of an integrated alarm system was included on the service risk register and
refurbishment plans included work to integrate the system. However, managers could not provide
a confirmation date for completion of the work.
Over the 12month period from 1 March 2017 to 28 February 2018 there were zero mixed sex accommodation breaches within this core service.
All three wards provided single sex accommodation, which meant all wards complied with
Department of Health guidance on eliminating mixed sex accommodation.
Information provided in the pre-inspection information confirmed that there were ligature risks in four areas within this core service. The trust had undertaken recent (from 28 April 2017 onwards) ligature risk assessments at four locations.
None of the four locations presented a high level of ligature risk and all locations presented some risk due to the acuity of service users and the remaining anchor points (Door handles, door corners, grab rails/mobility aids).
The trust had taken the following actions in order to mitigate ligature risks: risk management of service users includes risk assessment, observation levels and the removal of items that may be used. In addition, the learning and recreation hub is a fully supervised area.
During the inspection visit, we confirmed that each area had an up to date environmental ligature risk assessment that managers reviewed and updated when things changed. We observed ligature anchor points that were all included on the risk assessments. These are places where people intent on self-harm might tie something to strangle themselves. Staff managed blind spots
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by carrying out individual patient risk assessments and observations. One ward had plans to fit a convex mirror to improve observation in one area.
Staff had measures in place to maintain patients’ safety on the wards. All three wards had a nurse call system available in every room for patients to use if they needed help. When patients used the learning and recreation hub, staff who carried alarms were always present with them.
Maintenance, cleanliness and infection control
At our previous inspection in 2016, we raised concerns about the cleanliness of bungalow three
(now called the learning and recreation hub) and incomplete cleaning records. We told the trust
that it must ensure that all areas used for patient care are clean. At this inspection in 2018, we
found that all three wards and the learning and recreation hub had reliable systems and processes
to keep the wards clean and people safe. Staff were clear about their responsibilities, they kept up
to date cleaning records and all areas were clean. The wards were well maintained and provided
comfortable furnishings. All patients and carers we spoke with told us that wards were always
clean and comfortable.
At our previous inspection in 2016, we raised concerns about how staff ensured that food was
stored safely. We told the trust that it should ensure that staff take action when the temperature in
fridges used to store food exceeds five degrees. At this inspection in 2018, we found that the
service had made improvements. Staff checked fridge temperatures daily and recorded their
actions where fridge temperatures were not in the correct range.
All staff completed mandatory health and safety training and the service training compliance was
higher than the trust target. The site services officer raised maintenance requests for repairs and
improvements. At the time of our inspection, we saw housekeeping staff present on the wards and
trust maintenance staff working across the site. However, during the inspection we saw that not all
staff wore footwear that provided adequate protection and did not adhere to the trust dress code
policy.
All staff completed mandatory hand hygiene training and the service training compliance was
higher than the trust target. The service completed infection control audits and took part in
infection control roadshows provided by the trust. All areas had hand sanitisers available for staff
to use in addition to handwashing facilities. However, not all staff adhered to the trust dress code
and infection control principles. We observed staff across all three wards that had not tied up their
long hair or wore excessive jewellery and unsuitable footwear.
Patient led assessments of the care environment are carried out by local people who visit services
and assess the care environment. For the most recent Patient-led assessments of the care
environment (PLACE) assessment 2017 the location had a higher score than the similar trusts for
three of the four aspects overall and was not rated for the dementia friendly criteria.
Site name Core service(s)
provided
Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
Forest Close
MH - Long
stay/rehabilitation
mental health wards
for working age adults
99.7% 99.8% - 92.7%
20171116 900885 Post-inspection Evidence appendix template v3 Page 60
Site name Core service(s)
provided
Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
Trust overall 99.0% 96.4% 91.1% 91.8%
England average (Mental health
and learning disabilities) 98.0% 95.2% 84.8% 86.3%
Seclusion room
The wards did not have any seclusion facilities and did not seclude patients.
Clinic room and equipment
All three wards had clinic rooms where staff stored medication, equipment, and medical supplies.
The rooms were too small for an examination couch, which meant staff carried out physical
examinations with patients in their bedrooms. All clinic rooms were fully equipped with accessible
resuscitation equipment and emergency medicines that staff checked weekly. Staff maintained
equipment and kept it clean so that it was safe to use. However, staff did not have robust
procedures for date checking stock medical items. We found out of date items including dressings,
alcohol wipes, and urinalysis sticks in two ward clinic rooms.
Safe staffing
Nursing staff
There was enough adequately trained and skilled staff on duty across all three wards. The clinical
nurse manager and ward managers planned and reviewed staffing levels and skill mix daily.
The minimum establishment levels were set for each ward. Qualified nurses and support staff
worked across three shifts and managers usually worked between Monday and Friday during the
day and complimented the staffing establishment. The shift system across all three wards was
07.00 until 15.00, 13.30 until 21.30 and 21.18 until 07.10. Some staff worked a 'cross over' shift
that meant they worked flexibly over the two day shifts. The non-medical prescriber and senior
nurse practitioner also provided support to all three wards.
The service had agreed staffing levels. Ward one A had the largest staffing establishment for 14
patients with five staff each shift during the day with two qualified nurses, and three staff at night
with one qualified nurse. On wards one and two, staffing was three staff per shift during the day
and two at night with one qualified nurse on every shift. The manager told us that they could adjust
staffing levels easily and used additional staff from the trust bank or agency if needed.
At our previous inspection in 2016, we raised concerns about low staffing because staff reported
incidents of low staffing and sometimes one nurse covered more than one ward. We told the trust
that it must ensure that there is always at least one qualified nurse for each bungalow. At this
inspection in 2018, we checked the most recent staffing rotas and incidents related to low staffing
and found the trust had made improvements. The use of bank or agency staff was low and the
service had no vacancies for qualified nurses or support staff. This was because managers had
recently recruited to vacant posts. The managers knew about staff who would be leaving such as
retirement and had succession plans in place. This meant that managers could recruit staff in a
timely way and minimise any gaps in staffing. Staff and patients told us that there was usually
enough staff on duty and we saw that staff had enough time to spend with patients.
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The wards provided adequate and accessible medical cover that included dedicated consultant
psychiatrists, specialist and trainee doctors. All three wards had access to a doctor’s rota that was
updated by the trust. This meant staff knew which doctors to contact. In addition, the service had
two nurses who had completed additional training to become non-medical prescribers and a GP
visited all three wards weekly. Staff used the trust on call system for medical advice out of hours if
needed.
The trust provided details of staffing in the table below.
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 January 2018 96.6 N/A
Total number of substantive staff leavers 1 February 2017 to 31 January 2018
7.6 N/A
Average WTE* leavers over 12 months (%) 1 February 2017 to 31 January 2018
6% 13%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31March 2018 -9 N/A
Total vacancies overall (%) At 31March 2018 -10% NA
Total permanent staff sickness overall (%)
Most recent month (At 31 January 2018)
6% 5%
1 February 2017 to 31 January 2018
6% 5%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 March 2018 29 N/A
Establishment levels nursing assistants (WTE*) At 31 March 2018 39 N/A
Number of vacancies, qualified nurses (WTE*) At 31 March 2018 -5 N/A
Number of vacancies nursing assistants (WTE*) At 31 March 2018 -6 N/A
Qualified nurse vacancy rate At 31 March 2018 -17% N/A
Nursing assistant vacancy rate At 31 March 2018 -15% N/A
Bank and agency Use
Shifts bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 March 2017 and 28
February 2018 162 (3%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses)
1 March 2017 and 28
February 2018 9 (>1%) N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses)
1 March 2017 and 28
February 2018 77 (2%) N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018
722 (10%)
N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 9 (>1%) N/A
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Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants)
1 March 2017 and 28
February 2018 57 (1%) N/A
*Whole-time Equivalent
This core service reported an overall vacancy rate of -10%for registered nurses at 31 March 2018.
This core service reported an overall vacancy rate of -17% for qualified nurses (negative numbers indicate an over establishment). This core service reported an overall vacancy rate of -15% for registered nursing assistants.
Registered nurses Health care assistants Overall staff figures
Ward/Tea
m
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Forest
Close
Ward 1A
1 11 9% 2 16 13% 3 27 11%
Forest
Close
Central
-1 4 -25% 0 3 0% 1 30 3%
Forest
Close
Ward 1
-4 7 -57% 0 10 0% -4 17 -24%
Forest
Close
Ward 2
-1 7 -14% -8 10 -80% -9 17 -53%
Core
service
total
-5 29 -17% -6 39 -15% -9 91 -10%
Trust total 32 433 7% 15 353 4% 68 1339 5%
NB: All figures displayed are whole-time equivalents
Between 1 March 2017 and 28 February 2018, bank staff filled 3% of shifts to cover sickness, absence or vacancy for qualified nurses.
In the same period, agency staff covered less than 1% of shifts for qualified nurses. Two percent of shifts were unable to be filled by either bank or agency staff.
Forest Close Central is an administration area and no patient care is provided in this area.
Ward/Team Available shifts Shifts filled by bank staff Shifts filled by
agency staff
Shifts NOT filled by bank
or agency staff
Forest Close,
Bungalow 1
1450 34 (2%) 0 (0%) 57 (4%)
Forest Close,
Bungalow 1a
1972 64 (3%) 2 (>1%) 16 (1%)
Forest Close,
Bungalow 2
1347 64 (5%) 7 (1%) 4 (>1%)
Core service
total
4769 162 (3%) 9 (>1%) 77 (2%)
Trust Total 32,394
4977
(15%)
7252
(22%)
900
(3%)
*Percentage of total shifts
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Between 1 March 2017 and 28 February 2018, 10% of shifts were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.
In the same time period, agency staff covered less than 1% of shifts. One percent of shifts were unable to be filled by either bank or agency staff.
Ward/Team Available shifts Shifts filled by bank staff Shifts filled by
agency staff
Shifts NOT filled by bank or
agency staff
Forest Close,
Bungalow 1
2084 190 (9%) 6 (>1%) 10 (>1%)
Forest Close,
Bungalow 1a
2816 266 (9%) 3 (>1%) 39 (1%)
Forest Close,
Bungalow 2
2108 266 (13%) 0 (0%) 8 (>1%)
Core service
total
7008
722 (10%)
9 (>1%) 57 (1%)
Trust Total
59,514 21,770
(37%)
5623
(9%)
1760
(3%)
* Percentage of total shifts
This core service had 7.6 staff leavers between 1 March 2017 and 28 February 2018.
Ward/Team Substantive staff
Substantive staff Leavers Average % staff leavers
Forest Close Bungalow 1 21.4 5.8 10%
Forest Close Bungalow 1A 26.03 1.8 7%
Forest Close Central 28.24 0 0%
Forest Close Bungalow 2 20.9 0 0%
Core service total 96.6 7.6 6%
Trust Total 1351.6 129.6 8%
The sickness rate for this core service was 6% between 1 February 2017 and 31 January 2018. This was similar to the sickness rate of 7% reported at the last inspection in 31 July 2016.
Ward/Team Total % staff sickness
(at latest month)
Ave % permanent staff sickness
(over the past year)
Forest Close Bungalow 2 8% 8%
Forest Close Central 2% 6%
Forest Close Bungalow 1 7% 5%
Forest Close Bungalow 1A 10% 5%
Core service total 6% 6%
Trust Total 8% 7%
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The below table covers staff fill rates for registered nurses and care staff during November 2017, January 2018 and February 2018 (December 2017 information is missing).
In February 2018, Forest Close – W1a had fill rates of below 90% for care staff during day shifts. In February 2018, Forest Close – W2 had fill rates over 125% for care staff during night shifts. Key:
> 125% < 90%
Day Night Day Night Day Night
Nurses
(%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff
November 2017 January 2018 February 2018
Forest Close – Bungalow 1
121.9 107.8 93.3 97.1 114.4 103.9 100.3 116.1 118.6 96.1 100 92.9
Forest Close – Bungalow 2
108.9 104.2 100.9 101.5 124.5 94.2 103.4 122.3 109.4 111.7 103.6 136.0
Forest Close – Bungalow 1a
109 92.3 100 100 104.4 94 100 104.1 108.2 84.3 100 102
Medical staff
Between 1 February 2017 and 31 January 2018, no shifts were filled by bank staff to cover
sickness, absence or vacancy for medical locum shifts.
Mandatory training
The trust had mandatory training requirements for all staff to complete. Mandatory training was
made up of a mixture of on-line and face-to-face training. At our previous inspection in 2016, we
raised concerns about low compliance with mandatory training across the service. This was
because we were not assured that staff were competent and had the skills they needed to perform
their roles. We told the trust that it must improve mandatory training compliance. At this inspection
in 2018, we found that the service had improved their mandatory training compliance to reach 75%
and above for all 22 mandatory training courses. Twenty-one of the courses exceeded the trust
target of 80%. The lowest compliance was 75% for dementia awareness. Five courses had 100%
compliance, including risk assessment and respect training. The service had identified a
mandatory training champion who ensured that all staff kept up to date. Managers had oversight of
compliance via a trust electronic dashboard and regularly monitored mandatory training
compliance. Staff told us how they kept their training up to date and about the difficulties they
experienced accessing the on line e-learning system at times.
The trust reported the compliance for mandatory and statutory training courses at 28 February
2018 was 96%. Of the training courses listed one failed to achieve the trust target.
Key:
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Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service %
Trust target % Trust wide mandatory/ statutory training total %
Safeguarding Children (Level 3) 100% 80% 91%
Clinical Risk Assessment 100% 80% 91%
Hand Hygiene 100% 80% 94%
Health and Safety (Slips, Trips and
Falls) 100%
80% 97%
Respect Level 1 100% 80% 66%
Equality and Diversity 99% 80% 95%
Mental Capacity Act Level 1 99% 80% 94%
Fire Safety 2 years 99% 80% 96%
Mental Capacity Act Level 2 98% 80% 85%
Safeguarding Children (Level 2) 98% 80% 85%
Domestic Abuse Level 2 97% 80% 85%
Adult Basic Life Support 96% 80% 81%
Respect Level 2 96% 80% 80%
Safeguarding Adults (Level 2) 96% 80% 87%
Information Governance 95% 80% 80%
Immediate Life Support 94% 80% 88%
Rapid Tranquilisation 94% 80% 88%
Autism Awareness 94% 80% 88%
Medicine management training 94% 80% 87%
Mental Health Act 92% 80% 83%
Respect Level 3 88% 80% 83%
Dementia Awareness (inc Privacy &
Dignity standards) 75%
80% 85%
Core Service Total % 96% 88%
Assessing and managing risk to patients and staff
During the inspection, we reviewed care records for 12 patients from across the service.
Assessment of patient risk
Staff assessed, managed, and monitored patients to keep people safe. Staff completed the trust
electronic risk assessment tool called the detailed risk assessment management tool. This tool
has been adapted from the Distress and Risk Assessment Method, a nationally recognised risk
assessment tool to meet the needs of the service. Risk was reviewed in line with the trust policy.
This included at initial assessment, on admission, at regular multidisciplinary reviews or sooner if
needed.
Management of patient risk
All 12 records demonstrated that staff completed timely and comprehensive risk assessments and
management plans that they reviewed regularly. We observed multidisciplinary meetings and staff
handovers that included discussion about patient risks and management plans.
Staff observed all patients according to their individual observation levels that meant that staff
checked on patients’ safety at regular times during the day and night. Staff followed the trust
observation policy and could increase the frequency of observations quickly if risks changed. All
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seven patients we spoke with told us they felt safe on the ward and carers felt confident that staff
kept their relatives safe.
Staff did apply some blanket restrictions. These are restrictions on patients that staff had not
individually risk assessed and applied to all patients on all three wards. At our previous inspection
in 2016 and at a previous Mental Health Act Reviewer visit in 2017 we commented about blanket
restrictions. We told the trust that it must review blanket restrictions to ensure that care is
personalised for each patient. At this inspection in 2018, we found that each ward held a file with
information about the blanket restrictions. These restrictions were appropriate for the service and
approved on the trust wide blanket restriction register in March 2018. Restrictions included;
takeaway foods, smoke free environments, e-cigarettes and locked doors. Visiting times were
flexible and could take place between 10am and 8pm. Meal times were protected, therefore, visits
were not encouraged between 12pm and 1.30pm and 5pm and 6.30pm.
The service informed patients and their relatives about the blanket restrictions before and on
admission to the ward. Staff discussed and recorded the impact of the blanket restrictions with
each patient and included management plans in their care plans and risk assessments. Staff also
continued to discuss the impact of blanket restrictions at patient community meetings. For
example, staff encouraged patients to eat healthy meals and asked patients to get one takeaway
meal per week. We saw evidence of how staff reduced restrictive practice in response to patients’
feedback about conducting leave risk assessments. Staff asked that patients should be out of bed
one hour before they went on leave so that they could complete a risk assessment. This had
changed from two hours in response to patient’s feedback.
The doors to all three wards were secure and needed a key code for entry and exit. All three
wards displayed a notice about the locked doors and informed patients how they could leave. This
was important because patients detained under the Mental Health Act could only leave with the
correct authorisation. Others were informal that meant patients were free to leave the ward at any
time. Patients told us they knew about how to leave the ward. All wards had “green rooms” which
were quiet, low stimulus rooms that staff kept locked and used for de-escalation. The garden
areas for each ward were open during the day. The service adhered to the trust smoke free policy
and patients could not smoke on site. Staff offered smoking cessation advice and nicotine
replacement therapy to support patients who smoked.
The service also had a trust agreed restricted items list which applied to everyone. This included
items such as cigarettes lighters, matches, knives or other sharp objects/weapons, illicit
substances and alcohol. Staff did not routinely search patients for these items but asked if patients
had any of these items in their possession. Staff kept any restricted items in a secure place and
returned them to patients when they left.
Use of restrictive interventions
The trust reported there were 27 incidents of restraint and no incidents of seclusion between 1
March 2017 and 28 February 2018.
Nineteen of the 27 uses of restraint were within the last 3 months of the reporting period. In
February 2018 there were 11 restraints (on one service user) in Forest Close Bungalow 2
(Female). There were also eight uses of rapid tranquilisation in this month in Forest Close
Bungalow 2.
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The below table focuses on the last 12 months’ worth of data: 1 March 2017 and 28 February
2018.
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
Forest Close
Bungalow 2 0 17 7 0 (0%) 8
Forest Close
Bungalow 1 0 6 3 0 (0%) 0
Forest Close
Bungalow 1A 0 3 2 0 (0%) 0
Core service
total 0 27 13 0 (0%) 8
There were no incidents of prone restraint.
There were no instances of mechanical restraint over the reporting period.
There were no instances of long term segregation over the 12-month reporting period.
The service participated in the trust restrictive interventions project group to support wards to
become safe places for patients and staff. This was a trust wide agenda to implement safewards
interventions as a part of service improvement and safety agendas. In October 2017, the trust
awarded the service recognition of full implementation of all the safewards interventions.
Staff were knowledgeable about safewards interventions and reducing restrictive practice and
aimed to support patients in the least restrictive way without compromising safety. The staff team
on one ward worked together using reflective practice, formulation and debriefs to understand and
validate one patient’s experiences when they were struggling with their mental health. This
showed determination to use alternatives to restraint and their interventions significantly reduced
the number of incidences of restraint with this patient.
Staff rarely used restraint with patients but when they did, they offered debriefs with patient. Staff
used this as an opportunity to work in partnership with the patient and make changes that made a
difference to them. We saw one example where staff changed the care plan and named nurse
arrangements in response to the patient’s feedback about their experience. The patient could tell
us how this supported their recovery and had not been involved in further restraint.
All staff received mandatory training called Respect training at different levels according to their
role. This training included physical interventions and breakaway techniques that staff could safely
use with patients. Staff across the service had achieved compliance levels above the trust target
of 80% for all three levels of training. The service had an identified trainer who was training some
staff during our inspection.
The service took part in the trust restrictive interventions reduction programme and staff restrained
patients using the Respect techniques. All staff told us that they rarely used restraint and reported
any restraint as an incident. Staff had reported only one incident of restraint since February 2018.
We reviewed the restraint incident record, the patients care record and discussed the incident with
the patient and ward manager. Staff had fully recorded the incident and the manager reviewed the
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incident including debriefs with the patient and staff involved. The manager took the views of
everyone into account and took action to reduce the risk of further incidents. Following the
incident, staff made changes to the patients care. Staff reflected on their practice during
supervision and the patient told us things were much better now.
At our previous inspection in 2016, we found that staff did not always complete physical
observations following rapid tranquillisation in line with the trust policy. Doctors prescribe
medicines for rapid tranquillisation to help agitated or distressed patients. At this inspection in
2018, staff had made the improvements and now consistently followed the trust policy for
administration of rapid tranquilisation, post-administration observations, and incident reviews. At
our previous inspection in 2016, we found that staff did not follow national guidance for sodium
valproate. This is a medicine used to treat epilepsy and should not be prescribed to women of
childbearing age. At this inspection in 2018, no patients were prescribed sodium valproate.
Safeguarding
A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional.
Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.
This core service made no safeguarding referrals between 1 February 2017 and 31 January 2018.
Staff received mandatory training in adult and children safeguarding and knew how to raise and
report safeguarding concerns. Safeguarding training for adults and children was mandatory at
different levels for all staff depending on their role. The service had achieved mandatory
safeguarding training compliance above the trust target for all levels of safeguarding training. The
ward managers were identified safeguarding leads for the service and staff reported all
safeguarding concerns as incidents on the trust electronic reporting system. Ward managers
reviewed the incidents and raised issues with the trust safeguarding team for advice and support
to protect patients. Staff gave examples of when they discussed safeguarding that included
concerns about allegations of financial abuse.
The service followed safe procedures for children visiting. Staff followed the trust child visiting
policy and included information about children visiting in their service information booklet for
patients and relatives. Children did not enter the wards or learning and recreation hub and used a
designated visitor’s area in the “core house”. This was an on-site facility where staff such as
medical and psychology staff based themselves and where staff held meetings.
Sheffield Health and Social Care NHS Foundation Trust had submitted details of no serious case
reviews commenced or published in the last 12 months (1 March 2017 – 28 February 2018) that
relate to this core service.
Staff access to essential information
Staff had access to all the information they needed to deliver care safely. Staff kept all patient
information on a secure electronic system that required individual passwords for access.
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Administration staff scanned in any paper documents in a timely way that meant electronic patient
information was readily available and accessible to all staff. Staff shared and recorded essential
information at regular multidisciplinary meetings and during their staff handovers. We observed
two afternoon staff handovers where staff overlapped between the early and late shift. Both
handovers were comprehensive and all staff coming on duty had access to all the information they
needed about all the patients on their ward.
Medicines management
Staff followed good practices in medicines management that included transport, storage,
administration, reconciliation, recording, and disposal. However, staff in all wards did not note the
date of opening for medicines that had a reduced expiry date once in use such as creams, liquids
and an insulin pens. This was not in keeping with the trust medicines management policy. This
stated that ‘staff should ensure they take note of all advisory and cautionary labels and information
supplied by the pharmacy with the product’. The policy only specifically mentioned eye drops and
ointment as requiring a date of opening.
Staff completed the electronic prescription and administration records to show that people
received their medicines as prescribed. Staff said they received good pharmacy support and the
supply process ensured medicines were always available for patients. Non-medical nurse
prescribers attended all multidisciplinary meetings and met with patients.
The wards received support from clinical pharmacists and pharmacy technicians. The clinical
pharmacists attended multidisciplinary team meetings and regularly reviewed prescribing. The
wards had a patient-centred approach to medicines optimisation and patients told us they were
involved in decisions about their medicines. The pharmacist and non-medical prescriber held a
monthly informal drop-in session where patients could discuss their medicines.
Staff demonstrated a patient-centred approach through encouraging and supporting patients’ self-
administration of medicines. The staged process promoted independence whilst making sure
people were safe. However, we noted that the trust self-administration of medicines policy was
due for review in October 2015 and was therefore out of date at the time of our inspection.
Doctors reviewed the effects of medicines on patient’s physical health at least yearly, especially
when the patient was prescribed a high dose of antipsychotic medicine. Staff did a monthly audit
to identify patients on high dose or multiple antipsychotic medicines and reviewed prescribing at
the fortnightly multidisciplinary meeting.
At our previous inspection in 2016, we raised concerns that staff didn’t consistently monitor
patients’ physical health when they were prescribed Clozapine. This drug is used to treat patients
who do not respond well to other antipsychotic drugs. It has a number of potential side effects and
close medical supervision must take place because of the risk of side effects. We told the trust it
must ensure that medicines are managed safely and where required, physical health monitoring
and observations are carried out by staff. At this inspection, we found that staff had made the
improvements and now always followed the trust guidelines for Clozapine monitoring. However,
we noted that the trust guidelines for Clozapine were dated February 2014 and did not have a
review date. The guidelines did not guide staff on all the requirements for monitoring patient
parameters during long-term treatment with clozapine. For example, four to six monthly monitoring
of fasting blood glucose levels in line with the British National Formulary. We looked at six records
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for people prescribed clozapine. Three people out of the six did not have a fasting blood glucose
result in the previous six months. Further evidence submitted by the trust demonstrated that 30%
of patients had not had the required blood tests.
Track record on safety
Providers must report all serious incidents to the Strategic Executive Information System (STEIS) within two working days of an incident being identified.
Between 1 March 2017 and 28 February 2018 there were no STEIS incidents reported by this core service.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system also included no serious incidents relating to this core service.
Although there were no serious incidents about this service, managers informed staff about
lessons learned from other areas within the trust. The trust governance systems and processes
shared information about serious incidents and managers cascaded relevant information at team
meetings. Managers distributed team meeting minutes so that staff who were not present knew
about relevant safety issues.
Staff gave an example of changing their practice with one patient following incidents that involved
restraint and rapid tranquilisation. As a result, there was a significant reduction in the use of
restraint and rapid tranquillisation. Staff shared this information with other wards for their learning.
Reporting incidents and learning from when things go wrong
The Chief Coroner’s Office publishes the local coroners’ Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths.
In the last two years, there were no ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.
The service had a thorough system for reporting and reviewing incidents. All staff knew how to
report incidents through the electronic incident reporting system and managers reviewed the
incidents. We reviewed a range of incidents that staff reported such as verbal abuse and
medication related errors that senior staff discussed at their local monthly governance meeting
and ward meetings. Staff demonstrated their duty of candour about one incident of restraint with a
patient. The Duty of Candour regulation is in place to ensure that providers are open and
transparent with people who use services. It also sets out some specific requirements that
providers must follow when things go wrong with care and treatment, including informing people
about the incident, providing reasonable support, providing truthful information and an apology
when things go wrong.
The ward had a range of opportunities for staff and patients to de-brief following any incidents.
This meant that staff and patients had opportunities to receive additional support following
incidents. This included discussion at the multidisciplinary meeting, one to one support with the
ward manager, and weekly team reflection. We observed one staff reflective practice session
where any member of staff could attend. Staff had open and honest discussions about things
happening in the service that affected them.
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Is the service effective?
Assessment of needs and planning of care
We reviewed 13 electronic care records across the service. Staff kept all 13 records up to date
with evidence of risk assessment and management plans and timely reviews. All 13 involved
patients and considered their views. This was an improvement staff made following the Mental
Health Act Reviewer visits in 2017. The service had an individualised and holistic approach to
assessing, planning, and delivering care and treatment. Staff used a clear rehabilitation and
recovery pathway that commenced when the service received a referral. The multidisciplinary
team held weekly referral meetings, discussed new referrals to the service, and agreed their follow
up action. Two members of the team carried out a pre-admission assessment and planned
admissions with patients who were appropriate for the service. Staff worked together with patients
and other teams to support patients and their families. This included pre-admission visits and
providing written information about the ward.
Staff updated patient care records on the day of admission. This included risk assessment and
management plans, care plans and physical health assessments and monitoring. All three wards
had the necessary equipment to carry out physical health examinations. Nurses and support
workers carried out physical health checks with patients and the service employed one nurse who
took the lead for physical health monitoring. Staff referred patients to other specialist health
services when needed such as speech and language therapy and physiotherapy.
Staff and patients completed and reviewed personalised and recovery orientated care plans
together. Care plans covered a range of needs that included physical, mental health and social
needs. The service used collaborative care planning and the recovery model to set meaningful
patient-centred goals. Each care plan indicated how much involvement patients wanted in their
care plan. This five point coloured scale allowed patients to choose from “I would prefer not to be
involved in the process at the moment” through to “I am very keen to work on my goal. I keep
working on my goal and practice the steps with very little input and support from staff”. Staff asked
patients if they wanted a copy of their care plans and patients had copies if they wanted to keep
them. Patients and relatives told us they were aware of their care plans and goals for recovery.
Staff invited patients and their families to attend regular multidisciplinary meetings to discuss their
care and treatment. Care coordinators from community teams attended meetings that meant
everyone worked together to support individual patients ‘recovery.
Best practice in treatment and care
Staff used a range of interventions supported by best practice guidance. The service used the
rehabilitation standards set by the Royal College of Psychiatrists and conducted peer reviews to
measure their progress.
The service used the care programme approach framework to ensure that patients received care
and treatment in an organised way. All patients had a care coordinator identified within the
community teams. The wards worked with the community-enhanced recovery teams to support
patients’ timely discharge and reduced the need for hospital in-patient treatment. The service
supported individual patient needs such as arranging gradual discharge and short- term
admissions to support patient’s crisis plans in the community.
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The service employed psychology staff who worked across the wards. Psychology staff
received specialist training in using an approach called Reinforce Appropriate, Implode
Disruptive, recognised by the Association of Psychological Therapies. Psychology staff offered
and provided individual psychological therapies with patients where needed. They also
provided psychology support to the wider staff team. This included weekly staff reflective
practice sessions and formulation meetings. These meetings allowed the multidisciplinary team
to gain a shared understanding of individual patients and discuss psychological and psychiatric
approaches to their care and treatment. Staff gave us examples of how this supported their
clinical practice such as reducing restrictive practices. Psychology staff also facilitated a regular
carers support group for relatives and carers of patients who used the service.
At our previous inspection in 2016, we raised concerns that the service offered limited activities
that focused on rehabilitation. At this inspection in 2018, the service had improved access to
rehabilitation-focused activities and developed a recovery college at the learning and recreation
hub. The college reflected recovery principles and offered a range of courses to improve physical
health and wellbeing, life skills, and education and work opportunities. It also had links with other
partners and organisations in the community. Patients gave positive feedback about the college
but commented they would like more opportunity to learn computer skills. The service offered
activities over seven days per week that included art and music therapy sessions facilitated by
sessional therapists.
Staff used outcome measures to monitor patients’ progress. In October 2017 the service introduced a recognised recovery focused patient reported outcome measure called Recovering Quality of Life. Staff asked patients to complete the tool on admission and at their care programme approach review and on discharge. Occupational therapy staff used a recognised outcome measurement called the Model of Human Occupation Screening Tool. Occupational therapists used this tool to measure changes in patient’s recovery over time. However, occupational therapy staff were not fully using the tool on two of the three wards. The service had identified this issue in their accreditation action plan for improvement.
Staff followed best practice guidance for medicine in accordance with National Institute for Health
and Care Excellence medicine optimisation guideline (NG5). Nurses carried out ordering, storage,
and administration of controlled drugs in accordance with the Misuse of Drugs Act 1971 and the
associated regulations. The service completed treatment consent forms for detained patients in
accordance with the Mental Health Act 1983. Staff knew about good medicines practices and the
risks associated with medicines such as antipsychotics and Clozapine. These drugs can cause
serious side effects that affect physical health. This was important because some patients needed
long-term treatment for their mental health condition and could be at risk of developing physical
health conditions. Staff used a recognised side effect monitoring tool called the Liverpool
University Neuroleptic Side Effect Rating Scale. Staff documented when they completed physical
health tests such as blood tests, weight, and body mass measurements.
The service offered a range of interventions to help patients improve their physical health. The
dietician offered patient activities that related to diet and healthy eating on a weekly basis. This
was important because some patients had physical health conditions such as diabetes and others
needed support with weight management. Nurses provided smoking cessation advice and offered
nicotine replacement therapy to patients who smoked. The service had links with substance
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misuse teams and offered advice to patients with issues relating to substance misuse such as
drugs and alcohol.
Staff supported patients to find helpful strategies to support their recovery and offered patients a
range of self-help materials to support their mental health and well-being. This included
information about anxiety management and mindfulness, hearing voices, self-harm and
depression.
This core service participated in eight trust wide clinical audits in the 12-month period leading up to
the submission of the provider information return. During the inspection visit, we also found that
the service regularly took part in a range of audits across all three wards. This included audits of
adherence to the Mental Health Act, physical health, clinical records, and clinic rooms. The
governance officer supported the service with the audit process and ensured that staff collected
data in a timely way. The managers had oversight of the completeness of audits and took action
where things needed to improve. We reviewed weekly audits of nursing records and the action
taken by managers in response.
Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
Collaboration
with Primary
Care Clinicians
Service users
on CPA
Provider
wide Clinical on-going
Changes made following
previous audit round:
provide guidance to staff
on annual reviews of care.
Changes to care plan form.
Creation of a 'clinical
review for GP' IT system
solution.
Record keeping
audit 2016/2017 Trust wide
Provider
wide Clinical on-going
From data collected so far:
Further clarity provided to
staff on use of
abbreviations - to be
incorporated into the
relevant policy.
Audit of risk
assessments
2016/2017
Trust wide Provider
wide Clinical audit March 2017
Local action plans to
address identified issues.
Audit tool to be revised to
give clearer results.
Re-audit to be undertaken
in 2017/18.
Audit of risk
assessments
2017/2018
Trust wide Provider
wide Clinical audit ongoing Await findings
Audits of care
plans Trust wide
Provider
wide Clinical audit
January
2018
Agreed need for frequent
small scale audits.
Findings being shared with
teams.
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG43
Transition from
children’s to
adults’ services
Trust wide Provider
wide Clinical audit June 2017
Findings fed into
Commissioning for Quality
and Innovation and other
related joint work with child
and adolescent mental
health services to improve
transitions
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for young
people using
health or social
care services
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG13
Workplace
health:
management
practices
Trust wide Provider
wide Clinical audit
September
2017
Review practices against
guidance as necessary in
future
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG58
Coexisting
severe mental
illness and
substance
misuse:
community
health and
social care
services
Trust wide Provider
wide Clinical audit
December
2017
Action plan under
development
Skilled staff to deliver care
Patients had access to a range of specialists within the multidisciplinary team to support their care
and treatment. This included qualified mental health nurses, support workers, medical staff,
psychology and occupational therapy staff, activity support workers and administration staff. The
service also had access to pharmacy staff, art and music therapy staff and a dietician. The ward
worked closely with the community enhanced recovery team to support patients’ recovery and
discharge plans.
Managers ensured that any new staff to the wards received a local induction. This included any
student nurses on placement in the service. The induction was consistent across all three wards
that meant that when staff moved across the service they were already familiar with some systems
and processes.
The trust’s target rate for appraisal compliance was 90%. All teams within this Core Service met
this target. As at 31 January 2018, the overall appraisal rates for non-medical staff within this core
service was 99%.
Ward name
Total number of
permanent non-medical
staff requiring an appraisal
Total number of
permanent non-medical
staff who have had an
appraisal
% appraisals
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Ward name
Total number of
permanent non-medical
staff requiring an appraisal
Total number of
permanent non-medical
staff who have had an
appraisal
% appraisals
Forest Close Bungalow 1 25 25 100%
Forest Close Bungalow 1A 28 28 100%
Forest Close Bungalow 2 25 25 100%
Forest Close Central 31 32 97%
Core service total 109 110 99%
Trust wide 1440 1495 96%
The trust’s target rate for appraisal compliance was 90%. As at 31 January 2018, the overall
appraisal rates for medical staff within this core service was 100%.
Ward name
Total number of
permanent medical staff
requiring an appraisal
Total number of
permanent medical
staff who have had an
appraisal
% appraisals
Forest Close Central 2 2 100%
Core service total 2 2 100%
Trust wide 56 57 98%
During the inspection, we checked the appraisal arrangements for all staff on the wards and found
there were good arrangements in place. Managers ensured they supported the professional
development of staff through the trust appraisal process. The clinical nurse manager had oversight
of an appraisal matrix which included the arrangements for all staff and we saw examples of
completed records of staff appraisal. Appraisal identified any performance issues and specific
training needs.
Staff received additional specialist training appropriate to their roles such as positive behaviour
support, motivational interviewing, recognising and assessing medical problems in psychiatric
settings, and clinical skills training such as taking blood, electrocardiograms and early warning
scores. Two nurses had completed their non-medical nurse-prescribing course and two nurses
were completing a postgraduate certificate for recovery in mental health. These were all good
examples of how the appraisal system supported staff professional development to improve the
care the ward provided.
The trust’s measure of clinical supervision data was the number of sessions delivered.
Between 1 March 2017 and 28 February 2018, the average rate across this core service was 88% for non-medical staff compared to the trust’s target of 66%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide.
Ward name Clinical supervision
sessions required
Clinical supervision
sessions delivered
Clinical supervision
rate (%)
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Ward name Clinical supervision
sessions required
Clinical supervision
sessions delivered
Clinical supervision
rate (%)
Forest Close 321 281 88%
Core service total 321 281 88%
Trust Total 3420 2183 64%
During the inspection, we checked the clinical supervision arrangements for all three wards to
understand the information the trust provided. All three wards had good arrangements for clinical
supervision. This was an improvement from our previous inspection in 2016 because we told the
trust it must ensure that the service complied with the trust supervision policy.
Managers made sure that all staff received clinical supervision according to the policy. The clinical
nurse manager had access to an electronic database of the clinical supervision arrangements
across the service from across the trust. Nursing staff cascaded responsibilities for supervision,
which meant that band seven nurses supervised band six nurses through to band five nurses who
supervised support workers.
Psychology, occupational therapy, and medical staff also had supervision arrangements in place.
Managers raised any performance issues that involved bank and agency staff through the trust.
As well as formal clinical supervision, the ward team met on a regular basis to discuss and reflect
on patient care. This included reflective practice sessions, handovers, and debriefs. Staff told us
they felt well supported in their roles.
Managers used supervision and the trust disciplinary process to deal with any poor staff
performance promptly and effectively. Where managers identified issues with staff performance
they set and reviewed performance targets. We reviewed how managers used supervision to
improve staff performance and saw examples with targets for improving standards for record
keeping and collaborative care plans.
Multidisciplinary and interagency team work
The ward teams had effective working relationships with one-another and other professionals
involved in patient care.
The multidisciplinary teams held weekly meetings on all three wards to discuss patients care and
treatment. We attended one multidisciplinary meeting during the inspection. Staff kept
comprehensive records of the meeting. Staff invited patients and their carers to attend and
everyone had the chance to give their views. If patients did not want to go to their meeting, staff
spoke with them afterwards to provide feedback.
Staff invited other external professionals and members of the community teams to these
multidisciplinary meetings as appropriate. The teams had good working relationships with each
other and shared relevant information about patient needs. At our previous inspection in 2016, we
raised concerns that most patients did not have an identified care-coordinator from the community
teams. We told the trust that it should ensure that patients were allocated a care coordinator from
an appropriate community based mental health team. At this inspection in 2018, this had improved
and all patients had appropriate care-co-ordination in place. Members of the community teams
also visited patients on the ward and provided interventions as part of their care and treatment
plans.
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The service had well-established relationships with local housing providers that meant they could
support patients’ discharge to independent tenancies. The team on one ward worked closely with
one organisation to support a patient’s discharge to the community. This was important because
the patient had been in hospital for a longer than expected length of stay and everyone involved
wanted the discharge to be successful.
Staff held handovers at every shift change and discussed each patient. We observed two effective
staff handover meetings from the early to the late shift. The handover nurses provided
comprehensive and up to date information about each patient. This included information about
physical and mental health needs, leave arrangements and medication changes. Staff on day
shifts had 10-minute handover time with night staff. We did not observe these handovers, but staff
from all three wards spoke about how these meetings were less effective. One staff member told
us that the night-time handovers could last for up to 30 minutes; one told us that there was not
enough time and another said handovers started before all staff on shift were present.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
As of 28 February 2018, 92% of the workforce in this core service had received training in the Mental Health Act. The trust stated that this training was mandatory for all core services for inpatient and all community staff and renewed every three years.
As well as mandatory training, some qualified nurses had completed Mental Health Act
competency framework training to enhance their knowledge and understanding of the Mental
Health Act.
At the time of our inspection, there was a mixture of informal patients and patients detained under
the Mental Health Act across the service. All three wards had a locked entry and exit system that
meant patients could not leave the ward without staff to help them. All wards displayed a notice to
tell people how they could leave the ward freely. This was important because some patients were
informal and these patients told us they knew how they could leave the ward.
The wards had access to administrative support and advice about the Mental Health Act and staff
accessed the trust policies and procedures on the trust intranet. Staff had good understanding of
the Mental Health Act and how to get additional support and advice. They carried out regular
audits as part of the trust audit programme that included their adherence to the Mental Health Act.
We saw evidence that that all wards completed Mental Health Act Audits as needed by the trust.
The service governance officer had oversight of compliance with the Mental Health Act and
managers ensured that staff took any actions to improve compliance. This included making sure
patients understood their rights under the Mental Health Act.
All wards displayed information for patients about the independent mental health advocacy
service. Staff knew how to access the advocacy services and advocates visited the wards on a
regular basis. They could attend multidisciplinary meetings to support the patient’s voice and
patients told us how an advocate supported them.
All wards displayed other information about the Mental Health Act in patient areas. The information
was well organised and accessible. In addition, staff gave all patients the service welcome booklet
that contained helpful information about section 17 leave arrangements, legal support, and
advocacy services.
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The Mental Health Act Reviewer inspected the service in January 2017 and July 2017 and raised
a number of concerns following each visit. This included; blanket restrictions around locked
sensory rooms, issues with section 17 leave forms, lack of evidence of risk management plans,
and issues with patient and carer involvement in care plans. During this inspection in 2018, we
saw that the wards had made improvements that addressed all these concerns. All wards had a
clear process to identify and review blanket restrictions. Staff identified the locked doors, which
were identified as trust-approved restrictions. We checked section 17 leave forms and found them
to be in good order. Staff reviewed section 17 leave arrangements at multidisciplinary meetings.
They crossed out old section 17 leave forms that ensured staff could easily identify the most up to
date form and shared copies with patients and their carers. This was important because detained
patients need the right legal authority to be in place before they leave the ward. We examined 13
care records and all had evidence of patient views and carer involvement where appropriate.
Staff supported patients to take their section 17 leave, however, two carers told us that sometimes
staff cancelled section 17 leave at short notice. Staff told us they always facilitated section 17
leave providing the patient was well enough to leave the ward.
Staff asked patients for their consent to treatment and used second opinion appointed doctors
when needed. Staff ensured that all T2 and T3 forms were correct and up to date. These forms
give staff legal authorisation to administer certain medications to detained patients.
Good practice in applying the Mental Capacity Act
As of 28 February 2018, 99% of the eligible workforce in this core service had received training in
the Mental Capacity Act level 1 and 98% had received training in the Mental Capacity Act level 2.
The trust stated that this training was mandatory for all core services for inpatient and all
community staff and renewed every three years.
Staff had a good working knowledge of the Mental Capacity Act and its principles. Staff assumed
patients had capacity unless indicated otherwise. They knew that capacity assessments were
necessary for specific decisions such as discharging patients to alternative placements. Staff
documented their decisions about capacity on the patient’s electronic record. Staff always gained
patients’ consent and encouraged patients to make decisions for themselves such as setting their
goals and what activities they wanted to do. Staff had access to administrative support and advice
about the Mental Capacity Act and accessed the trust policies and procedures on the trust
intranet. We did not see any evidence that staff carried out audits in relation to the Mental
Capacity Act.
The trust told us that no Deprivation of Liberty Safeguard applications were made to the Local
Authority for this core service between 1 March 2017 and 28 February 2018.
CQC received no direct notifications from Trust between 1 March 2017 and 28 February 2018
relating to this core service.
At the time of our inspection, no patients were subject to Deprivation of Liberty Safeguards.
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Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
We offered all patients in the service the opportunity to speak with us, and seven patients spoke
with us. We held one focus group and left comments cards for patients to provide further feedback
to us about their experience of the service. The feedback we received from patients was overall
positive about the way staff treated them
Patients and carers had strong relationships with staff who were caring and supportive. The
managers of the service supported a culture of working in partnership with patients and their
carers. The clinical nurse lead attended every multidisciplinary team meeting and knew individual
patients well.
All patients described staff as kind, caring and respectful. Patients described staff as “wanting the
best for them” and “wanting to get me better”. Carers reported feeling the staff were consistent and
shared “a common goal” to help people recover. We observed that staff were respectful and
responsive to individual patient’s needs and took time to ensure patients with communication
needs understood information. Staff respected patients’ privacy and dignity by knocking on
bedroom doors before entering. All staff knew patients well and supported them to maintain their
independence and relationships with people who were important to them. This included daily living
skills, self-medication, and support to access individual cultural, social, and religious preferences.
Staff directed patients to other services to support their recovery. For example, the recovery
college linked patients with activities in the local community and patients attended groups such as
weight management and sports activities. Staff went with patients if necessary as part of the
patient’s recovery plan.
Staff maintained the confidentiality of all information about patients across all three wards. Staff
stored electronic information about patients in a secure system and made sure that information
displayed in ward offices was always kept confidentially.
Patient led assessments of the care environment are undertaken by local people visiting services
and assessing the care environment. The 2017 Patient-led assessments of the care environment
(PLACE) score for privacy, dignity and wellbeing at the core service location was higher than
similar organisations.
Site name Core service(s) provided Privacy, dignity and
wellbeing
Forest Close MH - Long stay/rehabilitation mental health wards for
working age adults 100%
Trust overall 96.6%
England average (mental health and
learning disabilities) 90.6%
Involvement in care
Staff involved and encouraged patients and their carers where appropriate to be involved in their
care. Patients and their families told us about how they were involved and knew what was
happening for example about discharge plans.
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Involvement of patients
Nurses used the admission process to show patients around the ward and gave them a welcome
information booklet that explained about the service and information about collaborative care
planning. Housekeeping staff spoke with patients to make sure the service provided individual
dietary preferences food in keeping with their cultural needs such as halal food. Patients told us
they felt welcomed to the ward and had opportunity to look around.
Staff recognised and respected all patients’ needs, and reflected this in the way staff delivered
care. This included patients’ cultural, religious and communication needs. Staff involved patients in
their care planning at a level they chose. Patients had copies of their care plans and risk
assessment plans if they wanted to keep them. Staff supported patients to think about what
activities and therapies would be helpful for their recovery and devised weekly activity schedules
with patients. Staff involved patients in decisions such as which day during the week they would
prefer housekeeping staff to deep clean their room. All three wards had ways to collect patient
feedback about their experience on the ward. Staff were committed to continually improving their
service. They asked patients to complete surveys and had increased the frequency of patient
community meetings from fortnightly to weekly. Staff persevered to encourage patients who were
less motivated to attend these community meetings and ensured that community-meeting minutes
were accessible on the ward. We reviewed minutes of community meetings held on the wards and
saw evidence that staff invited patients to be involved in decisions about the service such as what
activities and therapies to provide. Patients told us they felt they had enough opportunity to be
involved in ward decisions.
The service invited patients to be involved in the recruitment of staff. They formed an informal
panel and gave feedback to staff based on their conversations with candidates. The clinical lead
told us that the recruitment panel took patient views seriously when considering recruitment of
appropriate staff.
Involvement of families and carers
We spoke with four carers of patients who used the service. Overall, they gave positive feedback
about the support and information they received from ward staff. They were positive about the
care and support that staff offered to them and the patient. Carers told us that this was “the best
service” in terms of progress for their relative. We saw that relatives visited during our inspection
and attended care programme approach meetings.
The wards routinely gathered and shared feedback from carers about their experiences of the
service. This included a questionnaire that staff completed with carers and included their views
about involvement. We reviewed carer’s feedback from one ward and saw that overall it was
positive about their level of involvement and support from staff.
The service recognised that carers were a big part in helping patients care and recovery and staff
sought patients’ consent to involve their families. Staff gave carers information about how to
access carer’s assessments if they more needed help and advice. They offered access to a carers
support group both on and off site, facilitated and attended by staff from the service. Carers told us
they had attended the carers’ group meetings and “family days” that they found helpful.
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Is the service responsive?
Access and discharge
Bed management
The trust provided information regarding average bed occupancies for three wards in this core
service between 1 March 2017 and 28 February 2018.
Two of the wards within this core service reported average bed occupancies ranging above the
provider benchmark of 85% over this period in all of the 12 months. Forest Close 1 had an
average bed occupancy rate of less than 85% for January and February 2018.
We are unable to compare the average bed occupancy data to the previous inspection due to
differences in the way we asked for the data and the time period that was covered.
Ward name Average bed occupancy range (1 March 2017 – 28
February 2018) (current inspection)
Forest Close Bungalow 1 74.6 – 114.5
Forest Close Bungalow 1A 93.3 – 101.4
Forest Close Bungalow 2 100.0 – 104.2
At the time of our inspection, all three wards had vacancies. When patients went on leave, they
always had their bed available when they returned to the ward. All patients were from the trust
catchment area with no patients currently out of area waiting to use the service.
The service reconfigured approximately three years ago and managers were considering an
options appraisal to maximise bed use and meet the rehabilitation demands of the local
population.
The service held joint referral meetings with the community enhanced recovery team. Staff
discussed how best to provide care to meet the patients’ needs which could include community
services rather than hospital admission. Senior ward staff reviewed referrals and then planned
appropriate admissions.
The trust provided information for average length of stay for discharged patients for the period 1
March 2017 to 28 February 2018.
We are unable to compare the average length of stay data to the previous inspection due to
differences in the way we asked for the data and the time period that was covered.
Ward name Average length of stay range (1 March 2017 – 28
February 2018) (current inspection)
Forest Close Bungalow 1 57.6 – 1071.0
Forest Close Bungalow 1A 2.0 – 2155.0
Forest Close Bungalow 2 741.8 – 898.0
At our previous inspection in 2016, we raised concerns about the excessive length of stay for eight
patients. We told the trust it should ensure that patients were discharged to placements that were
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more appropriate. At this inspection in 2018, six of those eight patients had moved on to other
placements. Staff told us the average length of stay was up to 18 months and we examined the
care records to understand why the remaining two patients had not moved on. Both patients had a
clear discharge plan and staff provided interventions to support their recovery.
This core service reported no readmissions within 28 days between 1 March 2017 and 28
February 2018.
This core service reported 17 out area placements between 1 March 2017 and 28 February 2018.
As of 1 March 2018, this core service had seven ongoing out of area placements.
Due to inconsistencies in the presentation of the data it is not possible to calculate a range for the
length of the out of area placements. There were no placements that lasted less than one day.
All of the 17 out of area placements were to ‘place a patient with another provider due to this
better suiting their care or personal needs’.
Number of out of area
placements
Number due to specialist
needs Number due to capacity
Number of ongoing
placements
17 17 0 7
Discharge and transfers of care
Between 1 March 2017 and 28 February 2018 there were 26 discharges within this core service.
This amounts to 3% of the total discharges from the trust overall (804).
The trust has advised that during this time there were 62 delayed discharges within this core
service. Due to the way the data is recorded by the trust, patients whose discharge was delayed
by more than one month may appear multiple times within this total.
However, during the inspection visit, we checked how many patients the service had identified as
a delayed discharge. Managers told us there were no delayed discharges.
Staff used the care programme approach to ensure that patients had a smooth transition to
appropriate placements on discharge. Staff held discharge meetings with patients, carers and the
community providers so that everyone was prepared for the discharge arrangements.
The clinical nurse manager attended a local funding panel meeting to advocate for patients
complex housing and support needs in the community. The impact of this meant that the service
had agreed funding and created a bespoke care package for one patient who had been in hospital
for a long time. The package included support to recruit the right staff to support the patient’s
needs and provide out-reach from the ward to support a successful discharge. During the
inspection, staff supported this patient to visit the placement.
Staff supported patients during referrals and transfer between services. Staff only moved patients
to another ward if they could no longer meet their clinical needs such as when patients needed
more intensive care. Staff said they could quickly find an appropriate bed on another ward and told
us how they continued to support one patient who had moved quickly to another ward in the trust.
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Facilities that promote comfort, dignity and privacy
All patients had their own bedrooms with fitted furniture and ensuite bathroom facilities. Patients
personalised their bedrooms with their belongings. All patients had a key for a lockable drawer and
had safes in their bedrooms. This meant that patients had somewhere to store their possessions
securely. All patients we spoke with liked their bedrooms and told us that bedrooms were
comfortable and clean. Staff had arranged for one patient with specific needs to access a larger
room and bathing area with adequate space for everything they needed.
The wards were compact but had enough space to promote the comfort, dignity, and privacy of
patients. Visitors used a communal space in the ‘core house’ and the café area adjacent to ward
one A. The ‘core house’ was a separate building on site used by staff for offices and meeting
rooms. Carers commented they were happy with the visiting facilities but would prefer the choice
of more comfortable seating in the café area.
Patients had access to a communal lounge, beverage facilities, laundry, dining areas, and
pleasant garden spaces on the wards. The wards were comfortable and well maintained and staff
involved patients in choosing fabrics and furnishings. The only quiet space was the “green rooms”
that staff kept locked and used for de-escalation. However, patients could use their bedrooms at
any time as a quiet space. Bedrooms had pictorial screening on the door windows to promote
privacy and confidentiality that patients could control from inside. Patients had access to other
shared spaces off the ward. This included the café area on ward one A, as well as the recreation
and learning hub.
Patients could have access to their personal mobile phones and electronic devices. Where
patients did not have their own phone, the ward provided use of a ward phone and two public
telephones so that patients could maintain contact with others. We observed that the public phone
on bungalow one A was situated in a corridor outside the ward area and did not afford much
privacy. This was because it was close to the busy reception area where people entered and left
the ward.
We observed lunchtimes as sociable and relaxed times. Lunchtimes were protected times that
meant patients could eat their meals without disturbance from other things such as meetings.
Patients could self-cater but housekeeping staff also prepared food on site. The trust delivered
specialist foods to the wards depending on patients’ specific dietary or cultural needs. The wards
displayed a daily menu choice that was on a four-week rota. Housekeeping staff offered
alternatives to patients if they did not like the options available. Patients and staff regularly
discussed the meal choices at community meetings. Patients had access to drinks and snacks at
all times of the day and gave overall positive feedback about the food quality and the opportunity
to self-cater.
Patient led assessments of the care environment are undertaken by local people visiting services
and assessing the care environment. The 2017 Patient-led assessments of the care environment
(PLACE) score for ward food at the location scored higher than similar trusts.
Site name Core service(s) provided Ward food
Forest Close MH - Long stay/rehabilitation mental health wards for
working age adults 98.9%
Trust overall 96.4%
England average (mental health and learning disabilities) 91.5%
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Patients’ engagement with the wider community
Staff encouraged patients to be active within their local community. Patients had a seven-day
activity plan that included leave and activities in the community. This included educational,
vocational, and volunteering opportunities via the recovery college. Patients who used the
recovery college thought it offered them excellent opportunities for recovery. Managers planned
staffing requirements at their daily service-planning meeting so that patients could have leave if
they needed staff to support them. Identified staff had access to trust transport and acted as
designated drivers to take patients out as part of their care and treatment plan. Patients told us
they enjoyed activities in the community
Staff supported patients to maintain contact with their family and carers. The wards had mealtimes
as protected times but otherwise carers had open access to visit their relatives. We saw that family
contact took place and patients went out with their families.
Meeting the needs of all people who use the service
All three wards and the learning and recreation hub were situated in bungalows and were
accessible for people with mobility needs. All three wards had accessible communal bathing
facilities that patients used with staff support if they needed more help. We observed these
facilities did not have screening in the room to protect patients’ dignity.
Staff completed falls assessments on admission and referred patients to the physiotherapy service
for specialist assessments and equipment when they needed their advice.
Throughout all three wards, we saw information displayed to support patients such as how to
complain, how to contact the advocacy service and the Care Quality Commission.
Staff could access information from the trust in easy read, other languages, and formats to suit
individual patient communication needs. Staff told us they knew how to access interpreters and
signers through the trust system. We observed how staff communicated with patients with specific
communication needs. When we reviewed the care records, we saw clear evidence of the specific
support and adaptations that staff used after working together with the learning disabilities team.
This included a pictorial weekly activity planner, extra involvement from the community enhanced
recovery team and positive behaviour support plans.
The wards referred to a speech and language therapist and had regular involvement from a
dietician. Staff worked closely with housekeepers to ensure that patients had access to food that
met their dietary and religious needs.
Although the wards did not have a designated multi-faith area, patients accessed a multi-faith area
at the recreation and learning hub. Maintenance staff were re-furbishing this room at the time of
our inspection. Staff considered patients’ spiritual and cultural needs as part of their assessment
and supported patients to meet these needs. Staff supported patient to attend religious services of
their choice and facilitated visits from faith representatives.
Listening to and learning from concerns and complaints
This core service received two complaints between 1 March 2017 and 28 February 2018. One of
these was not upheld and the other was still under investigation.
Ward Total Fully Partially Not Under Referred to Upheld by
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name Complai
nts
upheld upheld upheld Investigation Ombudsman Ombudsman
Core
House 1 0 0 0 1 0 0
Bungal
ow 2 1 0 0 1 - 0 0
When we spoke with patients and their carers, they told us they had no complaints about the
service but knew how to make a complaint and would feel confident to do so. Staff knew how to
deal appropriately with concerns and complaints raised by patients or relatives. They directed
patients to the trust corporate affairs team that managed complaints. Staff listened to patient
complaints at ward community meetings and tried to deal with issues as they arose.
At the time of our inspection, the clinical nurse manager told us that no complaints were under
investigation. The two complaints reported by the trust had not been upheld. Senior managers
discussed any complaints at their monthly governance meetings and feedback relevant
information to ward staff through team meetings.
This core service received six compliments during the 12 months from 1 March 2017 to 28
February 2018 which accounted for 1% of all compliments received by the trust as a whole.
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Is the service well led?
Leadership
The leadership and governance arrangements and the culture at Forest Close promoted high
quality patient-centred care across the service. The clinical nurse manager was the most senior
nurse on site and was clear about their role. The clinical nurse manager was highly visible to staff
and patients and knew the service well. They received supervision from a senior operational
manager and were supported by a range of clinical and non-clinical staff on site. Senior staff had
the skills, knowledge, and experience they needed for their roles. Most had worked at the trust for
many years and had opportunities to develop their leadership and management skills. They had
been involved in the service transformation that began three years ago and could explain how the
service had progressed during that time. They had a shared vision for future developments and
improvements to the service. We visited all three wards and found that managers applied
consistent governance structures and staff felt well supported.
Vision and strategy
Managers and staff knew and understood the trust’s vision and values. The trust vision and
strategy was highly visible and accessible across the site. The service displayed a directorate
mission statement that reflected the trust vision and values and a culture of recovery. When we
spoke with staff and observed interactions with patients and each other, we saw how staff upheld
values of respect and compassion.
Managers had a clear vision for improvements to the service. Staff had reviewed their journey
from transformation three years ago and managers were beginning to think about future service
developments to meet local need.
Staff provided high quality care within the budgets available to them. Staffing levels across the site
had improved since our previous inspection in 2016. Managers reviewed staffing requirements,
thought about succession planning, and had fully recruited to all vacancies. Although some staff
we spoke with wanted more staff available on the wards, they did not report any effect on patient
safety or care due to financial restraints.
Culture
Staff shared a culture where they felt valued and supported and enjoyed coming to work. Many
staff had worked within the service for a number of years. They felt that changes to the service,
although difficult at the time, had definitely improved things for patients. Clinical and non-clinical
staff felt very positive and proud about the work they did to support patients’ recovery.
Staff felt confident to raise concerns because they worked within a supportive culture. They felt
managers were approachable and would listen to them. They knew how to raise the
whistleblowing process and some knew about the role of the freedom to speak up guardian. This
is an independent role that supports staff to speak up which trusts were asked to have in place
since October 2016.
During the reporting period, there was one case where staff had been either suspended, placed under supervision, or were moved to a different ward. One grade 3 member of bank staff had been suspended.
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Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these should be noted.
Ward name Suspended Under supervision Ward move Total
Forest Close 1 0 0 1
Core service total 1 0 0 1
Managers felt comfortable dealing with poor staff performance when they needed to. They referred
to trust polices and used management supervision to improve performance. Managers felt
supported by the trust human resources and occupational health departments. At the time of our
inspection, two staff were suspended from one ward while under investigation. The ward manager
told us these incidents were not directly associated with care on the ward at Forest Close.
Ward teams worked well together to promote the delivery of safe and high quality care. Sickness
levels across the service were below the overall trust level and remained similar to when we last
inspected the service. Managers increased the level of support available to staff during times of
increased difficulty such as when caring for highly distressed patients. This included more frequent
team meetings and opportunities for reflection. This was important so that staff felt supported and
could remain resilient.
Managers offered staff the opportunity to discuss their career and personal development at their
supervision and yearly appraisal. Managers used this information to support appropriate specialist
training needs to improve staff knowledge and skills and career progression.
The trust recognised contributions made by staff by holding yearly staff awards. Staff were
encouraged to nominate their colleagues in recognition of their contributions. One staff member
had received a trust award in recognition of the work they did to support the service. They were
instrumental in organising fund raising and social events that included staff and patients such as
barbeques and raffles.
Governance
Managers had effective governance systems to monitor the quality and safety of care the service
provided. This meant that the environments were safe and clean, and wards were adequately
staffed with staff with the right skills. Staff assessed and managed risks well. They protected
people from harm and reduced restrictive practices across the wards. The service used good
practice in accordance with national guidelines including National Institute for Health and Care
Excellence to provide evidence based care. Staff treated people with compassion and adhered to
the Mental Health Act and Mental Capacity Act requirements to ensure they protected patients’
rights. The service managed admissions and discharges in a timely and patient-centred way that
meant patients and carers had good experiences of the service.
The service had made all the improvements following concerns raised from the previous
inspection and Mental Health Act Reviewer visits. Staff completed audits and managers generated
action plans and timescales that sustained improvements in the quality of care.
Senior managers and ward staff held regular meetings that shared relevant information with staff.
Senior managers met to review information about performance, quality, and safety. Ward
managers held staff meetings to pass on information and we saw evidence that staff discussed
performance, quality, and safety issues.
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The service had a clear care pathway that managers and ward staff understood. This meant that
staff knew how the ward worked with other teams within the trust, wider teams, and external
parties such as educational, vocational, and housing partners.
However, we identified some areas of concern that we felt the service should improve. This
included:
• managers did not have robust systems or processes that ensured staff adhered to the
dress code and infection control policy, and some aspects of medicine management and
medical stock control
• managers could not provide assurance about the completion of safety work at the learning
and recreation hub or that staff always held effective handover meetings
• staff used some trust medicine related policies and guidelines that were not up to date or
had no review date.
Management of risk, issues and performance
The service held a risk register that managers reviewed and updated. The risk register was up to
date and included the issue about the integral alarm system in the learning and recreation hub.
This was the only outstanding action from our previous inspection. Senior managers could not
confirm a date for completion of the work. In the meantime, the service had implemented
measures to lessen the risks whilst waiting confirmation from the trust.
Information management
The service used an electronic system that all staff had access to so they could do their jobs.
Managers and other non-clinical staff used the system to submit and review information needed by
the trust. This included Mental Health Act audits, supervision, appraisal, and mandatory training
data. Managers used this information to monitor performance and ensure the service achieved
compliance levels. We saw evidence that compliance levels were always high across the service.
Ward staff accessed relevant clinical information about patient care. They knew how to access the
system and find the information they needed. Staff kept electronic information confidential such as
ensuring it could not been seen from outside the offices. We found that staff kept up to date
clinical information such as care plans and risk assessments that meant staff had the information
they needed to support patient care.
Managers were able to access service level and clinical information about the service in a timely
and well-organised way. This was an improvement from our previous inspection in 2016 when we
told the trust it must ensure that the service had effective governance systems in place to share
information in a timely manner.
Engagement
Everyone had access to up to date and relevant information about the service. The trust website
included up to date information about Forest Close with links to the most recent Care Quality
Commission inspection findings. The service displayed the most recent report across the site.
Staff provided information booklets about the service to patients and carers. The service involved
patients in their staff recruitment process and carried out a range of methods to gather patient and
carer feedback, which they acted on.
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The service was starting to think about making changes to the service following their
transformation almost three years ago. Senior managers told us that staff, patients, and other
stakeholders would be involved in the decision making process.
Staff told us senior managers were accessible and sometimes visited the service. During the
inspection, the senior operational manager visited to attend a meeting with the clinical nurse
manager to discuss aspects of the service.
The service produced a seasonal newsletter that contained information about events and activities
for staff and patients. It also contained personal information such as birthdays and names. The
newsletter was also available in communal areas such as the visiting area in the ‘core house’. This
meant that people could access information that contained personal information about others. It
was not clear that everyone had given permission for information sharing in this way.
Learning, continuous improvement and innovation
NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.
The table below shows which services within this core service have been awarded an accreditation, together with the relevant dates of accreditation.
Accreditation scheme Service accredited Comments and date of accreditation / review
AIMS - Rehab (Rehabilitation wards) Forest Close At Peer Inspection stage
The service was working towards achieving accreditation for all three wards in September 2018.
Some staff had completed peer review training and staff felt confident they could achieve the
standards needed.
The service was in the early stages of developing ‘safety huddles’. These short meetings aimed to
focus on improving safety on the wards. Staff could hold these meetings as well as handovers and
team meetings.
The service used the trust quality improvement methodology called microsystems. One manager
had completed additional training and took a lead role in quality improvement. The trust supported
the manager with coaching sessions and away days that shared good practice. The service used
the methodology to improve patient experience based on their feedback about boredom in the
evenings and weekends. Because of the work, the number of activities available had increased
and staff continually monitored progress through patient involvement and feedback. We saw from
activity schedules and patients told us that activities were available seven days a week including
evenings. The manager was positive about the methodology and planned to use the model for
other projects and encouraged more staff to get involved.
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Acute wards for adults of working age and psychiatric intensive care units
Facts and data about this service
Location site name Ward name Number of beds Patient group (male,
female, mixed)
The Longley Centre Endcliffe Ward
PICU 10 Mixed
The Longley Centre Maple Ward 17 Mixed
Michael Carlisle Centre Burbage Ward 19 Mixed
Michael Carlisle Centre Stanage Ward 18 Mixed
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. The majority
of patients were detained under the Mental Health Act at the time of our inspection, there were no
patients with deprivation of liberty safeguards in place.
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Is the service safe?
Safe and clean care environments
Safety of the ward layout
Ligature risks were identified and managed through regular assessment on each ward. A ligature
point is something that a patient intent on self-harm could use to tie something to in order to
strangle themselves. Individual risks were recorded, risk rated and control measures identified.
The trust had continued to work to reduce the number of potential ligature points via a programme
of works to include door handle replacement and en-suite door replacement. All wards had access
to a number of bedrooms which were reduced ligature specification. Doors in these bedrooms
were alarmed if any weight was applied to the door and had anti-barricade fittings, this meant the
door opened both ways. Bathroom doors in these bedrooms were collapsible.
Staff had mitigated the risks adequately. Mitigation of these risks was managed consistently on
each ward through thorough patient risk assessment, patient observation and regular monitoring
of the ward environment by staff. We observed a constant staff presence in communal areas on all
four wards.
All four wards had a ligature risk assessment completed within the last 12 months and had a copy
of the latest ligature risk assessment available for staff. However, following a serious incident on
Maple ward in September 2017, the trust had taken action to upgrade all en-suite bathroom doors
across all inpatient wards in order to mitigate ligature risks. However, the ligature risk
assessments for all wards had not been reviewed following this serious incident. The trusts’
Ligature Risk Reduction Policy 2017 states ligature risk assessments must be completed more
frequently if a significant event has occurred.
Fire risk assessments were undertaken by the trust’s estates team in collaboration with the ward.
Maple ward reviewed fire risk in December 2017 and had a copy available to staff on the ward.
Three wards had undertaken the annual fire risk assessment in March 2018 and were awaiting
final copies of the report to be produced by the fire officer at the time of this inspection. Ward
managers told us they had received an email to confirm actions that required attention. Issues
identified, included general housekeeping, linen storage and disposal of paper.
We identified blind spots on the two wards (Burbage and Stanage) at the Michael Carlisle Centre, and on Maple ward at the Longley Centre. None of these wards had identified the blind spots on their environmental risk assessments or had put measures in place to mitigate them. On Stanage ward, access to both dormitories was recessed and the clinic room had small corridors on either side. On Burbage ward blind spots were identified by the lounge, room 14 and near the bathroom. At the Longley Centre, blind spots on Maple ward included a corridor to the doctors’ office and an area near the female dormitory. Although staff were present on communal areas at all times, this meant there was an increased risk to staff and patient safety.
Female only lounges were available on all wards.
Staff had access to alarms and nurse call systems were in place for patients on each of the four wards. There was a system in place to test the alarms regularly.
With the exception of patients on Endcliffe, six patients we spoke with, told us they did not feel
safe and seven patients had experienced aggressive behaviour from others.
Over the 12-month period from 1 March 2017 to 28 February 2018 there were no mixed sex accommodation breaches within this core service. The trust had completed work to ensure the acute wards and psychiatric intensive care unit complied with the eliminating mixed sex accommodation guidance. Endcliffe and Maple wards complied with the guidance. Stanage and
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Burbage had sleeping accommodation in single rooms within mixed wards with toilet, washing and shower facilities. Each of these wards also had two four bedded bays and these were solely occupied by male or female patients, also with toilet, washing and shower facilities. A local standard operating procedure was also in place to ensure mixed sex wards bedrooms, toilets and bathing facilities were grouped together to achieve as much gender separation as possible. Staff we spoke with acknowledged it was extremely difficult to ensure bedrooms were grouped together for males or females due to the constant demand for beds, flow of patients on the wards and not moving patients that were already settled. However, we identified no concerns and the provider met the requirements as per guidance for mixed sex accommodation.
Maintenance, cleanliness and infection control
All four wards were clean, well maintained and furnishings were of a good standard.
Housekeeping staff were visible on all wards and each ward had a senior housekeeper to co-
ordinate and monitor housekeeping activity. All cleaning records were up to date. Stanage had
recently been decorated and Burbage ward looked tired but was scheduled to be redecorated. The
majority of patients we spoke with complimented the wards for their cleanliness.
We observed staff following infection control principles. There were hand gel dispensers across all
wards and we observed staff using these. Hand washing guidance was visible in all kitchen and
bathroom areas. All clinic rooms were fitted with sinks for staff to wash their hands prior to
dispensing medication or undertaking physical health examinations. Personal protective
equipment was available and was stored securely.
The wards participated in the 2017 patient led assessment of the care environment. These
assessments are self-assessments undertaken by teams of trust staff and specially trained
members of the public. They focus on different aspects of the environment in which care was
provided. For the most recent Patient-led assessments of the care environment (PLACE)
assessment (2017) the locations scored better than or equal to similar trusts for all four of the four
aspects overall.
Site name Core service(s)
provided
Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
Longley Centre MH - Acute wards for
adults of working age
and psychiatric
intensive care units.
MH - Mental health
crisis services and
health-based places of
safety.
99.6% 96.8% 92.4% 87.7%
Michael Carlisle Centre MH - Acute wards for
adults of working age
and psychiatric
intensive care units.
MH - Other Specialist
Services
MH - Wards for older
people with mental
98.0% 97.3% 88.7% 91.6%
20171116 900885 Post-inspection Evidence appendix template v3 Page 93
health problems.
Trust overall 99.0% 97.8% 91.1% 91.8%
England average (Mental health
and learning disabilities) 98.0% 95.2% 84.8% 86.3%
Seclusion room
Clinic room and equipment
Clinic rooms were well organised, fully stocked and clean. Clinic rooms on all four wards had
examination chairs that reclined and this meant all patients could be physically examined in a
clinical room. A blood pressure monitor, weighing scales, resuscitation equipment and emergency
drugs were available on all wards.
There were four seclusion rooms across the core service. Seclusion rooms allowed for clear
observation using observation windows and closed-circuit television. Two-way communication was
possible through the use of intercoms. All seclusion rooms had toilet facilities and a clock.
At the previous inspection in November 2016, we told the trust they must review seclusion room
provision on each of the wards. There were a number of issues identified with the seclusion rooms
on Stanage, Burbage and Maple wards. During this inspection we confirmed these issues had been
resolved.
A mattress was used rather than a bed in the seclusion rooms on Burbage and Stanage wards due
to the size of the rooms. Maple ward also used a mattress, due to the height of the ceiling, as a bed
created a potential ligature risk.
At the last inspection, the seclusion rooms on Burbage and Stanage wards did not have lock back
doors. Lock back doors are needed so patients can access the bathroom area independently.
Following review by clinical leaders and estates, the trust identified it was not possible to
accommodate lock back doors in the seclusion rooms on Stanage and Burbage wards. During this
inspection staff told us the bathroom doors remained closed and locked when the seclusion rooms
are in use. Unlocked, the door remains a high risk anchor point within the seclusion rooms. Staff told
us each patient would be risk assessed to decide if the door could be unlocked. We saw evidence of
this risk assessment in one of the two seclusion records we case tracked.
The trust’s action plan confirmed that the intercom on Burbage ward was fixed following the review
in December 2016.
The trust successfully addressed the issues on Maple ward regarding privacy and dignity. The
seclusion room was relocated to a different corridor than at the previous inspection. The seclusion
room had an entrance lobby, large seclusion room and accessible en-suite bathroom. Windows
provided clear observation into the en-suite bathroom. The seclusion room had a two way
functioning intercom facility. Large windows with internal, adjustable blinds provided natural light. A
clock was visible for patients to see.
Each ward had a ‘green room’, a protected therapeutic space for patients to access to reduce
distress, agitation or aggression. At the previous inspection in November 2016, we told the trust they
should ensure the operational procedure clearly stated that patients could leave the room at any
point. With the exception of Burbage ward, all wards had updated the standard operating procedure.
Staff on Burbage ward knew that patients could leave the green room.
20171116 900885 Post-inspection Evidence appendix template v3 Page 94
However, staff did not complete regular checks on all wards of the clinic room temperature, fridge
temperature, defibrillator and emergency equipment in line with trust’s policies. On Stanage and
Burbage wards, there were missed checks of the emergency equipment, the defibrillator and
emergency drugs between March and May 2018. This meant staff on these two wards could not
be assured that equipment was present, working effectively and safe to use. Medicine fridge
temperatures were not regularly checked on Maple, Stanage and Burbage wards. This could
mean that drugs were stored at the wrong temperature and may become less effective.
On Endcliffe Ward, cranberry juice was stored in the medicines’ fridge; this was removed
immediately during the inspection.
All medicines were securely stored on each ward.
Safe staffing
Staffing levels were not always adequate to meet the needs of patients. At the time of inspection,
sickness levels were just above the trust average, vacancies for qualified nurses had increased
16% since the last inspection and fill rates were not always sufficient. Patients did not raise any
concerns about the availability of staff to speak to on the ward; patients could access one to one
time with named nurses, however Section 17 leave did not always go ahead. Seven staff reported
concerns about staffing levels. Staff told us the focus most days was to successfully get through
each shift. Staff also felt the service relied on bank and agency staff to maintain sufficient numbers
on each shift and that the skill mix was not always appropriate to meet the needs of all patients.
The trust had 32 vacancies for qualified nurses and 17 of these vacancies were in this core
service. Stanage ward had the highest number of vacancies for qualified nurses, with eight
vacancies, Burbage and Maple had four vacancies and Endcliffe had one vacancy. Endcliffe ward
was the only ward to have vacancies for nursing assistants, with three vacancies. The remaining
three wards had above the establishment level for nursing assistants. Recruitment was ongoing
and the service was endeavouring to over recruit nurses.
Nursing staff
The table below shows staffing data from 1 February 2017 to 31 January 2018.
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 January 2018 169.4 N/A
Total number of substantive staff leavers 1 February 2017 to 31 January 2018
12.8 N/A
Average WTE* leavers over 12 months (%) 1 February 2017 to 31 January 2018
7.5% 13%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31March 2018 21 N/A
20171116 900885 Post-inspection Evidence appendix template v3 Page 95
Total vacancies overall (%) At 31March 2018 11% NA
Total permanent staff sickness overall (%) Most recent month (At 31 January 2018)
7.8% 5%
1 February 2017 to 31 January 2018
7.2% 5%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 March 2018 83 N/A
Establishment levels nursing assistants (WTE*) At 31 March 2018 46 N/A
Number of vacancies, qualified nurses (WTE*) At 31 March 2018 17 N/A
Number of WTE vacancies nursing assistants At 31 March 2018 -1** N/A
Qualified nurse vacancy rate At 31 March 2018 20.5% N/A
Nursing assistant vacancy rate At 31 March 2018 -2.2% N/A
Bank and agency Use
Shifts bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 March 2017 and 28
February 2018 2251 (18%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses)
1 March 2017 and 28
February 2018 655 (5%) N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses)
1 March 2017 and 28
February 2018 410 (3%) N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 6907 (39%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 3547 (20%) N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants)
1 March 2017 and 28
February 2018 791 (4%) N/A
*Whole-time Equivalent
** Negative numbers indicate an over establishment.
This core service reported an overall vacancy rate of 20% for registered nurses at 31 March 2018.
There was a spike in nursing staff vacancies in October 2017, the vacancy rate was 29%.
The vacancy rate for registered nurses was higher than the 4% reported at the last inspection.
This core service reported an overall vacancy rate of -2% for nursing assistants.
The vacancy rate for nursing assistants was higher than the -23% reported at the last inspection.
This core service reported a vacancy rate for all staff of 12% as of 31 March 2018. This was similar to the rate reported at the last inspection (between 1 August 2016 and 31 July 2017).
The vacancy rate for all staff was at its highest at 15% in October 2017.
Registered nurses Health care assistants Overall staff figures
Ward/Tea
m
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Endcliffe 1 17 6% 3 16 19% 9 46 20%
Stanage 8 20 40% -1 10 -10% 5 43 12%
20171116 900885 Post-inspection Evidence appendix template v3 Page 96
Ward
Burbage
Ward 4 20 20% -2 10 -20% 4 43 9%
Maple
Ward 4 26 15% -1 10 -10% 3 49 6%
Core
service
total
17 83 20% -1 46 -2% 21 181 12%
Trust total 32 433 7% 15 353 4% 68 1339 5%
NB: All figures displayed are whole-time equivalents
The trust was mitigating the risk of high vacancy rates for qualified nurses by using bank and
agency staff. The trust ensured bank and agency staff received induction and that they were
familiar with the wards, however they were not trained in physical interventions. Ward managers
confirmed they took a proactive approach to identifying and managing shortfalls in staffing,
including redeploying staff across the wards that were trained in physical interventions. This was
supported by block booking bank and agency staff to maintain some continuity in care.
Between 1 March 2018 and 5 June 2018, Burbage ward had 27 night shifts that had less than three RESPECT trained staff and Stanage had five night shifts. Between 1 March 2018 and 5 June 2018 there were four reportable incidents where staff felt this could have compromised a response team for the same period. The trust trained staff in the use of restrictive interventions, using the RESPECT model of management of violence and aggression. The training focuses on the importance of empathy and compassion in understanding why people may display disturbed behaviour. The training emphasises the use of de-escalation techniques before the use of any physical interventions, such as restraint. To safely carry out physical interventions, three trained members of staff are required. The trust confirmed some regular agency staff will be trained in RESPECT.
This meant that some night shifts on these wards did not have the required amount of staff to
safely carry out physical interventions without requiring support from other wards.
There were a number of shifts which could not be filled by bank or agency staff across all four wards. This equated to 7% of shifts across the service. This was highest on Burbage ward, between 1 March 2017 and 28 Feb 2018 352 shifts could not be filled and lowest on Maple ward where 215 shifts could not be filled.
Between 1 March 2017 and 28 February 2018, bank staff filled 18% of shifts to cover sickness, absence or vacancy for qualified nurses.
In the same period, agency staff covered 5% of shifts for qualified nurses. Three percent of shifts were unable to be filled by either bank or agency staff.
Ward/Team Available shifts Shifts filled by bank staff Shifts filled by
agency staff
Shifts NOT filled by bank
or agency staff
Burbage Ward 2964 641 (22%) 136 (5%) 111 (4%)
Endcliffe Ward
PICU 2893 888 (31%) 330 (11%) 151 (5%)
Maple Ward 3590 478 (13%) 112 (3%) 98 (3%)
Stanage Ward 2800 244 (9%) 77 (3%) 50 (2%)
Core service
total 12247 2251 (18%*) 655 (5%*) 410 (3%)
Trust Total 32,394 4977 7252 900
20171116 900885 Post-inspection Evidence appendix template v3 Page 97
(15%) (22%) (3%)
*Percentage of total shifts
Between 1 March 2017 and 28 February 2018, 39% of shifts were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.
In the same time period, agency staff covered 20% of shifts. Four percent of shifts were unable to be filled by either bank or agency staff.
Ward/Team Available shifts Shifts filled by bank staff Shifts filled by
agency staff
Shifts NOT filled by bank or
agency staff
Burbage Ward 3707 1781 (48%) 607 (16%) 241 (7%)
Endcliffe Ward
PICU
6034 2433 (40%) 1341 (22%) 164 (3%)
Maple Ward 3757 768 (20%) 758 (20%) 117 (3%)
Stanage Ward 4215 1925 (46%) 841 (20%) 269 (6%)
Core service
total
17713 6907 (39%) 3547 (20%) 791 (4%)
Trust Total 59,514 21,770
(37%)
5623
(9%)
1760
(3%)
* Percentage of total shifts
This core service had 12.8 (8%) staff leavers between 1 March 2017 and 28 February 2018. This was lower than the 14% reported at the last inspection (between 1 August 2016 and 31 July 2017).
Ward/Team Substantive staff
Substantive staff Leavers Average % staff leavers
Burbage Ward 39.4 4.23 11%
Maple Ward 49.2 5 10%
Endcliffe 39.9 1.8 5%
Stanage Ward 40.9 1.8 4%
Core service total 169.4 12.8 8%
Trust Total 1351.6 129.6 8%
The sickness rate for this core service was 9% between 1 February 2017 and 31 January 2018. The most recent month’s data January 2018 showed a sickness rate of 8%. This was similar to the sickness rate of 7% reported at the last inspection in 31 July 2016.
Ward/Team Total % staff sickness
(at latest month)
Ave % permanent staff sickness
(over the past year)
Burbage Ward 12% 11%
20171116 900885 Post-inspection Evidence appendix template v3 Page 98
Maple Ward 10% 9%
Stanage Ward 10% 8%
Endcliffe 6% 6%
Core service total 10% 9%
Trust Total 8% 7%
The below table covers staff fill rates for registered nurses and care staff between November 2017 and February 2018.
All wards had a fill rate of over 125% for care staff for all day shifts.
Burbage ward had a fill rate below 90% for registered nurses for all day shifts.
Maple ward had a fill rate below 90% for nursing staff for night shifts for all months reported. Key:
> 125% < 90%
N – Nurses
C – Care staff
Day Night Day Night Day Night Day Night
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
November 2017 December 2017 January 2018 February 2018 Burbage 87.2 216.0 113.6 332 86.9 214.4 88.4 380.6 84.6 200.3 93.4 322.6 80.3 184.8 101.7 320.9
Maple 73.9 160.1 79.3 320 89.4 214.7 78.5 528.5 97.1 246.2 80.8 627.3 85.3 267.5 70.2 592.9
Stanage 71 223.6 95.1 283.2 78.2 277.7 68.1 434 75.5 273.4 103.2 365.7 71.3 282.8 91.3 396.7
Endcliffe 79.7 176.5 88.3 217.3 83.3 195 100.5 250 93.4 239.5 100.0 308.6 101.8 254.4 100.1 335.3
Ward managers consistently told us they were able to adjust staffing levels to meet the changing
need of the patient group. Staff told us there was always at least one qualified nurse on each shift
at all times.
During this inspection we requested more up to date information regarding fill rates for qualified staff to establish if there had been any improvement in staffing. Themes remained consistent, Maple ward continued to have below 90% fill rates for qualified nurses on night shifts, in March and April they achieved less than 80%. Stanage continued to have less than 80% fill rate for qualified staff on day shifts, although this improved slightly in May 2018. Burbage and Stanage wards continued to achieve above 95% fill rate for qualified staff on nights. Endcliffe ward maintained fill rates above 100% for qualified staff on all shifts.
The service consistently maintained fill rates for nursing assistants above 100% for all shifts. Fill
rates for nursing assistants ranged from 160% to 627%.
The impact of not adequately maintaining safer staffing levels alongside a reliance on bank and
agency staff was evident during this inspection. Staff were busy and consistently in demand.
Medical staff
Consultants and junior doctors provided medical cover across all wards. There was access to a
doctor 24 hours per day who could attend the ward quickly in an emergency. All wards had a
20171116 900885 Post-inspection Evidence appendix template v3 Page 99
dedicated consultant psychiatrist. Medical cover out of hours was provided by a city wide on call
duty system, approximately 10 miles from the Michael Carlisle Centre and five miles from the
Longley Centre. Staff had access to basic life support equipment in the event of a medical
emergency.
Between 1 March 2017 and 28 February 2018, 48 shifts were filled by bank staff to cover
sickness, absence or vacancy for medical locum shifts.
In the same time period, agency staff covered 257 shifts. Zero shifts were unable to be filled by
either bank or agency staff.
Staff and patients on all wards could access a doctor when needed.
Ward/Team Shifts filled by bank staff Shifts filled by agency staff Shifts NOT filled by bank or agency staff
Burbage Ward 48 256 0
Mandatory training
The majority of staff had completed required mandatory training. The trust compliance target for mandatory training was 80%. The compliance for mandatory and statutory training courses at 28 February 2018 was 86%. Of the training courses listed five failed to achieve the trust target and of those, three failed to score above 75%. Mandatory training course that did not achieve the trust target were:
• Autism Awareness (77%)
• Mental Health Act (75%)
• Deprivation of Liberty Safeguards Level 1 (73%)
• Information Governance (72%)
• Dementia Awareness (71%)
The training compliance reported for this core service during this inspection was higher than the 51% reported at the last inspection. Ward managers told us a co-ordinated approach to booking training for staff was now embedded on the wards and staff had dedicated time to complete the required mandatory training. The mandatory training steering group monitored compliance and reported regularly to the executive directors group.
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service %
Trust target % Trust wide mandatory/ statutory training total %
Fire Safety 3 years 100% 80% 96%
Hand Hygiene 99% 80% 94%
Health and Safety (Slips, Trips and
Falls) 96% 80% 97%
Fire Safety 2 years 95% 80% 96%
Equality and Diversity 94% 80% 95%
Safeguarding Children (Level 2) 93% 80% 85%
Clinical Risk Assessment 93% 80% 91%
Respect Level 2 91% 80% 80%
20171116 900885 Post-inspection Evidence appendix template v3 Page 100
Mental Capacity Act Level 1 90% 80% 94%
Immediate Life Support 89% 80% 88%
Rapid Tranquilisation 88% 80% 88%
Medicine management training 88% 80% 87%
Deprivation of Liberty Safeguards
Level 2 88% 80% 85%
Domestic Abuse Level 2 87% 80% 85%
Safeguarding Adults (Level 2) 87% 80% 87%
Mental Capacity Act Level 2 86% 80% 85%
Safeguarding Children (Level 3) 84% 80% 91%
Adult Basic Life Support 84% 80% 81%
Respect Level 3 82% 80% 83%
Autism Awareness 77% 80% 88%
Mental Health Act 75% 80% 83%
Deprivation of Liberty Safeguards
Level 1 73% 80% 80%
Information Governance 72% 80% 80%
Dementia Awareness (inc Privacy &
Dignity standards) 71% 80% 85%
Core Service Total % 86% 80% 88%
Assessing and managing risk to patients and staff
Assessment of patient risk
During this inspection we reviewed 17 care records. The service used a standardised risk
assessment tool to support clinical risk management and this was based on Best Practice
Guidance (Department of Health, 2007). The risk assessment tool was called the Detailed Risk
Assessment and Management Plan.
All 17 risk assessments were up to date and had been regularly reviewed. Staff recorded the risk
history of all patients in detail and current risks were clearly documented. We saw evidence that
risk assessments were updated following incidents. The risk assessment addressed patient views
regarding mixed sex accommodation and identified the need to adjust observation levels to reflect
vulnerability.
Management of patient risk
Staff identified and responded to the changing needs of patients. The trust had an observation
policy to support and protect patients and staff. We saw staff regularly and consistently completing
general observations of patients on the wards, as required by trust policy. The previous inspection
highlighted a pilot project undertaken on Stanage ward which saw the use of an electronic tablet to
support staff undertaking routine observations. During this inspection we observed that this
practice had now been rolled out across all wards. The tablet alerted staff regarding which patients
were on specific observations and the frequency of observation required. The use of technology
ensured the service was responsive to individual patient risk and need. All ward managers told us
staffing had been increased to fulfil the increased levels of observations.
20171116 900885 Post-inspection Evidence appendix template v3 Page 101
There were minimal blanket restrictions within this core service. Individual access to bedrooms
varied across the wards. Not all patients had keys to their bedrooms, as many keys had been lost
and not replaced. Patients on Endcliffe ward required staff to open their bedroom doors as there
was a design fault with the doors; the ward manager confirmed these were awaiting repair.
Accessible bathrooms were locked on all wards due to the increased ligature risk and patients
required staff to open these. Based on individual risk assessment, patients could use these
unsupervised. Patient access to the laundry was supervised.
All patients had access to personal mobile phones, based on an individual risk assessment. All
patients had access to outside space. Patients could access hot and cold drinks during the day
and night. Staff implemented the trusts’ search policy in the least restrictive way. Staff told us
patients were not routinely searched and this reflected the trusts search policy and least restrictive
practice approach to care.
During this inspection the trust delivered training to staff on least restrictive practice. We saw
evidence that a standardised approach across the wards was being rolled out. Information for
patients and families was meaningful and set out clear expectations.
The implementation of the trusts’ smoke free policy was poor. The trust committed to a smoke free
environment in 2016. Patients, staff and visitors were not permitted to smoke on site. We observed
that smoking cessation advice and treatment was available on all wards. Staff we spoke with
stated smoking by patients remained a significant issue. During this inspection we consistently
saw evidence that smoking had occurred in outdoor spaces on Burbage, Stanage and Maple
wards. We saw patients smoking frequently and staff did not challenge any patients.
Use of restrictive interventions
Staff were trained in the use of restrictive interventions. Staff used restraint and seclusion only after de-escalation attempts had failed and reported restraint and seclusion episodes using the electronic incident reporting system.
Staff we spoke with understood the definition of seclusion and that restraint should be used only
after other de-escalation attempts had been made. Staff were able to describe methods they
would use to manage incidents prior to attempting restraint. Staff told us they would only use
restraint if it was necessary for the safety of patients and staff. The acuity of patients across the
service was high, however, in comparison the number of seclusions was low.
This core service had 283 incidents of restraint (on 161 different service users) and 259 incidents
of seclusion between 1 March 2017 and 28 February 2018. Over the 12 months, there was an
increase in the incidence of restraint in December 2017 (59 incidents of the use of restraint).
Maple ward had the highest number of restraints, however the data included those patients who
used the health based place of safety (136 Suite). Endcliffe ward had the highest use of seclusion.
Governance officers and the risk department monitored the use of restrictive interventions. A
weekly restrictive practice report was produced, which provided information on post incident
reviews, seclusion, restraint and rapid tranquilisation. This information was shared with ward
managers, senior managers, chief nurse and the trust leads for RESPECT and patient safety.
The below table focuses on the last 12 months’ worth of data: 1 March 2017 and 28 February
2018.
20171116 900885 Post-inspection Evidence appendix template v3 Page 102
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
Maple ward
(incl 136) 60 89 60 0 (0%) 16 (18%)
Endcliffe
ward 94 77 43 1 (1%) 13 (17%)
Stanage
ward 66 72 30 0 (0%) 21 (29%)
Burbage
ward 39 45 28 0 (0%) 28 (62%)
Core service
total 259 283 161 1 (<1%) 78 (28%)
There was one incident of prone restraint which accounted for <1% of the restraint incidents.
Over the 12 months, there was a peak in the use of restraint in December 2017, where there were a total of 59 incidents.
Incidents resulting in rapid tranquilisation for this core services seem to have been fluctuating, with the highest numbers in April 2017.
There have been no instances of mechanical restraint over the reporting period.
Over the 12 months, there was a decrease in the use of seclusion. There were 30 incidences in March 2017 which reduced to 15 incidences in February 2018.
22
39
108
14
4
149
19
59
46
39
0 0 1 0 0 0 0 0 0 0 0 00
10
20
30
40
50
60
70
Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18
Total restraints over the 12 month period
Number of incidents of the use of restraintsNumber of prone restraintsNumber of mechnical restraintsNumber of incidents resulting in the use of rapid tranquilisation
20171116 900885 Post-inspection Evidence appendix template v3 Page 103
Staff were not always adhering to the trust policy in carrying out and contemporaneously recording
nursing and medical reviews as required by the trust and Mental Health Act Code of Practice.
We reviewed six seclusion records. Seclusion care plans were in place for all patients, detailing a
clear rational for seclusion. However, only two of the records had a clear seclusion exit plan in
place. This meant the patient was not aware of what was required of them, in order to allow the
seclusion to end. This also meant that patients may have remained in seclusion for longer periods
than were necessary. None of the six records reviewed demonstrated that the post seclusion
review had been completed by staff, as required by the trust. Monthly clinical governance
meetings maintained oversight of these and monitored completions, refusals and incomplete
reviews but had not identified these issues
The trust policy on seclusion also states that ‘nursing observations must be recorded every five
minutes for the first hour and then at intervals of no more than ten minutes thereafter’ and ‘nursing
reviews should take place at least every two hours. These should be undertaken by two
individuals who are registered nurses’. Of the six records we reviewed, we found that there were
gaps in the recording of nursing and medical reviews for three records. This meant staff were not
carrying out the necessary reviews as outlined in the trust policy and the Mental Health Act Code
of Practice. The recording of information in these three records was fragmented as information
was recorded in paper records and on the electronic patient record.
Staff did not always adhere to trust policy in carrying physical health observations following rapid tranquilisation. Rapid tranquilisation is medication which is given in the short-term management of disturbed or violent behaviour. The trust policy stated after intramuscular administration, ‘physical health observations should be monitored and recorded every hour until there are no concerns about their physical health status.’ We reviewed seven rapid tranquilisation records and found five records did not have the required observations carried out. Therefore, staff did not always follow the trust procedures. Data provided by the trust prior to this inspection indicated the highest use of rapid tranquilisation was on Burbage ward. We discussed this with the ward manager and local data did not reflect this. We discussed our concern further with the clinical governance team and they confirmed an issue with the accurate recording of rapid tranquilisation within the electronic incident form had been identified in April 2018. We reviewed the reducing restrictive interventions reports from March 2018 to May 2018 and these reports confirmed a discrepancy in the reported figures. The reports highlighted a more even spread across the wards in the use of rapid tranquilisation. The clinical governance team confirmed the reporting issue had been discussed with senior managers and contingencies were in place. Governance officers manually reviewed all incident reports to identify
30
35
14 13
21 2219 18
23
31
1815
0
5
10
15
20
25
30
35
40
Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18
Total seclusions over the 12 month period
Number of incidents of the use of seclusion
20171116 900885 Post-inspection Evidence appendix template v3 Page 104
if rapid tranquilisation had been used, to ensure oversight of rapid tranquilisation could be maintained. There were no instances of long term segregation over the 12-month reporting period.
Safeguarding
A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional.
Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.
The trust required all staff to complete safeguarding training for adults and children and the level of
training required was determined on an individual role basis. Compliance for level two training in
child safeguarding was 92% and for adults 87%. Level three training in child safeguarding was
84%. During this inspection we observed that safeguarding information was easily accessible to
staff on the intranet and displayed on each ward.
All staff members we spoke with were able to identify potential safeguarding concerns relevant to
the patient group. Staff spoke confidently about how they would respond to such a concern and
would seek advice from the trust safeguarding leads. We spoke with a safeguarding lead for the
trust and confirmed staff regularly contacted them for advice and support. Several members of
staff described examples of safeguarding referrals made to the safeguarding team, these included
concerns about different types of abuse. The single point of access and care co-ordinators
investigated safeguarding concerns and worked with other agencies, such as the police and local
authority.
When children visited the service, there were processes in place to keep them safe, however these were not sufficiently robust. Maple and Endcliffe wards had visiting rooms away from the main patient areas. Burbage and Stanage wards had rooms available on the ward and could access additional rooms in the occupational therapy department.
During this inspection one incident gave us cause for concern, a child visitor was left unsupervised
by family members in the green room on Burbage ward and staff were not clear for how long. The
green room operational procedure clearly indicates the room should not be used for visits and the
ward did not have a local process for child visits, as indicated in the trust policy. The incident had
been recorded but no safeguarding alert had been made. We discussed our concerns with the
ward manager and they informed us they were aware of the incident, however no investigation
had commenced or action taken to ensure this type of incident could not be repeated. Following
our inspection, the trust confirmed a safeguarding alert had been made in relation to this incident.
This core service made no safeguarding referrals between 1 February 2017 and 31 January 2018. We clarified this information with the trust and they confirmed 67 adult safeguarding referrals were made from this core service.
Sheffield Health and Social Care NHS Foundation Trust has submitted details of zero serious case reviews commenced or published in the last 12 months [1 March 2017 and 28 February 2018] that relate to this core service.
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Staff access to essential information
The service had a secure electronic system to store and record patient information. Access to the
system was password protected. Some patient information remained paper-based, such as
seclusion records. Staff told us these documents were scanned into patient records. Ward
managers told us that agency staff did not have access to the electronic care record. Agency staff
received information regarding risk and care plans during clinical handovers. Agency staff were
expected to handover patient information to regular staff members to record in the patient care
record. However, agency staff could add some notes to care records via the electronic tablet when
completing observational checks of patients.
Medicines management
We looked at 40 electronic prescription charts and the clinic environment across all four wards.
We saw evidence of a monitoring system in place for the use of high dose antipsychotic
medication and this included additional physical health checks and blood tests.
We spoke with pharmacy staff and confirmed they attended the wards regularly to support
medicines reconciliation, provide clinical support, review prescription charts and completed
medicines related audits. Pharmacists were part of the ward multidisciplinary team and were
available to speak with patients on request.
However, the management of medicines was not always sufficient within this core service. We
reviewed the controlled drug registers on all four wards. Whilst, staff told us that these drugs were
regularly checked, only Maple ward had successfully completed all the required weekly checks.
The remaining three wards had gaps in their audits.
The recording of controlled drugs was not compliant with trust policy and we found discrepancies
in the recording of controlled drugs on Stanage and Maple wards. We raised our initial concern
with a pharmacist during this inspection and the trust provided a written response detailing how
they were going to address these issues with staff. Staff on Burbage and Endcliffe wards did not
regularly check stock levels of controlled drugs, as required by the trust.
We also found that patient specific medicines such as eye drops and insulin were not labelled
correctly. On Stanage ward, eye drops did not indicate when they were opened. On Burbage
ward, two insulin pens had only the patient initials on the pens. On Maple ward, eye drops were
patient specific but had passed the use by date. On Endcliffe ward, medicine bottles were not
dated when opened.
Track record on safety
Providers must report all serious incidents to the Strategic Executive Information System (STEIS) within two working days of an incident being identified.
Between 1 March 2017 and 28 February 2018 there were three STEIS incidents reported by this core service. Of the total number of incidents reported, the most common type of incident was Apparent/actual/suspected self-inflicted harm with two.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.
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We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with STEIS.
The number of serious incidents reported during this inspection was higher than the two reported at the last inspection.
During this inspection we reviewed the data provided by the trust in relation to the three serious
incidents reported for this core service. One serious incident indirectly related to this core service,
therefore we did not focus on this. We examined closely the two remaining incidents in relation to
the action the trust took and how learning was identified and shared within the service.
Following the death of a patient, the trust investigated the incident and identified areas of
improvement the service must make. The trust took immediate action and replaced all bathroom
doors within patient bedrooms. We reviewed the action plan and the majority of the required
actions were incomplete, although most were in progress and within agreed timescales. The ward
manager also provided an update on each specific action. We reviewed clinical governance
meeting minutes and team business meeting minutes from all wards following the release of the
report in March 2018 and there was no evidence to support that required actions or learning had
been shared across the service.
Following an incident at height in 2017 and a similar incident in early 2018, the trust completed
work to remove door handles and assess the requirement for anti-climb guttering on one ward.
Again, there is no evidence to support that the nature of these issues were considered relevant to
other wards.
Number of incidents reported
Type of incident reported on STEIS Stanage
ward
Maple
Ward
Burbage
ward
Endcliffe
ward
Total
Apparent/actual/suspected self-inflicted
harm meeting SI criteria
1 1 0 0 2
Pending review (a category must be
selected before incident is closed)
1 0 0 0 1
Total 2 1 0 0 3
Reporting incidents and learning from when things go wrong
All staff regularly reported incidents, however, learning from incidents was limited. The trust had
an electronic system for reporting incidents. Staff had a clear understanding of what constituted an
incident and how to report it. Agency staff did not have access to the incident reporting system and
had to report incidents to regular ward staff. The majority of staff told us they received a de-brief
and support following serious incidents and additional support was available through weekly staff
support meetings on each ward. Patients received a de-brief following incidents, although this did
not happen following every episode of seclusion.
We reviewed clinical governance meeting minutes from March 2018 to May 2018 from all four
wards. The quality and consistency of these minutes varied across the service. All wards followed
a standardised template that reflected the five domains of the Care Quality Commission. Burbage
and Stanage used data effectively to scrutinise incidents and to identify themes and trends specific
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to their ward. The meeting minutes for Endcliffe and Maple did not contain detailed information.
Outcomes and actions from these meetings were limited.
Some staff we spoke with told us feedback and learning was received in handover, team business
meetings or via email. We observed that the safety huddle on Maple was a very responsive
mechanism for providing timely feedback to staff and raising awareness of incidents. Learning
from trust wide incidents was available through the intranet. Most managers we spoke with
confirmed that learning from incidents within the service was an identified area of improvement
and that there was a need to ‘close the loop’ regarding learning.
The duty of candour is the requirement that staff are open and honest to patients and/or carers
when things go wrong with care and treatment. Staff knew about their responsibilities under duty
of candour and some staff gave examples from their practice where the principles had been
applied.
The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths.
In the last two years, there have been zero ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.
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Is the service effective? Assessment of needs and planning of care
We reviewed 17 electronic patient care records. Staff completed a comprehensive mental health
assessment for all patients upon admission, taking into consideration the patients physical,
psychological and social needs and this was evident in all 17 records reviewed. All patients
received an assessment of their physical health needs in a timely manner after admission. We
noted three patients had declined to have their physical health assessed and staff had repeatedly
followed these patients up and offered further opportunity to have this assessment.
Of the 17 care records reviewed, 14 care plans reflected all issues identified in the initial risk
assessment. Whilst we saw the use of an interpreter in a patients’ care and staff described how
this supported communication, this was not reflected in the care plan. Staff regularly reviewed and
updated care plans
The majority of care plans were holistic, personalised and goal and recovery-orientated. Fifteen
care records contained care plans that were personalised and had evidence of co-production
between staff and patients, with one care record being particularly good in relation to care plans
addressing complex physical health needs and life-threatening reactions to medication. The
majority of care plans reflected the patient voice.
All four wards completed quarterly care plan audits. This information was used in the clinical
governance meetings to identify areas of improvement. Data analysis identified themes and trends
from each ward. The service agreed to benchmark against Maple ward, as all care plans sampled
were collaborative.
Best practice in treatment and care
The service provided a range of care and treatment interventions suitable for the patient group.
Psychiatrists told us that when prescribing medication, National Institute for Clinical and
Healthcare Excellence guidance was followed, along with recommendations from the Royal
College of Psychiatrists.
We examined 40 electronic prescription charts and all prescribed medication was within British
National Formulary limits. An effective monitoring system was in place for those patients
prescribed high dose antipsychotic medication.
The service had a commitment to improving access to physical healthcare for patients. The
majority of patients had a comprehensive physical health examination and assessment upon
admission to each ward. We saw evidence in care records that long-term health conditions such
as asthma, diabetes and epilepsy were addressed. Staff had referred patients to specialist
services, including diabetes team, ophthalmology and neurology. At the point of admission most
patients received screening for the risk of malnutrition and staff used a recognised screening tool.
Clinical governance meeting minutes confirmed Burbage and Stanage ward had a compliance rate
for this tool between 58-60% for 12 months up to March 2018. No data was available in the clinical
governance meeting minutes for Maple and Endcliffe. Staff could access the electronic patient
care record to obtain the outcome of blood test results for patients. This proactive approach
ensured patients physical health needs were being met.
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Staff supported patients to live healthier lives. Information was available to patients on a variety of
issues, including healthy eating, exercise, substance misuse and smoking cessation. Staff were
committed to increasing levels of physical activity, we observed patients attending the gym and
participating in outdoor activities such as cycling, walking and basketball. Occupational therapy
teams provided an activity programme that covered seven days a week and evenings.
We spoke with clinical staff and found that knowledge of best practice was fair. Some staff
struggled to describe how guidance from the National Institute for Health and Care Excellence
was implemented on the wards. Senior clinicians and medical staff demonstrated good
understanding of national guidance in relation to prescribing, depression and the management of
violence and aggression.
Interventions and treatments recognised by the National Institute for Health and Care Excellence
were promoted alongside medication regimes. The service used a range of outcome measures
and rating scales, nursing staff and the occupational therapists completed these. The occupational
therapist used The Model of Human Occupation tool to assess patient functioning in cognitive and
motor skills. Nursing staff used the mental health clustering tool to evaluate the patients’ mental
health, presentation and diagnosis to identify a package of care.
All wards had access to psychological services. However, staff told us availability was reduced
due to vacancies. Recruitment was ongoing at the time of this inspection. Psychology
predominantly supported staff through regular formulation meetings, an approach to encourage
teams to formulate a joint understanding of the difficulties patients may experience and support
the care and treatment of those patients. Referrals for psychological input were made through the
multi-disciplinary team. Psychology staff provided some 1:1 interventions for patients based on a
cognitive behavioural therapy framework.
This core service participated in the following clinical audits as part of their clinical audit
programme in the 12 months leading up to the submission of the provider information return.
Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
Audit of NICE
Guidelines for
Borderline
Personality
Disorder
Burbage, Maple
and Stanage
wards
MH - Acute
wards for
adults of
working age
and
psychiatric
intensive
care units
Clinical Feb-18
To discuss with relevant
quality and service
management teams
Audit of Physical
Investigations for
Admitted
Psychiatric
Patients
Burbage ward
MH - Acute
wards for
adults of
working age
and
psychiatric
intensive
care units
Clinical Apr-17
The audit findings were
presented at the trust
weekly training event –
Quality Improvement
Group: Physical Health
Screening.
Increasing awareness of
the Physical Health
Investigations SOP.
Omitted and
Delayed Stanage ward
MH - Acute
wards for
adults of
Clinical on-going Already agreed to extend
scope of audit.
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Medicines working age
and
psychiatric
intensive
care units
Physical Health
Monitoring
Before, During
and After Rapid
Tranquilisation /
Emergency
Sedation
Endcliffe ward
MH - Acute
wards for
adults of
working age
and
psychiatric
intensive
care units
Clinical on-going Awaiting findings
ECG Monitoring
on Admission
Stanage,
Endcliffe,
Burbage and
Maple wards
MH - Acute
wards for
adults of
working age
and
psychiatric
intensive
care units
Clinical on-going Awaiting findings
Collaboration
with Primary
Care Clinicians
Service users
on CPA
Provider
wide
Clinical on-going Changes made following
previous audit round:
provide guidance to staff
on annual reviews of care.
Changes to care plan form.
Creation of a 'clinical
review for GP' IT system
solution.
Record keeping
audit 2016/2017
Trust wide Provider
wide
Clinical on-going From data collected so far:
Further clarity provided to
staff on use of
abbreviations - to be
incorporated into the
relevant policy.
Audit of risk
assessments
2016/2017
Trust wide Provider
wide
Clinical audit March 2017 Local action plans to
address identified issues.
Audit tool to be revised to
give clearer results.
Re-audit to be undertaken
in 2017/18.
Audit of risk
assessments
2017/2018
Trust wide Provider
wide
Clinical audit ongoing Await findings
Audits of care
plans
Trust wide Provider
wide
Clinical audit January
2018
Agreed need for frequent
small scale audits.
Findings being shared with
teams.
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG43
Transition from
children’s to
Trust wide Provider
wide
Clinical audit June 2017 Findings fed into
Commissioning for Quality
and Innovation and other
related joint work with child
and adolescent mental
health services to improve
transitions
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adults’ services
for young
people using
health or social
care services
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG13
Workplace
health:
management
practices
Trust wide Provider
wide
Clinical audit September
2017
Review practices against
guidance as necessary in
future
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG58
Coexisting
severe mental
illness and
substance
misuse:
community
health and
social care
services
Trust wide Provider
wide
Clinical audit December
2017
Action plan under
development
Medical staff attended weekly meetings which were used for training and to examine current best practice and guidance. Medical staff discussed the outcome from completed audits. Ward managers completed quarterly care plan and risk assessment audits, outcomes were
monitored through monthly clinical governance meetings and quarterly performance review
meetings with senior operational managers in the crisis and emergency care network. Clinical
administrators had a key role in supporting ward managers with audit activity. On a weekly basis
staff completed updates on activities that required completion following a patient’s admission.
Maple ward had developed a task sheet to identify all areas of care to be addressed, including
areas that were incomplete. The use of colour acted as a visual quick glance guide to identify what
actions had been completed and those that required attention.
Skilled staff to deliver care
The service had access to a comprehensive multidisciplinary team. This included consultant
psychiatrists, junior doctors, pharmacists, occupational therapy staff, nurses, support workers,
psychology, physiotherapist, activity workers and administrators. Staff could also access additional
specialist knowledge and support through the trusts safeguarding and Mental Health Act teams.
All staff had undertaken an induction programme. The trust undertook employment checks to
ensure staff were suitably qualified. Staff told us they had had opportunities to develop additional
skills and knowledge in relation to psychosocial interventions. Endcliffe ward had involvement with
the national association of psychiatric intensive care units, an organisation committed to
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developing and promoting the speciality of such units. Endcliffe hosted an event in 2017 and
attend quarterly meetings. Staff from Endcliffe accessed weekly teaching and learning club
sessions. The purpose of this initiative was to support staff in learning on the ward, themes
discussed included the Mental Health Act, physical health, substance misuse and medical
diagnosis. Training was provided by a range of professionals from the trust. All qualified nurses
completed ‘Medicines With Respect’ training to demonstrate competence in administering
medications.
Some staff had undertaken additional training in food hygiene and physical exercise. This
extended the scope of their roles and supported therapeutic activities on the wards.
Psychology staff provided direct support to staff following serious incidents.
The trust’s target rate for appraisal compliance is 90%. As at February 2018, the overall appraisal
rates for non-medical staff within this core service was 97%.
The rate of appraisal compliance for non-medical staff reported during this inspection was higher
than the 88% reported at the last inspection.
Ward name
Total number of
permanent non-medical
staff requiring an appraisal
Total number of
permanent non-medical
staff who have had an
appraisal
% appraisals
Burbage Ward 42 40 95%
Endcliffe 40 40 100%
Maple Ward 54 50 93%
Stanage Ward 45 45 100%
Core service total 181 175 97%
Trust wide 1495 1440 96%
The trust’s target rate for appraisal compliance is 90%. As at February 2018, the overall appraisal
rates for medical staff within this core service was 100%.
The rate of appraisal compliance for medical staff reported during this inspection was higher than
the 98% reported at the last inspection.
Ward name
Total number of
permanent medical staff
requiring an appraisal
Total number of
permanent medical
staff who have had an
appraisal
% appraisals
Burbage Ward 2 2 100%
Endcliffe 1 1 100%
Maple Ward 1 1 100%
Stanage Ward 1 1 100%
Core service total 5 5 100%
Trust wide 57 56 98%
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The service was not meeting the trust target for compliance with clinical supervision. Not all staff received clinical supervision regularly. The trust was aware they were not accurately documenting and reflecting all elements of supervision activity. The trust policy stated that staff ‘should generally complete a minimum of 1 to 1½ hrs every 4-6 weeks.’ The trust’s target for clinical supervision was 66%. Between 1 March 2017 and 28 February 2018
the rate across all four teams in this core service was 36%. The rate of clinical supervision
reported during this inspection was lower than the 60% reported at the last inspection.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. Ward name Clinical supervision
sessions required
Clinical supervision
sessions delivered
Clinical supervision
rate (%)
Burbage Ward 172 87 51%
Stanage Ward 170 73 43%
Endcliffe 146 43 29%
Maple Ward 197 46 23%
Core service total 685 249 36%
Trust Total 3420 2183 64%
Staff did not raise concerns about not being able to access supervision. We spoke with ward managers and assistant ward managers regarding supervision. Supervision was available to staff, however, the acuity of patients on all wards and competing clinical priorities, often meant individual clinical supervision did not go ahead as planned. All staff had access to weekly staff support meetings on each ward, which provided an opportunity for staff to have protected time to discuss issues relevant to staff. Ward managers told us attendance was good and staff told us they valued the time. Staff also attended formulation meetings with psychology based on each ward and had access to regular team business meetings.
Ward managers recognised the recording of clinical supervision was not accurate. The trust introduced an electronic form to record supervision. However this was not consistently completed across the service. Compliance with supervision was regularly reviewed and monitored through clinical governance meetings on each ward and the requirement to improve this activity was recorded, however no plans were identified in how to achieve this.
Between 1 March 2017 and 28 February 2018 the clinical supervision rate for medical staff was 400%. The trust’s target for clinical supervision is 66%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. The rate of clinical supervision reported during this inspection was higher than the 60% reported at
the last inspection.
Ward name Clinical supervision
sessions required
Clinical supervision
sessions delivered
Clinical supervision
rate (%)
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Burbage Ward 12 48 400%
Core service total 12 48 400%
Trust Total 91 250 275%
Multi-disciplinary and inter-agency team work
The service had regular and effective multidisciplinary meetings. There were three daily clinical
handovers within the team; these occurred when the shift changed. In addition, Maple ward
participated in a daily safety huddle, involving all staff members on the ward at the time.
Embedding this process remained a challenge due to acuity on the wards.
The service held daily and weekly multi-disciplinary meetings. Daily multi-disciplinary planning
meetings were held to discuss each individual patient. Staff told us these were effective for
discussing information regarding patients’ needs, risk and levels of observation. It also enabled
more effective and responsive planning for patients. Occupational therapy staff told us they found
this helpful and it reflected a team approach to care. Each ward also had weekly multi-disciplinary
meetings to review patients’ care and treatment. With the exception of Endcliffe ward, all wards
had a dedicated discharge co-ordinator. This role ensured an inclusive approach to patient
discharge, involving community mental health teams, housing and benefits. The wards had
established effective working relationships with mutual aid organisations, social and community
networks.
Staff told us that independent mental health advocates, pharmacists and carers attended multi-
disciplinary meetings. We observed one multi-disciplinary meeting during this inspection. The
meeting took a multidisciplinary approach to care and treatment. Although the patient had declined
to attend, their views were represented throughout. The discussion remained patient focussed and
discharge planning was thorough. A need to provide an independent mental capacity advocate
was identified in relation to ongoing care and treatment. Staff updated care records during the
meeting and verbal feedback was provided to the patient.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
As of 28 February 2018, 75% of the workforce in this core service had received training in the Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient and all community staff and renewed every three years. The training compliance reported during this inspection was higher than the 33% reported at the last inspection.
Staff we spoke with had a fair understanding of the Mental Health Act and the Code of Practice
guiding principles. Staff told us they would access support from the wider clinical team and the
Mental Health Act office, as they were confident in the depth of knowledge and understanding
available.
The trust employed Mental Health Act officers who provided guidance on the application of the
Mental Health Act and its Code of Practice to staff. The Mental Health Act office was responsible
for ensuring that all Mental Health Act documentation was accurate and complete. Ward staff had
access to a checklist to support them in the scrutiny of Mental Health Act documentation. Each
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ward had an identified contact within the Mental Health Act office and all staff knew who they were
and were confident in contacting them for advice. Staff told us they could access the policy and
procedure via the intranet.
The service had an organised system for storing detention paperwork, consent to treatment forms,
approved mental health professional reports and second opinion approved doctor reports. This
systematic approach ensured the Mental Health Act officers had oversight for patients’ ongoing
detention. The trust made provision for safe storage of detention paperwork. Copies of Mental
Health Act documentation were scanned onto the electronic patient care record which meant all
staff could access them when needed.
All wards had access to an independent mental health advocate and staff told us they visited
regularly. We observed information about this service on notice boards on all wards and via the
electronic patient information store on Stanage ward.
We reviewed care records of 15 detained patients. Of these, 13 care records showed evidence
that patients had their rights under the Mental Health Act explained to them at regular intervals.
Two records contained reminder letters to prompt staff to complete this. The majority of patients
we spoke with confirmed this. Both staff and patients told us that escorted leave from the ward
was occasionally cancelled due to staffing levels. All wards consistently took a flexible approach to
facilitating escorted leave throughout the day. We asked the trust to provide us with information on
the frequency of cancelled Section 17 leave and the trust confirmed they were not able to report
on the frequency of this.
Staff discussed Section 117 aftercare with most patients, of the 15 care records reviewed, ten care
plans referenced some discussion.
Ward managers completed weekly Mental Health Act documentation audits and these were
monitored by the Mental Health Act office. During a recent Mental Health Act monitoring visit by
the Care Quality Commission, the unlawful detention of a patient was highlighted by the trust.
During this inspection we discussed the learning from this incident with the Mental Health Act
Manager. They confirmed there had been a change in process to safeguard against a
reoccurrence of such an incident. The trust also met with the family to offer an apology and an
explanation.
The CQC completed four Mental Health Act monitoring visits to this core service between
February 2017 and May 2018. Issues identified included eliminating mixed sex accommodation,
timely seclusion reviews and availability of information. The trust had submitted provider action
statements to identify how they intended to address these issues.
Informal patients were aware of their rights and there were signs on display informing them they
could leave. Informal patients we spoke with confirmed staff had discussed with them on
admission their rights.
Good practice in applying the Mental Capacity Act
As of 28 February 2018, 90% of the workforce in this core service had received training in the
Mental Capacity Act Level 1 and 86% of the workforce had Mental Capacity Act Level 2. The trust
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stated that this training is mandatory for all core services for inpatient and all community staff and
renewed every three years. The training compliance reported during this inspection was higher
than the 17.5% reported at the last inspection.
The trust had a policy to guide staff and this was available on the intranet for staff to access. The
Mental Health Act office provided information and support to staff in relation to the Mental Capacity
Act. Staff audited the application of the Mental Capacity Act as part of the Mental Health Act audit.
The outcomes of these audits were monitored through regular clinical governance meetings and at
quarterly performance review meetings with senior clinical operational managers within the crisis
and emergency care network.
Capacity to consent to treatment was assessed on admission and with exception of one, all care
records demonstrated this had been completed.
Staff we spoke with had a fair understanding of Mental Capacity Act and its five statutory
principles. Care records demonstrated that staff had completed capacity assessments when
required, which were time and decision specific. Examples included, suitability for long term
supported accommodation and refusal of essential physical health medication. Staff did not make
decisions in isolation relating to capacity, and discussion and decisions were documented in
medical and multidisciplinary reviews. Staff recorded the outcome of assessment clearly in the
patients care record.
The trust told us that three Deprivation of Liberty Safeguard (DoLS) applications were made to the Local Authority for this core service between 1 March 2017 and 28 February 2018. CQC received zero direct notifications from Trust between 1 March 2017 and 28 February 2018. The number of DoLS applications made during this inspection was higher than the zero reported at the last inspection. We discussed this with the trust and they confirmed these three applications did not relate to this core service.
At the time of our inspection, the majority of patients admitted to the service were detained under
the Mental Health Act and some patients were voluntarily in hospital. The trust had a policy to
guide and assist staff to apply the Deprivation of Liberty Safeguards.
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Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
We spoke with 18 patients during this inspection, received comment cards from eight additional
patients, and met with 11 patients at two focus groups. We spoke with eight carers. Feedback was
mostly positive across all four wards. Patients told us staff were professional, caring and
reassuring. Patients felt respected by staff and commented how staff were always there to provide
help and support. We saw how one patient had been supported by the ward in their cultural and
religious needs during Ramadan. The patient could access food when required and medication
was provided at alternative times.
Throughout our inspection, we observed a mix of positive interactions between staff and patients.
Whilst we saw times when staff were very busy and were not always able to meet the needs of
patients in a timely manner, we also observed interactions where staff displayed compassion,
understanding and mutual respect, with staff directly supporting patients in a calm, caring and
reassuring manner. Staff demonstrated respect for patients by discreetly carrying out
observational checks. During the inspection, we observed incidents of patients becoming
distressed and agitated. Staff managed these situations well by acting quickly and responding
appropriately to patients’ needs. Business meeting minutes for all wards demonstrated that staff
discussed the privacy and dignity of patients during the use of restrictive interventions, such as
restraint. The majority of patients we spoke with felt staff had a genuine interest in their wellbeing.
Staff supported patients to understand their care, treatment and conditions. We saw evidence in
care records of detailed care plans and discussions regarding chronic physical health problems.
Doctors discussed with patients the importance of physical health assessments in relation to their
care.
Staff maintained the confidentiality of patient information through the use of secure access to
electronic patient records. Patient information was not on display in offices.
The 2017 Patient-led assessments of the care environment (PLACE) score for privacy, dignity and wellbeing at two core service locations scored better than similar organisations.
Site name Core service(s) provided Privacy, dignity and
wellbeing
Longley Centre
MH - Acute wards for adults of working age and
psychiatric intensive care units.
MH - Mental health crisis services and health-based
places of safety.
94.7%
Michael Carlisle Centre
MH - Acute wards for adults of working age and
psychiatric intensive care units.
MH - Other Specialist Services
MH - Wards for older people with mental health
problems.
94.3%
Trust overall 96.6%
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England average (mental health and
learning disabilities) 90.6%
Involvement in care
Involvement of patients
Staff we spoke with told us that new patients were orientated to the ward by a member of staff.
With the exception of one patient, all patients we spoke with confirmed they had been shown
around the key areas, such as toilets, showers, bedrooms and dining room.
We reviewed 17 care records. In the majority of the care records we reviewed, there was evidence
that care plans were co-produced with patients. Four records did not demonstrate any evidence of
patient involvement. The trust used a colour coding system to indicate the level of involvement the
patient had in their care plan. The five different colours indicated involvement from ‘I do not want
to be involved in this goal at the moment’ to ‘I feel I am taking the lead on my goal’. Five patients
told us they were not involved in planning their care and did not have a copy of their care plan. Of
the 17 care records reviewed, 12 patients had a copy of their care plan, one did not and four
records were unclear. Each patient had a collaborative care plan, this was a universal template
used in both community and in-patient settings. The care plan supported a continuity of care for
patients admitted via the community teams. Patients were invited to attend multidisciplinary team
meetings and were supported to actively participate in the meetings and input into their care and
treatment.
Staff could access external organisations to support patients with communication difficulties. Staff
described creative ways to communicate with patients with communication difficulties. One staff
member told us how the service had provided ear defenders and located a patient in a quieter
room to support them with their sensitive hearing.
Independent advocacy services were available for patients. The service clearly displayed in
communal areas information about how to access the services. Patients told us advocates visited
the wards regularly.
Patients were able to give feedback on the service in a number of ways. Community meetings
were held across all four wards. These meetings provided an opportunity for patients to express
their views. The trust had a service user engagement strategy and this promoted the recruitment
of volunteers who had experience of using services. The service supported volunteers. Maple and
Endcliffe wards had volunteers during this inspection. Volunteers worked directly with patients in a
number of activities. They also supported patients to complete patient questionnaires to identify
service improvement ideas.
Patients could provide feedback upon discharge by completing ‘care opinion’ and the friends and
family test. This feedback was closely monitored by the trust.
The service user engagement team at the trust had been instrumental in gaining feedback from
service users relating to the design and development of the Longley Centre as a city-wide location
for all adult acute and psychiatric intensive care unit provision within the trust. This involvement
had led the trust to change the design of the new health based place of safety to include individual
outdoor space for each bedroom within the suite.
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Involvement of families and carers
The service had a positive approach to involving families and carers. A monthly carers meeting
was available for families and carers to attend; one carer confirmed they had previously attended
this. Information was on display regarding carers’ week in June 2018.
At the point of a patient’s admission, consideration was given to carers and families. Of the 17
care records reviewed, nine records had evidence of family or carer involvement and one record
stated the patient did not want any family involvement. We saw evidence of one referral for a
carers’ assessment. Families and carers were actively encouraged by the nursing and medical
teams to be part of their relative’s care. Regular appointments were available for families and
carers to attend the wards to discuss patients’ care and treatment with the doctor and nurses. Staff
told us these appointments were used regularly and were a valuable source of information and
additional support for patients.
However, feedback from carers regarding the care and treatment of patients was mixed, with poor
communication from the wards was the most common issue raised. Carers told us responses to
requests for information were slow, and that they did not always receive feedback about issues
raised or share information about care and treatment. Two carers told us they we not informed
when their family member was transferred and admitted to the general hospital.
Carers could provide feedback about the service in person, or via the telephone or the internet.
However, four of the eight carers we spoke with did not know how to provide feedback to the
service. Carers knew how to make a complaint and felt able to do so. Two carers told us they had
made informal complaints on the ward, these were managed quickly and with a satisfactory
outcome.
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Is the service responsive?
Access and discharge
Bed management
The core service had bed occupancy numbers above 85%. The Royal College of Psychiatrists
recommends bed occupancy rates of 85% or less, stating that lowered bed occupancy rates
enabled local timely admissions and provides optimal support for patients.
The service aimed to ensure there was always a bed available when patients returned from leave.
Ward managers told us the contingency plan would be to extend leave if it was safe to do so or
arrange a ‘sleepover’ on one of the other acute wards, this meant patients were moved onto other
wards for non-clinical reasons. We discussed this with the trust and no specific information was
recorded in relation to this. The current system used did not differentiate between the use of a
leave bed or surge bed for an admission. Maple, Stanage and Burbage wards had ‘surge beds’.
This meant the male and female bays on each of these wards were typically used by just two
patients, however, they were used to their four-bedded capacity when demand was high. The trust
had in place an escalation protocol to follow in circumstances when the surge beds were used
which had been ratified by the trust board.
The trust provided information regarding average bed occupancies for four wards in this core service between 1 March 2017 and 28 February 2018. We are unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the time period that was covered.
Ward name Average bed occupancy range (1 March 2017 and 28
February 2018) (current inspection)
Burbage Ward 95.24-120.05
Burbage Ward plus detox 87.54-105.94
Maple Ward 91.27-111.01
Stanage Ward 89.81-105.73
Endcliffe Ward 70.67-99.64
With the exception of Endcliffe, all wards had average bed occupancy above 85% for all months reported. We examined the dashboard for all wards, from November 2017 until March 2018, both Burbage and Stanage wards were consistently above 100% bed occupancy. Maple ward was above 100% bed occupancy from January 2018 to March 2018. Ward managers confirmed that surge beds were regularly used to meet the demand for new admissions. Capacity and flow within in-patients services was proactively managed. Weekly bed management meetings were held and attended by doctors, discharge co-ordinators, ward managers, home treatment team doctors, crisis house staff and senior managers. This meeting provided the opportunity to examine closely the anticipated requirements from the community and bed pressures on the wards. Ward managers confirmed they also received twice daily emails from the bed manager, providing ‘live data’ on capacity and flow. This information was also shared with discharge co-ordinators. Staff we spoke with told us admissions continued to increase, acuity remained high and demands on staff were constant. Some staff we spoke with felt the reconfiguration of community services had impacted on the inpatient service. Senior managers acknowledged the increase in demand on
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services in the last three months and were keen to understand the reasons for this and the impact. Work had commenced to examine closely the data, though this was still in the early stages. Staff supported patients during transfers between services. If a patient required more intensive
care there was access to a psychiatric intensive care unit within the trust. Endcliffe ward provided
ten beds available to both male and female patients. This was a city-wide service. The service
would gate keep their own admissions to ensure patients’ needs were appropriate for the service
and this was completed by the multi-disciplinary team.
The trust provided information for average length of stay for the period 1 March 2017 and 28 February 2018. Endcliffe ward had the highest average length of stay at 69 days and Maple ward the lowest average at 15 days. The trust monitored the average length of stay through clinical governance meetings. Between November 2017 and March 2018, Burbage and Stanage wards average length of stay was consistently above 31 days, and Maple was below 31 days. To understand this more, a senior nurse worked with the wards to examine admissions and discharges.
Ward name Average length of stay range (1 March 2017 and 28
February 2018) (current inspection)
Burbage Ward 54.27
Maple Ward 15.25-48.10
Stanage Ward 22.61-42.82
Endcliffe Ward 22.00-69.00
This core service reported 59 out area placements between 1 March 2017 and 28 February 2018. As of 28 February 2018, this core service had one ongoing out of area placements. There were two placements that lasted less than one day, and the placement that lasted the longest amounted to 86 days. All of the out of area placements were due to alternative providers better suiting the service users care or personal needs. We requested further information from the trust in relation to out of area placements. The trust confirmed a number of reasons for these placements. These included requests from families for care closer to home, Sheffield registered patients repatriated back to local services and staff members requesting care outside of the trust.
Number of out of
area placements
Number due to
specialist needs
Number due to
capacity
Range of lengths
(completed
placements)
Number of ongoing
placements
59 59 - 1- ongoing 1
This core service reported 15 readmissions within 28 days between 1 March 2017 and 28 February 2018. Seven of readmissions (47%) were readmissions to the same ward as discharge. The average number of days between discharge and readmission was eight days. There were no instances whereby patients were readmitted on the same day as being discharged.
Number of
readmissions (to any
ward) within 28 days
Number of
readmissions (to the
same ward) within
% readmissions to
the same ward
Range of days
between discharge
and readmission
Average days
between discharge
and readmission
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28 days
15 7 47 2-23 8
Discharge and transfers of care
Between 1 March 2017 and 28 February 2018 there were 636 discharges within this core service. This amounted to 79% of the total discharges from the trust overall (804). Maple, Stanage and Burbage wards had a discharge co-ordinator who was a band six nurse. This
role enabled the service to address barriers to possible discharge and assisted in accessing most
appropriate discharge support packages of care. Staff we spoke with told us that discharges were
discussed with patients at the earliest opportunity in their care. We reviewed 17 care records and
14 records demonstrated that staff had discussed and planned for a patient’s discharge.
Discharge co-ordinators worked closely with community teams to ensure care packages were
timely, co-ordinated and appropriate to patients’ needs.
We reviewed discharge data from each ward between March 2018 and May 2018. There had
been a total of 55 discharges in March 2018, 59 in April 2018 and 66 in May 2018.
There were 27 delayed discharges between 1 March 2017 and 28 February 2018, 22 of which were on Maple ward. We reviewed board paper minutes from January 2018 and it was evident that work was ongoing to
monitor delayed discharges effectively. We requested further information from the trust in relation
to the delayed discharges from Maple ward. Of the 22 delayed discharges reported for Maple
Ward between 01/03/2017 and 28/02/2018 these related to 12 individual patients. Reasons for the
delayed discharge of these 12 patients included; three patients awaiting a care home placement,
nine patients a care package in their own home, and one patient awaiting public funding.
Facilities that promote comfort, dignity and privacy
With the exception of Endcliffe ward, all ward environments presented challenges to both staff and
patients. These included the availability of rooms and layout of the ward. All patients on Endcliffe
had individual bedrooms. Maple, Stanage and Burbage wards had individual bedrooms and
dormitory style accommodation. Dormitories could accommodate up to four patients, the trust
attempted to maintain a maximum of two patients in dormitories at any one time to promote the
dignity and privacy of patients. However, between January 2018 and March 20118, all three wards
have consistently had bed occupancy over 100%, this meant ‘surge beds’ were used in each
dormitory. Dormitories were of a traditional layout and bays were screened by privacy curtains. All
dormitories had toilet and shower facilities.
Patients that had individual bedrooms were able to personalise these, although we observed that
most were bare in appearance. All patients could safely store their possessions.
The service had a full range of facilities and equipment to support treatment and care. These
included fully equipped kitchens for patients to use to develop their skills for daily living and meal
preparation. Other rooms available included television lounges, quiet rooms and activity rooms.
Patients at the Michael Carlisle Centre had access to an onsite gym. Maple ward had a ward
based gym and Endcliffe ward had access to various outdoor physical activities such as football,
cycling and basketball. Each ward had access to outside space, patients could access this freely.
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Stanage and Burbage wards had small flagged areas but outdoor furnishings were minimal and
seating was limited. The trust were completing work to extend the outside space available to
patients.
Maple and Endcliffe wards had dedicated visitor rooms located off the ward. Stanage and Burbage
wards did not have a dedicated visits room due to the limited space on these wards. Most rooms
were multi-purpose and staff told us visits would go ahead on the ward, including in patient
bedrooms and in the occupational therapy department.
All patients could make private telephone calls. Mobile phones were not restricted and patients
could use their own mobile phones or the ward portable telephone if required in private.
Hot and cold drinks were available twenty-four hours a day. A variety of healthier snacks were
available to patients, including fruit. Patients at the Michael Carlisle Centre and Longley Centre
were complimentary about the quality of food.
• The 2017 Patient-led assessments of the care environment (PLACE) score for ward food at the locations scored better than similar trusts.
Site name Core service(s) provided Ward food
Longley Centre
MH - Acute wards for adults of working age and
psychiatric intensive care units.
MH - Mental health crisis services and health-based
places of safety.
94.4%
Michael Carlisle Centre
MH - Acute wards for adults of working age and
psychiatric intensive care units.
MH - Other Specialist Services
MH - Wards for older people with mental health
problems.
97.5%
Trust overall 96.4%
England average (mental health and learning disabilities) 91.5%
Patients’ engagement with the wider community
Patients were supported to maintain contact with their community, families and carers. Care and
treatment pathways included access to section 17 leave. Patients could utilise leave independently
or if required, with the support of staff. Staff and patients told us leave was essential for
maintaining community contact and achieving recovery goals. Patients had the opportunity to
explore employment and education activities, this was individually based and determined by the
acuity of each patient. We saw evidence in some care records of discussions with patients
regarding accessing higher education and engaging in voluntary work following discharge from
hospital.
The occupational therapy team were key to driving and maintaining a patients’ engagement with
their community and that activities were meaningful and linked to patients’ recovery goals. The
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trust had links with community based organisations that provided creative opportunities that
promoted health and wellbeing.
Meeting the needs of all people who use the service
All wards had disabled accessible bedrooms and bathrooms with handrails to assist in the use of
the bath and toilet.
During the inspection, we saw information on display across all wards for patients, including
information about how to complain, how to contact the Care Quality Commission and the
independent mental health advocacy service. Information was also available on a variety of
physical health and wellbeing topics, including smoking, use of illicit drugs and alcohol. Staff told
us that information could be easily obtained in different languages and formats via the internet.
Stanage ward had a useful electronic patient information store. Information was available about all
aspects of care and treatment and we observed patients using this during this inspection. The trust
had a contract in place to provide interpreting services. Staff told us they could readily access
interpreters for patients where English was not their preferred language. We saw that interpreters
had attended the wards to support patients during multi-disciplinary meetings and whilst in
seclusion. Staff could access a telephone interpreting service and the internet to print leaflets in
different languages.
Patients had access to spiritual care and could also access a range of spiritual support on the
wards. A variety of religious books and quiet areas were available for patients to use. Private
washing facilities were also available for patients. We spoke with a member of the pastoral team
and they were complimentary about the trusts commitment to spiritual care. The trust worked in
partnership with a number of local organisations to support specific ethnic groups, these included
the Somali and Asian communities. The service had identified a pathway to refer patients into the
gender identity service where this was appropriate.
Listening to and learning from concerns and complaints
This core service received 14 complaints between 1 March 2017 and 28 February 2018. One was
upheld, four were partially upheld and nine were not upheld. No complaints were referred to the
Ombudsman. Four complaints were related to discharge and one complaint was made in relation
to an alleged assault.
The number of either partially or fully upheld complaints reported during this was lower than the 23 reported at the last inspection.
Total Complaints Fully upheld Partially upheld Not upheld Referred to Ombudsman Upheld by Ombudsman
14 1 4 9 No No
Complaints about this core service were low. All wards displayed information on how to complain
and provided fast track complaint forms on each ward. Ward managers we spoke with were
confident in the mechanisms available for patients to complain. The majority of patients we spoke
with were aware of how to complain and were confident to do so. Staff told us they were
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encouraged to manage concerns raised by patients or escalate if required to the ward manager.
Most staff felt confident in dealing with a patient complaint. Of the 18 patients we spoke with
during this inspection, two patients had made complaints. One patient was satisfied with the
response and felt the issue had been resolved, the other patient was dissatisfied.
This core service received 87 compliments during the last 12 months from 1 March 2017 and 28
February 2018 which accounted for 13% of all compliments received by the trust as a whole.
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Is the service well led?
Leadership
The acute and psychiatric intensive care wards formed part of the crisis and emergency care
network. The trust had recently completed a restructure of the organisation that had seen changes
in the leadership of services. The new structure had been operational from April 2018. The trust
had leaders at all levels with a variety of skills, knowledge and experience. Senior managers we
spoke with were relatively new to their posts but were established within the organisation and had
a good understanding of the service they managed.
Ward managers had different levels of experience. Of the four wards, only Endcliffe and Burbage
had substantive wards managers in post. At the time of our inspection, the remaining two wards
had acting or temporary managers. All ward managers spoke positively about the organisational
and peer support available to them.
Staff told us immediate line and operational managers were visible and supportive. Ward based
staff spoke positively about their leaders, felt supported and listened to. Managers at all levels
were committed to delivering high quality care services but were candid regarding the progress
due to the staffing pressures, bed occupancy levels and environmental challenges.
The trust supported the development of managers and key staff networks, such as the BME staff
network group supported learning opportunities.
Vision and strategy
Staff knew and understood the trust’s visions and values. Extensive information was visible on
wards and available on the intranet. Patient information, including leaflets and posters clearly
reflected the values of the organisation. Interactions between professionals and with patients,
demonstrated the commitment staff had to delivering care based on the trusts vision and values.
There was a clear connection between the senior leaders’ vision and strategy and how this
translated into the delivery of care on the wards. Staff were focussed, worked inclusively with
patients and were driven to provide the best possible care.
The approach taken by the trust in the development of the Longley Centre clearly demonstrated
how ambition and partnership working underpinned this key service development. The trust
consulted patients, carers, staff and key stakeholders in its development.
Culture
Managers at all levels promoted a culture that supported and valued staff. Staff spoke with genuine
warmth about their teams and immediate managers. Staff supported each other within the service
and this made a positive difference to staff. Lines of communication were open and honest within
the service and staff felt listened to. Staff reported strong working relationships with the
multidisciplinary team. We saw that staff were committed to their roles and there was resilience in
teams that enabled staff to manage the daily challenges of providing care.
All staff we spoke with felt able to raise concerns without the fear of retribution. Staff were familiar
with the trust whistleblowing policy and were confident in using it. The trust’s freedom to speak up
guardian had been used by the service. Staff had raised concerns regarding staffing issues and
increased acuity of patients. This process allowed open and honest conversations with staff,
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examining options and possible solutions to these concerns. The service’s staff sickness and
absence rate was similar to that of the provider. Staff had access to support for their physical and
emotional wellbeing, the trust participated in the mindful employer and workplace wellbeing
schemes. Staff could access support following incidents through the psychology department.
The trust celebrated staff success through its annual recognition and achievement awards.
During the reporting period, there were no cases where staff had been either suspended, placed under supervision or were moved to a different ward.
Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these should be noted.
Governance
The service monitored and reported on a range of key performance indicators such as length of
stay, discharge and re-admissions. Senior managers attended regular patient safety meetings with
colleagues from across the emergency care network to understand current themes and issues.
Therefore, managers were aware of key areas of improvement within the service, such as staffing
levels and bed occupancy levels. The trust had taken some action to address these issues,
however these remained a concern at the time of this inspection. The service also had processes
in place to monitor the performance of wards and a programme of audits; however these were not
always consistent or effective in implementing change.
The trust completed annual risk assessments of the environment which included ligature risks and
fire. None of the wards reviewed the ligature risk assessment following a serious incident in the
service and blind spots had not been identified on most wards. Annual fire risk assessments
completed in March 2018 were not available on wards for staff to use in June 2018.
Staff could not regularly access clinical supervision and the recording of all elements of
supervision was poor. Although supervision was discussed at clinical governance meetings, there
were no clear plans of how to improve this.
The recording of controlled drugs and labelling of patient specific medication was not sufficient.
We saw gaps in audits for emergency medical equipment and fridge and clinic room temperatures.
Systems and process in place did not identify the issues in relation to medical reviews and
physical observations following episodes of seclusion and rapid tranquilisation, or the issues with
exit care plans following seclusion. Section 17 leave was cancelled due to staffing, the trust did not
have a system in place to record and monitor the frequency of this. The trust did not have
arrangements in place to monitor when no bed was available following section 17 leave on the
ward, including the use of surge beds, sleepovers and extending section 17 leave.
Visiting procedures were not robust or sufficient to safeguard children and appropriate action was
not taken following an incident, nor was the process for visitors reviewed to identify any learning or
potential changes to the procedures.
Business meetings occurred frequently on all wards, however there was no standard agenda and
minutes were handwritten. Not all wards recorded attendance or action to be taken. A
standardised approach was taken in monthly governance meetings on each ward, however
recording of discussion, outcomes and actions were inconsistent.
However, systems and processes were effective at ensuring staff were trained and appraised, the
use of restrictive interventions was low, and staff understood the Mental Health Act and Mental
Capacity Act and the application of the Acts was consistent.
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The trust had a clinical effectiveness team that was responsible for the day to day management of
National Institute for Health and Care Excellence implementation and assurance process. This
group reported to the clinical effectiveness group who had responsibility for the oversight and
monitoring of activity. This approach supported the trust in meeting its overall responsibilities in
relation to implementing national guidance.
Management of risk, issues and performance
Managers discussed the risk register at quarterly performance review meetings within the crisis
and emergency care network. All wards had a local risk register, these were reviewed regularly at
monthly clinical governance meetings. We reviewed the local risk register and items included
staffing, risk of violence and aggression and harm to service users on Section 17 leave.
The trust had business continuity plans in place that staff could refer to in emergency situations.
Information management
Team managers had access to information to support them with their management role. This
included information on the performance of the service, staffing and patient care. Information
governance officers collected data to inform the service on performance, quality and safety. This
included information on mandatory training, supervision, audit activity, restrictive interventions and
service user feedback. Following the restructure into the crisis and emergency care network,
governance arrangements had altered and systems were being aligned. Governance dashboards
were developing to reflect these changes.
The effective use of these systems enabled the service to identify issues in recording the
frequency of rapid tranquilisation. Governance officers escalated this issue and contingency plans
were put in place to ensure accurate information was used to monitor restrictive interventions.
Staff had access to the equipment and information technology needed to do their work. This
included the use of electronic tablets to accurately record patient observations. The trust used
information technology to support care and treatment through electronic care records and
prescribing. Confidentiality was maintained through password protected access.
Engagement
The trust engaged positively with staff, patients and carers. Up to date information was
available through a number of mechanisms.
Staff and patients had access to information on the ward. Information boards were on display
on each ward and Stanage ward had access to an electronic patient information store. The
availability of volunteers within the service was an additional way patients could obtain
information and express their views. Staff and patients had access to the trust website and
staff could access the intranet for information. The trusts website was informative, up to date
and provided extensive information.
Feedback from patients and carers about the service was obtained through community
meetings, carers’ forum, and managers told us they monitored the care opinion survey online.
The trust worked in partnership with community organisations to promote recovery, health
and well-being.
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Learning, continuous improvement and innovation
NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.
There were no accreditations for this core service.
Maple ward continued to be involved in the microsystems work of the trust, an approach involving senior colleagues from the crisis and emergency care network supporting innovation and change on the ward.
This core service had representation as an executive member of the national association of psychiatric intensive care units. This supported learning and practice in this specialised area of care.
In June 2018 the trust were successful in winning a national award for improving patient safety and experience through the RESPECT training programme.
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Community-based mental health services for older people
Facts and data about this service
Location site name Team name Number of clinics Patient group (male,
female, mixed)
Fulwood House Memory Service 39 clinics Mixed
Fulwood House
Dementia Rapid
Response and
Home Treatment
Teams,
48 Mixed
Fulwood House
Functional
Intensive
Community
Service (FICS)
0 Respond to people in
crisis Mixed
Fulwood House
Older Adult
Community
Mental Health
Teams
0 Respond to people in
crisis Mixed
Is the service safe?
Safe and clean environment
All the community teams for older adults were in the same building. Although it was not routine for
patients to come to the building for appointments this did sometimes occur. The building was
clean, tidy and very well maintained. There was clear signage outside of the building so that
people visiting for the first time knew they were at the right location. The reception area was bright
and welcoming with lots of up to date information available for patients and carers. All rooms
where patients were seen were fitted with nurse call alarms. These were in the form of a push
button which sounded out in reception. Staff were able to explain to us how they responded once
the alarm sounded although this rarely happened. All staff we spoke with told us that if a patient
was known to be high risk they would be seen in the room that could be observed from reception
and the interview would take place with two members of staff.
There was one clinic room that was shared by the community teams. This contained all equipment
that the teams needed to carry out physical health checks. There was only a small amount of
medication stored on the premises relating to a few patient own medications that were being used
by the dementia rapid response team. This was all stored correctly and labelled. The clinic was
clean and tidy and equipment in the room was cleaned and labelled. There was however, a
physical health bag that staff used for doing physical health checks on visits to patient homes. We
found that although there was a schedule in place for this to be cleaned every Sunday, it had not
been signed for since January 2018. There was also some out of date equipment such as wipes
for cleaning. However, this was low risk equipment such as blood pressure cuffs, thermometer and
weighing scales and the equipment did not look visibly dirty. We raised this immediately with the
team manager and this was sorted out whilst we were still on inspection.
Safe staffing
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Staffing levels were adequate to meet the needs of the service. At 31 March 2018 there were six
vacancies, however, on the inspection we found this had improved and there were three
vacancies across the two teams we visited. The trust had a rotational post system in place
whereby staff could choose to go on a rotational contract where they would move around different
services to learn new skills and cover gaps in staffing. Therefore, the vacancies in the community
teams that were created by staff being successful in securing a secondment to a higher band were
covered by rotational staff.
Bank and agency staff were not routinely used. If cover was required then staff within the team
would do a bank shift to cover for gaps in staffing. This meant that staff covering shifts always
knew the patients they were visiting. Between May 2017 and March 2018 there were 82 bank
shifts across all of the community teams, this equates to around 7 per month. Agency staff were
never used, due to the nature of the service it was important that people visiting patients in their
own homes knew the patient history and needs well.
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 January 2018 106.4 N/A
Total number of substantive staff leavers 1 February 2017 to 31 January 2018
8.4 N/A
Average WTE* leavers over 12 months (%) 1 February 2017 to 31 January 2018
8% 13%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31March 2018 6 N/A
Total vacancies overall (%) At 31March 2018 7% NA
Total permanent staff sickness overall (%)
Most recent month (At 31 January 2018)
8% 5%
1 February 2017 to 31 January 2018
6% 5%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 March 2018 38 N/A
Establishment levels nursing assistants (WTE*) At 31 March 2018 13 N/A
Number of vacancies, qualified nurses (WTE*) At 31 March 2018 5 N/A
Number of vacancies nursing assistants (WTE*) At 31 March 2018 0 N/A
Qualified nurse vacancy rate At 31 March 2018 13% N/A
Nursing assistant vacancy rate At 31 March 2018 0% N/A
Bank and agency Use
Shifts bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 March 2017 and 28
February 2018 82 N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses)
1 March 2017 and 28
February 2018 0 N/A
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Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses)
1 March 2017 and 28
February 2018 1 N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 59 N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 0 N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants)
1 March 2017 and 28
February 2018 4 N/A
*Whole-time Equivalent
This core service reported an overall vacancy rate of 13% for registered nurses at 31 March 2018. This had reduced to 7% by the time of our inspection.
This core service reported an overall vacancy rate of 0% for registered nursing assistants.
This core service has reported a vacancy rate for all staff of 7% as of 31 March 2018.
Staffing levels were established by the team analysing the amount of referrals they receive The dementia rapid response team had formed when the trust reduced the number of inpatient beds for the area with a view to keeping people with dementia in their own homes rather than being admitted into a hospital bed. Staff from the wards were moved to that team. There were enough staff that had relevant experience in caring for older adults to manage the teams caseloads.
The average caseload for the community mental health team was around 30 per staff member and around six for the dementia rapid response team. The community mental health team monitored staff caseloads using a red, amber and green rating system and weighted staff caseloads accordingly. Patients who were rated red were more complex and would take more of the staff members time, therefore staff would be allocated fewer amber and green patients. Likewise, if a staff member had more amber and green patients they would have a higher caseload. In the dementia rapid response team staff only held around six patients on a caseload. This was due to the fact that patients under this team were in crisis and could be having up to daily visits (more regularly if staff were supporting patients with medication). Staff in the dementia rapid response team would work with patients for more intense but shorter periods than the community mental health team.
Registered nurses Health care assistants Overall staff figures
Team Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Functional
Intensive
Comm
Serv
0 9 0% 1 3 33% 2 15 13%
Rapid
Response 2 15 13% 0 7 0% 3 27 11%
Memory
Service 1 12 8% -1 3 -33% 2 26 8%
Edmund
Road
Central
Admin
0 0 0% 0 0 0% 0 1 0%
CMHT
Managem
ent
2 2 100% 0 0 0% -1 17 -6%
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Registered nurses Health care assistants Overall staff figures
Core
service
total
5 38 13% 0 13 0% 6 86 7%
Trust total 32 433 7% 15 353 4% 68 1339 5%
NB: All figures displayed are whole-time equivalents
There are data issues with the bank and agency information as the shifts filled totals are more than the available shifts. We therefore cannot report on the proportion of shifts filled for this core service.
Team Available shifts Shifts filled by
bank staff
Shifts filled by
agency staff
Shifts NOT filled by
bank or agency
staff
Dementia Rapid
Response and Home
Treatment Teams,
0 5 0 1
Functional Intensive
Community Service
(FICS)
0 77 0 0
Core service total 0 82 0 1
Trust Total 32,394
4977
(15%)
7252
(22%)
900
(3%)
*Percentage of total shifts
There are data issues with the bank and agency information as the shifts filled totals are more than the available shifts. We therefore cannot report on the proportion of shifts filled for this core service.
Team Available shifts Shifts filled by
bank staff
Shifts filled by
agency staff
Shifts NOT filled
by bank or agency
staff
Dementia Rapid
Response and Home
Treatment Teams,
0 24 0 3
Functional Intensive
Community Service
(FICS)
0 35 0 1
Core service total 0 59 0 4
Trust Total 59,514 21,770
(37%)
5623
(9%)
1760
(3%)
* Percentage of total shifts
This core service had 8.4 (8%) staff leavers between 1 March 2017 and 28 February 2018. This was lower than the 10% reported at the last inspection.
Team Substantive staff Substantive staff Leavers Average % staff leavers
Edmund Road Central Admin 0.9 0.4 22%
CMHT Management 45.7 6 13%
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Team Substantive staff Substantive staff Leavers Average % staff leavers
Memory Service 23 1 4%
Rapid Response 23.5 1 4%
Functional Intensive Comm Serv 13.2 0 0%
Core service total 106.4 8.4 8%
Trust Total 1351.6 129.6 8%
The sickness rate for this core service was 6% between 1 February 2017 and 31 January 2018. This was similar to the sickness rate of 7% reported at the last inspection.
Team Total % staff sickness
(at latest month)
Ave % permanent staff sickness
(over the past year)
Rapid Response 15% 9%
Functional Intensive Comm Serv 11% 7%
Memory Service 10% 6%
CMHT Management 3% 5%
Edmund Road Central Admin 0% 2%
Core service total 8% 6%
Trust Total 8% 7%
Medical staff
The service employed a team of psychiatrists and junior doctors who were routinely available
across the service to support the medical care of patients. The medical staff we interviewed spoke
positively about the training opportunities available to them. The dementia rapid response team
who worked up until 8pm and at weekends had access out of hours to an on call doctor system,
which was staffed by a junior doctor and a consultant psychiatrist.
Medical locum information was not provided for this service.
Mandatory training
The compliance for mandatory and statutory training courses at 28 February 2018 was 90%. Of the training courses listed two failed to achieve the trust target and of those, zero failed to score above 75%.
During our inspection, we reviewed this and found that the two courses that were below the trust target when the trust submitted the evidence were now above the trust target of 80%. This meant that most of the staff were provided with the training to carry out their role on an ongoing basis.
The training compliance reported for this core service during this inspection was higher than the 70% reported at the last inspection.
Key:
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Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service %
Trust target %
Trustwide mandatory/ statutory training total %
Mental Health Act 100% 80% 83%
Immediate Life Support 100% 80% 88%
Dementia Awareness (inc Privacy &
Dignity standards) 97% 80% 85%
Fire Safety 2 years 96% 80% 96%
Fire Safety 3 years 96% 80% 96%
Equality and Diversity 95% 80% 95%
Health and Safety (Slips, Trips and
Falls) 95% 80% 97%
Mental Capacity Act Level 1 93% 80% 94%
Safeguarding Children (Level 3) 92% 80% 91%
Safeguarding Adults (Level 2) 92% 80% 87%
Rapid Tranquillisation 90% 80% 88%
Safeguarding Children (Level 2) 90% 80% 85%
Autism Awareness 90% 80% 88%
Hand Hygiene 90% 80% 94%
Mental Capacity Act Level 2 89% 80% 85%
Domestic Abuse Level 2 89% 80% 85%
Clinical Risk Assessment 88% 80% 91%
Medicine management training 88% 80% 87%
Respect Level 2 88% 80% 80%
Information Governance 80% 80% 80%
Adult Basic Life Support 78% 80% 81%
Respect Level 1 78% 80% 66%
Core Service Total % 90% 80% 88%
Assessing and managing risk to patients and staff
Assessment of patient risk
We reviewed eleven care records across the two teams. We found that risk was assessed for
every patient. This was completed on triage for the dementia rapid response team and then in
more detail on the initial visit. For the community mental health team, a risk assessment was
expected to come with every new referral and then the team would complete another risk
assessment on the first visit to the patient. Risk assessments were reviewed at every visit and this
was documented in the patient record. If risks had significantly changed then a new risk
assessment would be completed and a new risk management plan commenced.
Management of patient risk
Staff completed crisis plans which included the relevant telephone numbers of who to contact in
an emergency. There was a dementia helpline for patients who had been diagnosed under the
memory clinic at the service. This meant that if a carer was struggling in any way they could ring
this helpline directly and receive advice and support over the telephone for the patient. This was
also a route for a direct referral into the dementia crisis team to eliminate the carers having to go
through various different services to get help.
Staff were able to prioritise service users who were experiencing a deterioration of their mental
health. This was due to manageable caseloads and a supportive team approach. This meant that
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for patients in crisis the team could visit a number of times per day to enable that person to stay at
home. This included supporting with medication although this remained the responsibility of social
care teams, the team were able to support this short term if it prevented a hospital admission.
There was no waiting list to be assessed by the service or allocated to worker. The community
mental health team aimed to see all new referrals within two weeks and the dementia crisis team
within 48 hours. However, his was usually always met sooner unless the person needed to wait
longer for example to accommodate a relative attending the initial visit.
Safeguarding
A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional.
Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.
This core service made 65 adult safeguarding referrals during the 12 months prior to 30 April 2018.
All staff were trained in safeguarding up to level 3. The training rate was 90%. Staff had a good understanding of safeguarding and what type of things they would report. Staff knew the internal procedure for reporting via the incident reporting system and who to ask for advice within the trust. We were able to review examples of incidents staff had referred to the safeguarding team for example, suspected financial abuse.
There was a lone working policy for staff working on the community. This included the use of electronic diaries so that the person who was the coordinator on each shift knew where each member of staff was and when they were due back. Staff were aware that they needed to leave mobile phones switched on at all times (turned to silent during home visits). If a patient was deemed as higher risk then staff would always visit in twos.
Sheffield Health and Social Care NHS Foundation Trust has submitted details of zero serious case reviews commenced or published in the last 12 months (1 March 2017 and 28 February 2018) that relate to this core service.
Staff access to essential information
Patient information was stored on a secure electronic system that required a password to access
it. The system had been in place for a number of years and staff found this easy to navigate. Staff
had access to part of the primary care records and hospital records for their patients. This meant
they could access blood results, x-ray and scan reports and discharge summaries for stays in the
acute hospital setting. Staff reported they found this invaluable for keeping up to date with the
physical health needs of their patients.
Medicines management
The service only stored a small amount of patient own medication that was being used by the dementia rapid response team. Patients in the community who required depot medication ordered their own and this was kept with the patient until it was dispensed. For patients who needed
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support, family or carers would assist with ordering and collection of depot medication. If medication was prescribed by the consultant psychiatrist there were prescription pads kept at the service. Doctors were aware to only carry a small number of these with them on visits and the full prescription pads were securely stored on the premises.
Track record on safety
Providers must report all serious incidents to the Strategic Information Executive System (STEIS) within two working days of an incident being identified. Between 1 March 2017 and 28 February 2018 there were two STEIS incidents reported by this core service. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period. We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with STEIS. The number of serious incidents reported during this inspection is the same as the two reported at the last inspection. The team managers were able to talk to us about serious incidents that had occurred in the service. This included access to the full investigation and to demonstrate how learning was shared across the community teams. For example, following a suicide the team had reviewed the incident as part of the trust investigation process. This meant that the senior managers and staff involved in the incident were able to have input into the investigation report. Once complete the report and learning was fed back to the wider team (and other community teams) in order for the learning to be shared. Although it was found the team had done everything possible to care for the patient they were still able to discuss how they could do things differently in the future including better communication with other organisations such as local pharmacies. For all incidents learning was fed back via team meetings or if necessary at individual staff supervision where learning was for an individual staff member. The trust used an electronic incident reporting system and all staff had access to report incidents.
Senior members of the team were able to access to review and sign off incidents. Staff were able
to tell us what type of things they would report as an incident, for example, medication errors,
deaths, breaches of confidentiality and physical health emergencies.
Staff told us that they received feedback from incidents during staff meetings and individual
supervision. We were able to review some of the minutes from meetings and found this to be the
case.
Staff were aware of their responsibilities under duty of candour and the need to apologise in the form of a letter if something went wrong. Staff were open an honest with patients and told them about more minor errors as well as serious ones. Patients were always offered and apology if an appointment needed to be changed at short notice although this was rare.
Number of incidents reported
Type of incident reported on STEIS OA
CMHT
SW
Dementia
Rapid
Response
South
Total
Apparent/actual/suspected self-inflicted
harm meeting SI criteria 0 1 1
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Medication incident meeting SI criteria 1 0 1
Total 1 1 2
Reporting incidents and learning from when things go wrong
The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths.
In the last two years, there have been zero ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.
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Is the service effective?
Assessment of needs and planning of care
We looked at eleven records across the two teams we visited. We found that all patients had a
comprehensive assessment of their needs. This included assessment of physical health, reason
for referral, past history, presenting problems and social factors. We found that care plans were
completed to a high standard and showed a good level of involvement from patients and carers.
Where possible care plans were shared and left with the patient. However, for some patients with
more severe cognitive impairment this would be kept either with family or at the community team.
If patients refused a copy of their care plan this was documented clearly and further attempts
made to explain to the patient about their care plan during home visits.
Best practice in treatment and care
We observed staff following national institute for health and care excellence guidance for the
prescribing of medication. Both teams were aware of the need to reduce antipsychotic prescribing
for patients with a cognitive impairment. There were measures in place to monitor those on
antipsychotics and lithium including checklists for physical health checks prior to commencing
medications and during to monitor.
The team also had therapy dolls for people with dementia who showed symptoms of anxiety or
distress. The team had recognised that some families may find this distressing to see their relative
effectively playing with a doll. Therefore, the team kept journal articles with the dolls so they could
show patients families the evidence base around the use of this type of therapy.
Physical health was monitored by the team although interventions were carried out by the GP. The
team would check weight and blood pressure during visits if required and some patients were on
weekly weighing regimes if there were concerns about nutritional intake or weight loss.
There was access to psychological therapies and psychologists and trainee psychologists were
based within the team. This meant that referrals could be actioned quickly and there was no wait
for psychological therapies. Psychologists offered both group and one to one sessions with
patients and carers. These included, anxiety management and depression groups and 1-1
therapies with carers for people with dementia. The teams worked together well to facilitate this,
for example arranging visits to the patient whilst the carer attended psychology sessions.
Outcomes were measured using the health of the nation outcome scale and this was completed
on initial visit and throughout the time the patient was under the community team in order to
measure the effectiveness of the care the patient was receiving. There were other tools used
dependent on the patient’s diagnosis for example depression and anxiety scales.
The teams used information technology in a number of innovative ways to maintain independence
and reduce confusion for patients with a memory problem. This included the use of “just checking”
an activity monitoring system that allows people to remain in their own homes for longer by
showing the team their capabilities on a day to day basis and where extra support was needed.
They also had an advanced version of the system that allowed them to attach sensors to items
such as the fridge, kettle and tap to show if sequencing was maintained in day to day activities.
For patients who liked to walk out but sometimes got lost, the team also had a “buddy system”
device. This was effectively a GPS tracking device which allowed a family member to monitor
where the patient walked to without having to follow them or even stop them going out. Lastly for
patients who had trouble remembering who family members were the team used a photographic
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diary where they could work with the patient and their families and record who the family member
was and things they liked to do so when the page was turned it played the memories back. This
not only helped to reduce agitation and confusion but it gave the families a nice activity to do
together with the person with dementia.
Staff supported social interventions such as support with housing or benefits. Staff identified
concerns during the initial assessment process and referred to other external agencies.
This core service participated in the following clinical audits as of their clinical audit programme in
the 12 months leading up to the submission of the provider information return.
Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
Collaboration
with Primary
Care Clinicians
Service users
on CPA
Provider
wide Clinical on-going
Changes made following
previous audit round:
provide guidance to staff
on annual reviews of care.
Changes to care plan form.
Creation of a 'clinical
review for GP' IT system
solution.
Record keeping
audit 2016/2017 Trust wide
Provider
wide Clinical on-going
From data collected so far:
Further clarity provided to
staff on use of
abbreviations - to be
incorporated into the
relevant policy.
Audit of risk
assessments
2016/2017
Trust wide Provider
wide Clinical audit March 2017
Local action plans to
address identified issues.
Audit tool to be revised to
give clearer results.
Re-audit to be undertaken
in 2017/18.
Audit of risk
assessments
2017/2018
Trust wide Provider
wide Clinical audit ongoing Await findings
Audits of care
plans Trust wide
Provider
wide Clinical audit
January
2018
Agreed need for frequent
small scale audits.
Findings being shared with
teams.
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG43
Transition from
children’s to
adults’ services
for young
people using
health or social
care services
Trust wide Provider
wide Clinical audit June 2017
Findings fed into
Commissioning for Quality
and Innovation and other
related joint work with child
and adolescent mental
health services to improve
transitions
Assessment of
National
Institute for
Trust wide Provider
wide Clinical audit
September
2017
Review practices against
guidance as necessary in
future
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Health and Care
Excellence
Guidance: NG13
Workplace
health:
management
practices
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG58
Coexisting
severe mental
illness and
substance
misuse:
community
health and
social care
services
Trust wide Provider
wide Clinical audit
December
2017
Action plan under
development
We also found that regular clinical audits took place to monitor things such as care records and
collaborative care planning. This included checking assessments, risk assessments care plans
and other documentation was available and up to date.
Staff told us that the results of audits were fed back during staff meetings, or if necessary in
individual supervision. We saw evidence of this in the minutes of staff meetings and supervision
records.
Skilled staff to deliver care
Each team consisted of nurses, consultant psychiatrists, occupational therapists, psychologists,
support worker, administration staff and team managers. There were no social workers as part of
the team; patients with identified social care needs such as those requiring residential care funding
assessments were referred for social work input via the local authority. Staff who worked in the
team had worked there for many years and were skilled and knowledgeable about the field they
worked in.
We looked at the compliance rates for the community older adult services during our inspection.
Although clinical supervision figures were low across the functional intensive care team and the
rapid response team with an average compliance rate of 59%, staff told us that they felt very well
supported within their team and received regular supervision. We reviewed records that showed
that staff had access to supervision in a number of formats, They were able to access formal
supervision with their supervisor and could access reflective practice sessions facilitated by the
psychology team as a group or individually. Reflective practice sessions happened on a monthly
basis although these were not recorded as formal supervision sessions. Staff who were from a
profession other than nursing, for example, psychologists and occupational therapists were able to
access clinical supervision via an approved list of supervisors from their own profession. The trust
had recently introduced an electronic recording system for clinical and managerial supervision as
they had recognised the recording of supervision was not always captured as it was being
delivered. This new system showed who had received supervision, the date, whether it was
clinical or managerial and when it was next due. From the time the new system was implemented
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we were able to see all staff had received supervision in line with the trust target. The managers
had access to all figures and were alerted when this was due for each member of staff. Although
this was a new system we were able to see from previous paper records that staff within the team
were having regular supervision on a monthly basis. Staff told us they felt very well supported in
the team and that they felt able to ask any member of staff for advice regarding their work if they
needed it. The trust also held a complex cases clinic on a monthly basis where practitioners could
bring patients cases with whom they were struggling to the panel and they would offer advice and
support around how to manage the case. Staff had taken more complex cases to this panel and
found it to be helpful.
There was a budget available for staff to apply for specialist training relevant to their role. There
were two members of staff awaiting a start date for the non-medical prescribing course. Other
courses completed by staff in the teams we visited included a masters degree in dementia care at
the local university. Staff told us they were encouraged to develop their knowledge and skills
within the team and were supported to do so by senior staff.
Managers told us that they felt confident to manage staff who were underperforming on their
individual teams. There were no staff that were being performance managed at the time of our
inspection but managers were able to give us examples of when they had done this. They felt
confident they could manage with support from human recourses if necessary.
Most staff had received a recent appraisal which helped them to provide high quality care and help
develop them personally and professionally. The trust’s target rate for appraisal compliance is
90%. As at February 2018, the overall appraisal rates for non-medical staff within this core service
was 96%.
The rate of appraisal compliance for non-medical staff reported during this inspection was higher
than the 79% reported at the last inspection.
Team name
Total number of
permanent non-medical
staff requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an appraisal
% appraisals
Rapid Response 27 27 100%
Functional Intensive Comm Serv 16 16 100%
Edmund Road Central Admin 2 2 100%
CMHT Management 45 45 100%
Memory Service 29 24 83%
Core service total 119 114 96%
Trust wide 1495 1440 96%
The trust’s target rate for appraisal compliance is 98%. As at February 2018, the overall appraisal
rates for medical staff within this core service was 100%.
The rate of appraisal compliance for medical staff reported during this inspection was the same as
the 98% reported at the last inspection.
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Team name
Total number of
permanent medical staff
requiring an appraisal
Total number of
permanent medical
staff who have had
an appraisal
%
appraisals
CMHT Management 6 6 100%
Memory Service 4 4 100%
Rapid Response 1 1 100%
Core service total 12 12 100%
Trust wide 57 56 98%
The trust’s target for clinical supervision is 66%.
Between 1 March 2017 and 28 February 2018 the rate across all four teams in this core service was 59%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. The rate of clinical supervision reported during this inspection was lower than the 64% reported at
the last inspection.
Ward name Clinical supervision
sessions required
Clinical
supervision
sessions delivered
Clinical
supervision rate
(%)
Memory Service 131 110 84%
Older Adult Community Mental Health Teams 202 141 70%
Functional Intensive Comm Service 88 43 49%
Rapid Response 158 48 30%
Core service total 579 342 59%
Trust Total 3420 2183 64%
The trust’s target for clinical supervision is 66%.
Between 1 March 2017 and 28 February 2018 the clinical supervision rate for medical staff was 158%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. The rate of clinical supervision reported during this inspection was higher than the 64% reported at
the last inspection.
Ward name Clinical supervision
sessions required
Clinical
supervision
sessions delivered
Clinical
supervision rate
(%)
20171116 900885 Post-inspection Evidence appendix template v3 Page 144
Rapid Response 12 48 400%
Memory Service 24 24 100%
OA CMHT 12 4 33%
Core service total 48 76 158%
Trust Total 91 250 275%
Multidisciplinary and interagency team work
Each team had monthly team meetings that were structured and followed a set agenda. This
covered issues such as risk and governance. The teams were informed about any changes to the
service and feedback was given on incidents.
There were weekly meetings to discuss new referral and allocations for the teams. We observed
one of these meetings for each team and found them to be effective in discussing issues such as
risk and who would be the best practitioner for that particular patient.
The teams consisted of staff that carried out initial referral through to community mental health
teams, memory assessment, crisis care and intensive home treatment. Staff liaised with acute
hospital wards to provide ongoing support to patients being discharged from hospital. Staff within
teams had a shared understanding of each other’s roles and were committed to working together
to ensure patients’ needs were met. This helped to ensure patients were moved through the health
system and received care from the most appropriate team at any given time according to their
needs including when they were in mental health crisis. Staff linked in with the inpatient services
for people who had been admitted informally or detained under the mental health act.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
As of 28 February 2018, 100% of the workforce in this core service had received training in the
Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient
and all community staff and renewed every three years.
Staff were able to demonstrate knowledge regarding the Mental Health Act and the guiding
principles. Staff were aware of Community Treatment Orders and how they were implemented and
care planned.
Community Treatment Orders were not frequently used by the teams. There was only one patient
who was subject to a community treatment order and they had recently been recalled to hospital.
We found that all paperwork had been filled in and stored correctly in this case.
Staff could contact a central team to seek advice about the Mental Health Act. Staff knew how to
contact the team.
There was an independent mental health advocacy service available for patients who were
detained under the Mental Health Act. Staff were aware of the service and knew how to refer
service users.
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Good practice in applying the Mental Capacity Act
As of 28 February 2018, 93% of the workforce in this core service had received training in the
Mental Capacity Act Level 1 and 89% of the workforce had Mental Capacity Act Level 2. The trust
stated that this training is mandatory for all core services for inpatient and all community staff and
renewed every three years.
The training compliance reported during this inspection was higher than the 56% reported at the last inspection.
Patients of the community mental health teams for older adults were living in the community with a
degree of autonomy and patients' capacity was assumed unless it was indicated otherwise. Staff
had a very good understanding of the guiding principles of the Mental Capacity Act. We found
really good examples of where capacity had been considered and assessed in the care records.
We saw how staff had considered capacity on a decision specific basis for example around things
such as access to finances, moving home or agreeing to go into a care home. We saw evidence
that where patients were deemed to lack capacity to make a certain decision, staff were making
sure that best interest meetings had taken place and decisions were made in the best interest of
the patient.
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Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
We observed interactions between patients and staff on five home visits over the two teams. We
also made telephone calls to four patients and carers to ask questions about the team. Staff
showed a kind, compassionate attitude towards patients and their carers. During home visits we
saw staff displaying a genuine and caring attitude towards not only patients but their carers too.
For example, on one visit the patients’ carer had some additional needs that were not the
responsibility of the team. However, the team felt that it was important to ensure that the carer was
fully involved in decisions regarding their loved ones care and planning of how to break news such
as diagnosis with the carer present were well thought out before the visit went ahead. This meant
ensuring that members of other teams outside of the trust were present at the visit to give support
to the carer. On another visit the visiting nurse found that the patients dog was unwell on arrival.
Knowing how important the patients pet was to them in terms of alleviating symptoms of their
mental health problem the visiting team member went above and beyond the call of duty to ensure
that the dog was seen by a local vet in order to ensure the pet was cared for thus maintaining the
patient’s mental wellbeing. Staff had a very detailed understanding of the patients they were
providing care for and whilst maintaining professional boundaries ensured that these needs were
addressed and cared for in a sensitive, caring and empathetic way. Patients we spoke to
commented on this and told us that staff showed a genuine interest in them and their lives not just
their mental health diagnosis. For example, one patient used to enjoy swimming but was unable to
continue to go alone due to their diagnosis. The team arranged for a support worker to accompany
the patient to the local swimming baths to ensure their safety but to also maintain links with their
pre- diagnosis interests and hobbies.
All patients and carers gave universally positive comments about the team. Patients made
comments such as “she gave me a reason to live” and “I couldn’t have asked for anything more at
the worst time of my life”. Staff treated patients as individuals and applied a person centred
approach to their practice. Staff knew the patients extremely well. Staff listened to patients and
were sensitive to their needs establishing a good rapport.
All service user information was stored within the electronic recording system which was safe and
secure.
Involvement in care
Involvement of patients/ Involvement of families and carers
Every patient record we reviewed contained a person centred collaborative care plan. It was clear
that the patients’ voice was captured in the care plan and their views were taken seriously and
recorded accurately. Patients we spoke to told us they were actively involved in their care plans
and were always offered a copy. The trust used the collaborative care planning approach and this
documented the involvement the patient had in their care plan. This ranged from “I do not want to
be involved in this goal” to “I feel like I am taking a lead on my goal. I have written my goal and
practice the steps with very little input and support from staff”. This meant staff were aware of how
involved their patients were in care and could monitor this as an indication of the patient gaining
insight into their illness where possible.
All carers we spoke to were positive about the support they had received from the teams. During
our observed visits, we saw that staff were attentive to the carer’s needs as well as the patients.
Carers we spoke to told us that staff had “gone over and above” what they expected of them and
that they felt supported “all the way through the journey”. Carers were involved in care planning (if
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patients agreed) and this enabled the staff to understand the triggers for patients as well as what
helped to calm them down when agitated. Carers we spoke to told us that they felt their opinions
and views on the patient’s care were taken seriously and that they were able to be involved in
things such as care planning which made them feel a true partner in their loved ones care. Carers
told us that the team members were available when they needed them and not just during
appointments. There was a crisis phone line that patients’ carers could ring if they needed support
and advice at any given moment. Carers told us that crisis care plans which directed them to
particular services dependent on the time of day and the nature of the problem made them feel
more equipped to cope in times of a crisis.
There was an active service user group that was regularly attended by around 30 people. The
group had made decisions regarding the service and its development. For example, the group had
identified that the font on the letters sent out from clinic appointments was too small for them to
read. They had a discussion around the best size and colour and these changes were then
applied to clinic letters going forward. When the trust introduced its new vision, senior members of
the executive team at the trust came to the group to explain these to patients and take feedback
and comments on them. The group was named by the service users that attended and was called
“helping each other”. Guest speakers attended each meeting for example the fire service had
attended to give a talk about fire safety in the home, a group called boot camp who support people
if they have an issue in the local community such as street lighting or bin collections. Trading
standards had also attended to talk about new types of scams via email and mobile phones.
Carers and patients were also encouraged to attend a local dementia involvement group that was
organised in partnership with the Alzheimers Society. This was called Sheffield dementia
involvement group or “SHINDIG”. The group met four times per year and aims to encourage
people living with dementia and their carers to share views and opinions on local services and
developments within Sheffield.
Service users took part in interviews for new staff and this was sought via the trust who had a list
of service users who had been through training to assist with this.
Staff were aware of local advocacy services available to service users and carers. Staff knew how
to refer and signpost service users and carers to advocacy services. There was information about
the service displayed in the reception of the building. We saw evidence of when patients had
accessed advocacy for support. One example of this was to support a patient who was moving to
another area and did not have any family/friends to support them with this.
The service sought feedback from patients and carers via an exit questionnaire when patients
were discharged. The results of these were collated annually and discussed within team meetings
and governance meetings to allow staff to reflect and think of ways to improve.
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Is the service responsive?
Access and waiting times
Each team assessed service users referred to the service quickly as demonstrated in the figures
below. Patients who needed to be assessed more urgently could be seen the same or next day if
necessary. There was a triage system in place which meant that patients were contacted quickly
in case their situation had changed since referral.
Staff were able to respond quickly to telephone calls and patients and carers we spoke to reported
they were able to get hold of a member of the team quickly when they needed them. Appointments
ran on time and were not cancelled. Patients were offered appointments at times which suited
them and their carers in order for all people important to the patient could attend.
If patients were reluctant to attend or were difficult to engage with then staff would make several
attempts to visit, unplanned visits were carried out if required.
The trust has identified the below services in the table as measured on ‘referral to initial assessment’ and ‘assessment to treatment’.
Name of
hospital
site or
location
Name of
team
Days from referral to initial
assessment
Days from assessment to
treatment Comments,
clarification Target Actual
(mean)
Target Actual
(mean)
Fulwood
House
Older Adult
Community
Mental
Health
Teams
28 N/A N/A N/A
Urgent - 4 hours
Routine - 28days 92%
of referrals in the last
12 months have been
assessed within 21 to
28 days.
Fulwood
House
Dementia
Rapid
Response
and Home
Treatment
Teams,
Triage - 4 hours
Urgent - 24 hrs
routine - as
determined by
triage
N/A N/A N/A
Treatment starts at
point of assessment.
All targets met or
exceeded within last
12 months.
Fulwood
House
Functional
Intensive
Community
Service
(FICS)
Triage - 4 hours
Urgent - 24 hrs
routine - as
determined by
triage
N/A N/A N/A
Treatment starts at
point of assessment.
All targets met or
exceeded within last
12 months.
Fulwood
House
Memory
Service 42 N/A 56 N/A
The local target set for
referral to assessment
is 6 weeks. Local
target set for
assessment to
treatment is 8 weeks.
The service has met
this target over the
last 12 months, and
consistently exceeds
20171116 900885 Post-inspection Evidence appendix template v3 Page 149
Name of
hospital
site or
location
Name of
team
Days from referral to initial
assessment
Days from assessment to
treatment Comments,
clarification Target Actual
(mean)
Target Actual
(mean)
this target, able to
offer assessment
between 1 - 3 weeks
of referral as
standard. Note
patient choice is taken
into account when
offering appointments
and those outside of
the standard may be
due to specific
requests from patients
or carers.
The facilities promote comfort, dignity and privacy
The building had a full range of rooms to support care and treatment. This included a clinic room
where patients could be examined, interview rooms that were private with obscured glass and
conversations could not be overheard. There were also rooms that could be discreetly observed
by other staff if there was a known risk with a patient coming to the building. Staff told us that
rooms were always available when they needed them and they could use other floors of the
building if they needed to for example a bigger room or smaller room.
Staff were based in an open plan office with staff of different disciplines sitting together. Staff
reported they liked this as they could offer each other advice and support in an informal way if a
colleague wanted to discuss a patient. Senior members of the team also sat in the office so that
staff knew where they were and they were easily accessible by staff.
There was a wide range of leaflets on display for patients and carers who visited the service. This
included information about different mental health problems, local groups and clubs and
information about complaints and how to give feedback on the service. These were all specific to
older adults and included information about third sector organisations. Patients were given
information on how to complain and on local services when visited by community staff.
Patients’ engagement with the wider community
Staff supported and encouraged people to maintain contact with their families, carers and wider
networks where they wished to maintain this.
There were opportunities for people to engage with the wider community. Local groups included
‘singing for the brain’, where people with dementia and their carers can go and sing along to past
music as a form of reminiscence therapy. There was also a group at the local library where people
with dementia could go to do sport reminiscence. The local leisure centre had a bowling group that
some patients attended and there was also a local allotment that patients were able to attend.
Some of the patients took part in walking football which maintained a healthy lifestyle at a pace
that was manageable for patients with reduced mobility. The teams were also flexible in the way
they worked with patients and would try and tailor therapies to meet patients’ interests. Examples
of this included taking patients to the local swimming baths. The team had recognised that the
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need to reach out to male older adults and had sought out a local ‘men’s shed’ group where men
could go and connect with other men whilst being creative and reducing isolation.
There was a local dementia involvement group named SHINDIG (Sheffield Dementia Involvement Group). The group was organised by the Trust in partnership with Sheffield Alzheimer’s Society. The group met quarterly and the focus of the forum was to provide opportunities for people living with dementia in Sheffield (and their family carers) to share ideas, views and opinions on local services and developments.
Meeting the needs of all people who use the service
The service was able to accommodate people’s differing levels of need. There was a slope to enter the building, accessible toilets and there was a stair lift down to the bottom floor. There was dementia friendly signage around the building and there was welcome information displayed in different languages relating to the most relevant languages in the local area.
Staff had access to interpreters and signers to help enable effective communication with people
where required. Staff could undertake assessments gradually and over several sessions to help
allow for extra time where people may have additional communication needs.
The teams had tried hard to reach out to hard to reach communities. They had attended groups for
the South East Asian community, the Chinese community and the Somalian community. During
these meetings staff from the teams had spoken to the attendees about mental health and what
the team could offer in terms of support. They had taken interpreters with them in order to support
communication.
Listening to and learning from concerns and complaints
All patients and carers we spoke to told us that they felt comfortable raising any issues they had
with their named member of staff in the first instance. Although they all knew how to complain,
they said they had not had any reason to do so. Service users and carers felt that any complaint
would be addressed appropriately. Staff were aware to raise any complaint to the team manager.
Managers told us they would try and resolve any complaint informally before the formal complaints
procedure. Staff knew there was a complaints leaflet to inform service users and carers of the
complaints.
We were able to see where the team managers reviewed feedback received from patients and
carers. Even though feedback forms were completed anonymously there was space to leave a
name and contact number/address if they wanted feedback from an issue they raised. We were
able to see responses that had been sent out to patients who had done this. The team managers
reviewed all feedback questionnaires annually and used the data to present at the team meetings
to show any themes or trends occurring over the year.
There were low numbers of complaints made by patients and cares. Managers were committed to
looking at complaints and learning lessons. This core service received seven formal complaints
between 1 March 2017 and 28 February 2018. None were upheld and three were partially upheld.
No complaints were referred to the Ombudsman. Three complaints are under investigation and
two complaints were related to patient care.
The number of either partially or fully upheld complaints reported during this was lower than the 23 reported at the last inspection.
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Total
Complaints
Fully
upheld
Partially
upheld
Not
upheld
Referred to
Ombudsman
Upheld by
Ombudsman
7 0 2 1 No No
This core service received 64 compliments during the last 12 months from 1 March 2017 and 28
February 2018, which accounted for 10% of all compliments received by the trust as a whole.
During our inspection, we saw lots of examples of compliments to the service displayed
throughout the building in the form of letters and cards from people wanting to show their gratitude
to the service for the care they received.
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Is the service well led?
Leadership
The teams were managed and overseen by experienced professional nursing staff who had
worked there for a number of years.
There had been no staff surveys that directly related to this core service.
Sickness and absence rates were low across the service. Sickness was not due to work related
stress and managers had good oversight of the sickness levels within their teams. Managers used
the trust policy to manage staff who were having higher levels of sickness and felt confident to do
so. There had been no bullying or harassment cases within the service in the last 12 months.
Managers were able to tell us how they would manage this with support from human resources if
needed.
Staff we spoke to were aware of the whistleblowing policy and were able to describe the process
well. Staff felt confident to raise concerns initially with their manager without fear of victimisation.
Staff stated they regularly raised concerns during team meetings and other forums.
There were opportunities for leadership development. The senior members of the team had
completed leadership training and courses around sickness absence and performance
management. Staff reported being encouraged by their managers to attend training courses
outside of mandatory training.
Both teams we visited reported excellent team working and mutual support. Staff were supportive
of each other and valued each other’s contribution.
Staff were aware of the duty of candour policy and were able to describe situations where they
have needed to apologise to service users. Staff confirmed they used an open and transparent
approach when addressing these issues.
Vision and strategy
Most staff we spoke to could tell us about the trust values. These were very similar to the team
vision and values. The values were within the appraisal process so that staff aligned their work
ethics to the trust values.
Senior members of the team felt supported by more senior managers and told us how most of
them had worked in less senior positions within the trust prior to promotion. Less senior staff did
not feel they saw a lot of senior level staff above their own team managers but they felt confident if
they wanted to speak to them this would be easy to arrange.
Culture
During the reporting period, there were no cases where staff were either suspended, placed under supervision or were moved to a different ward.
Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these should be noted.
Morale and staff motivation was high throughout the whole service. All staff we spoke with were
positive about their role and the service they provided. They showed a commitment and dedication
to supporting patients. There was a strong culture of team work and staff worked collaboratively
with each other and partner agencies. Staff morale was positive and the trust was considered to
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be a good employer. Staff development was encouraged and discussed during supervision and
appraisal sessions.
Staff respected managers and told us they felt supported. Staff were able to raise concerns
without fear of victimisation and knew how to use the trust whistle blowing process. There was an
open and honest culture and a positive environment for learning from incidents and complaints.
Staffs hard work and successes were recognised. This was through positive feedback in one to
one supervision sessions and through staff awards.
Governance
Mandatory training was all above the trust target of 80% for this core service at the time of
inspection. Managers were able to view their teams training status at a glance on the electronic
system that collates the information. Staff were responsible for booking their own training but
managers would prompt at supervision and team meetings if necessary. Staff had access to the
electronic training record and could check and book training modules.
Team managers were able to monitor compliance with appraisal and supervision. This was done
via the introduction of a new electronic recording system. Prior to this recording was done via
paper records and there was nowhere to record if supervision was managerial or clinical. The new
electronic system allowed managers to see at a glance who had accessed supervision and
whether this was managerial or clinical. As most staff had the same person for managerial and
clinical supervision this was usually done as a joint session. However, staff were able to request a
person from outside of their own team for clinical supervision if they preferred, staff were aware of
this but all were happy to have supervision with the person who carried out managerial
supervision.
Staff knew how to report adverse incidents and received feedback on learning from incidents.
Learning was communicated to staff in team meetings and in governance meetings so that
learning could be shared and feedback received. The senior team members of all community
teams attended the governance meetings and therefore learning from other teams could be
cascaded through this meeting.
Team managers had sufficient authority to manage their teams and were well supported by senior
management. There was a commitment to personal development. Staff had accessed specialised
training and managers had access to leadership training.
Management of risk, issues and performance
Team managers were able to add items directly to the trust risk register. They were also aware of
how to escalate a concern through the line management and governance structure if this was
required. Risks were discussed at locality and service level governance meetings.
The building manager was responsible for ensuring that health and safety checks were carried out
as well as managing the risk to the building. This included fire safety checks, legionella checks
and weekly monitoring of emergency alarms. The service had a business continuity plan. This
provided guidance for staff in the event of scenarios such as a building service failure, infectious
disease outbreak, loss of staff or premises, and technological failure
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Information management
Staff had access to the equipment and information they required to do their job. Care records were
captured on an electronic system available to all staff. The service submitted notifications to
outside agencies as required.
Engagement
There was a trust intranet which provided staff with the latest news from around the trust and a
central system which contained policies and procedures. The trust also had a public facing
website which provided staff, patients, carers and members of the public with information on the
trust.
The service gathered feedback from patients and carers via exit questionnaires sent out on
discharge from the service. The team managers collated this evidence and provided feedback to
patients and carers if they chose to leave their contact details. On an annual basis, the team
managers collated the feedback they had received and used this to pick out themes and trends
that were emerging from feedback, this was presented to the team during meetings.
Learning, continuous improvement and innovation
NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.
There were no accreditations for this core service. However, the teams had begun looking into accreditation schemes relevant to their service and were using the benchmarking criteria to improve the work they do.
Student nurses as well as students from other disciplines did placements at the service. Feedback
received from them was positive and students reported enjoying their placements with the team. .
Staff completed mentorship training or associate mentor training in order to support student nurses
and keep up to date with the current curriculum. Staff gave positive feedback about having student
nurses and felt they were a valuable part of the team.
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Mental health crisis services and health-based places of safety
Facts and data about this service
Location site name Team name Number of clinics Patient group (male,
female, mixed)
The Longley Centre 136 Suite / Maple
Ward N/A Mixed
Fulwood House Liaison and
Diversion Service
Not clinic based.
Responds to what’s
presented via court/police
etc.
Mixed
Fulwood House
Liaison
Psychiatry
Service
16 Mixed
Fulwood House Out of Hours N/A N/A
Fulwood House Single Point of
Access
Crisis (unplanned)
assessments only N/A
Fulwood House Central AMHP
Team MHA assessments only N/A
Under our methodology for inspecting community services, we inspect a third of all sites registered under NHS trusts. There were six services registered under Sheffield Health and Social Care NHS Foundation Trust’s Crisis and health based place of safety so we inspected two sites covering three teams. These were the single point of access and emotional wellbeing team, the out of hour’s team both based at Netherthorpe House and the health based place of safety at the Longley Centre. The trust has one health based place of safety.
Sheffield Health and Social Care NHS Foundation Trust provide a crisis and out of hours service to people living in Sheffield. The single point of access dovetails with the out of hours service, creating a single point of referral 24 hours a day, seven days a week to people who are between 18 and 65 years of age and who are registered with a GP practice in the city of Sheffield.
The single point of access and emotional wellbeing team carried out triage, crisis assessment, routine assessments and brief interventions. Staff are co-located with out of hours staff and the citywide approved mental health practitioner service and work closely with the home treatment service and liaison psychiatry service.
Referrals are accepted from GPs or other clinical teams within Sheffield Health & Social Care NHS Foundation Trust. Referrals could also be accepted from other health or social care professionals, housing, voluntary sector, relatives and by self-referral. This inspection was unannounced, which meant that staff did not know we were coming to inspect the service. However, before the inspection visit, we reviewed information that we held about the services. We last undertook a comprehensive inspection of the crisis and health based place of safety in November 2016. At that inspection, we rated the services overall as requires improvement. We rated the key questions safe and well led as requires improvement and effective, caring and responsive as good.
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Is the service safe?
Safe and clean environment
Staff did regular risk assessments of the environment. Assessments were in place for both
premises; these were comprehensive and covered all areas.
Interview rooms at Netherthorpe House did not have alarms. However, staff were provided with
personal alarms to take into interview rooms. Staff in the main office were able to respond to
alarms and assessments were done in pairs if risks were high. There were no clinic rooms.
All areas were clean, tidy, and well maintained. Cleaning staff worked daily and cleaning
schedules were in place. The waiting room was small but well maintained with drinking water
facilities.
Staff adhered to infection control procedures. Hand sanitising gel was available throughout the
building and there were washing facilities available. Equipment was well maintained and clean.
The service ensured security processes were followed at all times. All visitors to the services were
required to sign in and out and provide personal identification. However, the door at Netherthorpe
House, which led from reception to the clinic rooms, was faulty and so did not always close. The
manager had reported this to estates.
The health-based place of safety was on Maple ward at the Longley Centre. There was access to
the ward but this was managed by staff. The health-based place of safety met the national
standard. Alarm systems were in place. The room had adequate lighting; there was a bed, a
television, access to food and drinks and a toilet and ensuite shower.
Safe staffing
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 January 2018 90.4 N/A
Total number of substantive staff leavers 1 February 2017 – 31 January 2018
1.8 N/A
Average WTE* leavers over 12 months (%) February 2017 – 31 January 2018
2% 13%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31 March 2018 9 N/A
Total vacancies overall (%) At 31 March 2018 9% N/A
Total permanent staff sickness overall (%) Most recent month (At 31 January 2018)
7% 5%
1 February 2017–31 January 2018
4% 5%
Establishment and vacancy (nurses and care assistants)
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Establishment levels qualified nurses (WTE*) At 31 March 2018 64 N/A
Establishment levels nursing assistants (WTE*) At 31 March 2018 12 N/A
Number of vacancies, qualified nurses (WTE*) At 31 March 2018 5 N/A
Number of vacancies nursing assistants (WTE*) At 31 March 2018 3 N/A
Qualified nurse vacancy rate At 31 March 2018 8% -
Nursing assistant vacancy rate At 31 March 2018 25% -
Bank and agency Use
Shifts bank staff filled to cover sickness, absence or vacancies
(Qualified nurses) 1 March 2017- 28
February 2018 61 N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses) 1 March 2017- 28
February 2018 0 N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses) 1 March 2017- 28
February 2018 9 N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 March 2017- 28
February 2018 16 N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 March 2017- 28
February 2018 0 N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants) 1 March 2017- 28
February 2018 3 N/A
*Whole-time Equivalent
This core service reported an overall vacancy rate of 8% for registered nurses at 31 March 2018. The vacancy rate for registered nurses within this service was above the trust average for 11 of the 12 months. Between April 2017 and March 2018, the vacancy rate reduced from 23% to 8%; although the lowest rate was in August 2017 at 3%.
The vacancy rate for registered nurses was lower than the 16.6% reported at the last inspection.
This core service reported an overall vacancy rate of 25% for registered nursing assistants at 31 March 2018. Between April 2017 and March 2018, the vacancy rate reduced from 56% to 25%; for all months, this was above the trust average, which lay between 1% and 8%.
The vacancy rate for nursing assistants was higher than the 0% reported at the last inspection.
This core service has reported a vacancy rate for all staff of 9% as of 31 March 2018; the trust does not have a target vacancy rate. This is lower than the rate of 15.5% reported at the last inspection (as of 31 July 2016). Between April 2017 and March 2018, the vacancy rate reduced from 28% to 9%; for all months, this was above the trust average, which lay between 3% and 5%.
Registered nurses Health care assistants Overall staff figures
Team
Vacan
cies
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Out of Hours
Service
2 15 13% 0 0 - 2 15 13%
Liaison
Psychiatry
1 25 4% 2 7 29% 5 41 12%
Liaison &
Diversion
1 5 20% 0 2 0% 1 9 11%
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Registered nurses Health care assistants Overall staff figures
Service
SPA/Emotio
nal
Wellbeing
1 19 5% 1 3 33% 1 38 3%
Core
service total
5 64 8% 3 12 25% 9 103 9%
Trust total 32 433 7% 15 353 4% 68 1339 5%
NB: All figures displayed are whole-time equivalents
Between 1 March 2017 and 28 February 2018, bank staff filled 61 shifts to cover sickness, absence, or vacancy for qualified nurses.
In the same period, no shifts for qualified nurses were covered by agency staff. Nine shifts were unable to be filled by either bank or agency staff.
Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by
bank or agency staff
Liaison
Psychiatry
Service
825 44 (5%) 0 (0%) 7 (<1%)
Out of Hours -* 17 0 2
Core service
total 825 61 0 9
Trust Total 32394
4977
(15%)
1629
(5%)
900
(3%)
*The Trust did not provide total shift data for this team so percentages cannot be calculated
Between 1 March 2017 and 28 February 2018, 16 shifts were filled by bank staff to cover sickness, absence, or vacancy for nursing assistants.
In the same time, no shifts for nursing assistants were covered by agency staff. Three shifts were unable to be filled by either bank or agency staff.
Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by bank
or agency staff
Liaison
Psychiatry
Service
238 0 (0%) 0 (0%) 0 (0%)
Out of Hours -* 16 0 3
Core service
total
238 16 0 3
Trust Total 59514 21770 (37%) 5623 (9%) 1760 (3%)
*The Trust did not provide total shift data for this team so percentages cannot be calculated
Team Substantive staff
Substantive staff Leavers Average % staff leavers
Liaison Psychiatry 38.2 1.8 5%
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Liaison & Diversion Service 8.0 0 0%
Out of Hours Service 12.9 0 0%
SPA/Emotional Wellbeing 31.4 0 0%
Core service total 90.4 1.8 2%
Trust Total 1351.6 129.6 8%
The sickness rate for this core service was 4% between 1 February 2017 and 31 January 2018.
This was lower than the sickness rate of 8% reported at the last inspection as of 31 July 2016.
Team Total % staff sickness
(at latest month)
Ave % permanent staff
sickness (over the past year)
SPA/Emotional Wellbeing 10% 8%
Liaison & Diversion Service 14% 5%
Liaison Psychiatry 5% 3%
Out of Hours Service 0% 2%
Core service total 7% 4%
Trust Total 8% 7%
The trust felt that staffing numbers had not been calculated correctly during the reconfiguration.
Senior managers were currently addressing this by reviewing the service. Staff were struggling to
deal with the volume of calls to the crisis service. The service was unable to monitor the volume of
calls and so it was unclear how many people had not been able to access the service. The single
point of access/emotional well-being team had been operational since January 2018. The staff
worked across the two teams on a rotation basis. Staff in the single point of access took crisis calls
and carried out triage and emergency assessments. Staff in emotional well-being carried out
routine assessments and offered brief interventions. There was not enough administrative
resource to support the team and the volume of referrals. The admin team were going through a
reconfiguration so that the support to the team could be increased.
Managers assessed the size of caseloads and staff carried a maximum of 20 patients. However,
staff reported that they were often asked to assist the single point of access to deal with the
volume of calls. There were issues with staff sickness and people leaving the team due to work
related stress. Some staff felt that the role was not what the trust had described during the
reconfiguration. During the reporting period, staffing figures show low vacancy and sickness, rates.
However, the figures are taken from before the reconfiguration. The manager confirmed that there
were two full time nurses on long term sick. Two admin staff were on sick leave and there were
two agency social workers.
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The out of hour’s team was fully staffed and any sickness was managed with staff working extra
shifts if required. The team took over the crisis function after 5pm and carried out the single point
of access function from 5pm until 8 am. Street triage workers were also part of this team.
Staffing the health-based place of safety led to capacity issues on Maple ward. The health based
place of safety was part of Maple ward. A band five nurse was available on each shift to cover the
health based place of safety. However, the health based place of safety was receiving a high
number of people detained under section 136 of the Mental Health Act.
A full time psychiatrist and two locums were based at Netherthorpe House, which gave patients
access to medical appointments. The out of hour’s service could access the on call consultant.
Mandatory training
The compliance for mandatory and statutory training courses at 28 February 2018 was 87%. Of the training courses listed, six failed to achieve the trust target and all six failed to score above 75%.
At a team level the Liaison Diversion Service (97%), Liaison Psychiatry Service (92%) and Out of Hours team (88%) all met the Trust Target. The Single Point of Access/Emotional Wellbeing Service completion rate was below the trust target of 80% at 76%. The manager at the single point of access and emotional well-being service thought there were some inaccuracies in the data. They believed that more staff had completed training and this was being addressed. Staff had not received immediate life support training, however the service were not administrating any medication and the service did not have a clinic room. Staff from Maple ward had received training as they worked in the health based place of safety.
This training data is reported based on compliance at the last day of the month, on a month-by-month basis. The training compliance reported for this core service during this inspection was higher than the 74% for the previous 12 months.
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service
Trust target % Trustwide mandatory/ statutory training total %
Fire Safety 2 years 100% 80% 96%
Rapid Tranquilisation 100% 80% 88%
Mental Capacity Act Level 1 95% 80% 94%
Fire Safety 3 years 94% 80% 96%
Health and Safety (Slips, Trips and
Falls) 94% 80% 97%
Medicine management training 93% 80% 87%
Clinical Risk Assessment 93% 80% 91%
Hand Hygiene 93% 80% 94%
Equality and Diversity 93% 80% 95%
Autism Awareness 93% 80% 88%
Mental Capacity Act Level 2 91% 80% 85%
Safeguarding Children (Level 3) 90% 80% 91%
Respect Level 2 89% 80% 80%
Safeguarding Adults (Level 2) 84% 80% 87%
Domestic Abuse Level 2 82% 80% 85%
Dementia Awareness (inc Privacy &
Dignity standards) 80% 80% 85%
Adult Basic Life Support 74% 80% 81%
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Training course This core service
Trust target % Trustwide mandatory/ statutory training total %
Information Governance 73% 80% 80%
Mental Health Act 67% 80% 83%
Safeguarding Children (Level 2) 61% 80% 85%
Respect Level 1 53% 80% 66%
Core Service Total % 87% 88%
Assessing and managing risk to patients and staff
Assessment of patient risk
Staff did a risk assessment for every patient. These were completed during initial triage and
updated with any incidents or contacts with the service. We reviewed 20 patient records. We found
that all records contained a current risk assessment.
The trust used a national risk assessment tool, which was comprehensive and fit for purpose. The
detailed Risk Assessment and Management plan recorded each patient’s history and included
templates for making referrals to GPs and other health professionals. The tool included the
patient’s risk to themselves and others, details of any self-neglect, risk of exploitation and risks to
dependants as well as others.
All service users had a triage completed by the single point of access team. This included a
summary of their presentation and current risks as part of the initial action plan. The triage
document pulled information together in an easily accessible format. However, some staff felt that
they were not given enough time to fully understand the triage information before completing an
assessment. There had been a significant increase in referrals to the team and a new system had
been introduced which meant that routine assessment appointments were offered each morning at
9.30 and 11.00. There were high rates of people not attending for appointments and the trust had
introduced a double-booking system. Staff felt that this was unsafe as if both patients attended
then one would be allocated to another team member. This meant that staff could be assessing a
patient they knew very little about. Managers were available each morning to help staff prepare
for assessments.
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. Referrals were passed to the team through a dedicated mailbox, this was checked
daily. The out of hours service took over the crisis calls from 5pm and carried out triage and
assessments either over the phone or face-to-face. The out of hour’s service staff updated any
existing risk assessments or created new ones if required.
Joint risk assessments were carried out between the police and nursing staff at the health based
place of safety. The police would stay if risks were deemed significant. A standard operating
procedure had been introduced to ensure that everyone admitted had physical health observations
recorded. A safety checklist of all the actions that must happen when a person was admitted was
in place. The last inspection identified a number of issues in the recoding of patients detained at
the health based place of safety and improvements had been made.
Management of patient risk
Staff were responding promptly to deterioration in patients’ health and were triaging and assessing
urgent referrals within four hours. However, there were currently 400 people on a waiting list at
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Netherthorpe House. The waiting list had been inherited from the reconfiguration when the teams
reduced from four to one. There were 1000 people on the list when the team became operational
in January 2018. Patients had been triaged and sent letters to tell them they were on the waiting
list and given phone numbers of services to contact if in further crisis. Multi-disciplinary meetings
were taking place weekly to review the waiting list. If there had been no further contact then the
referral was closed and a letter sent to the patient. The service worked closely with GPs who were
also sent letters to say if a patient had been closed.
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. One patient
had been waiting 10 days. We reviewed five of these records. In one record, a mental health
assessment had been attempted. In one record, the recovery team had recorded that the patient
had refused medication but that no further attempt to contact the patient had been made. The
reasons for delay in assessment were documented as a lack of available beds, lack of police
support and approved mental health practitioner availability. The trust did not use out of area
mental health beds. We reviewed incidents at Netherthorpe House from March – June 2018 and
found that out of 26 incidents 16 related to a delay in a Mental Health Act assessment. Managers
were aware of the issues and these were contained within the risk register. Bed managers were
making decisions about the priority for assessments and there was support from managers within
the team. The approved mental health practitioner team had been centralised as part of the
reconfiguration. The team were located at Netherthorpe House. Daily meeting took place to review
patients on this list. However, there was a disconnect between what staff and managers were
saying. Senior managers felt that the risks were being appropriately managed but staff felt that the
process was very unsafe.
Patients brought into the health place base of safety were managed on an individual basis. The
police would stay if the risks were deemed high. There had been four incidents’ during May 2018
where the health based place of safety had been closed to accommodate a patient admitted on to
the ward. A protocol was in place which clearly stated what staff must do if this occurred. The
protocol ensured that senior managers and the police were involved in the decision to close the
health based place of safety.
Lone working procedures and policies were in place. Staff would carry out assessments in pairs if
risks had been identified. The out of hour’s team would arrange any face-to-face assessments
when the night shift staff arrived so that staff were not working alone.
Safeguarding
A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include physical, emotional, financial, sexual, neglect and institutional.
Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.
This core service made no safeguarding referrals between 1 February 2017 and 31 January 2018. However, this data was taken from before the reconfiguration. We requested further data and found that the service made five referrals between 1 February 2018 and 31 July 2018. Any safeguarding concerns were discussed with the Safeguarding Manager within the trust. This
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process was in place to provide oversight of the safeguarding process and outcomes of any concerns.
Staff were up to date with safeguarding level one training for adults and children. Some staff were waiting to access level two. They knew and understood their responsibilities around safeguarding.
Staff could give examples of how to protect patients and could identify possible reasons why adults and children could be at risk.
Sheffield Health and Social Care NHS Foundation Trust has submitted details of zero serious case reviews commenced or published in the last 12 months (1 March 2017 and 28 February 2018) that relate to this core service.
Staff access to essential information
The trust used an electronic patient record system. The system was easy to use and patient
records could easily be found. The system was used across all trust services so patient’s records
could be shared across different teams.
Staff at the health-based place of safety had a new tablet to use during assessments. This meant
that they had access to a patient’s record while off the ward and could update records.
Medicines management
Medication was managed through agreement with a patient’s own GP. Psychiatrists prescribed medication and this was managed locally with GPs and pharmacist. There were good working relationships between the two.
Track record on safety
Providers must report all serious incidents to the Strategic Executive Information System (STEIS) within two working days of an incident being identified.
Between 1 March 2017 and 28 February 2017 there was one STEIS incidents reported by this
core service. This incident was categorised as an ‘Apparent/actual/suspected homicide’.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS.
The number of serious incidents reported during this inspection was similar to the two reported at the last inspection between April 2015 and March 2016.
Number of incidents reported
Type of incident reported on STEIS Liaison Psychiatry Total
Apparent/actual/suspected homicide 1 1
Total 1 1
Reporting incidents and learning from when things go wrong
The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths.
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In the last two years, there have been zero ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.
The trust had an electronic system to report incidents. Staff could describe how to complete an incident form. We reviewed 12 incidents at the health-based place of safety and found that these had been investigated and findings were shared with staff. Changes were been made to the environment at the health based place of safety in response to incidents. We saw that staff had been debriefed after a serious violent incident. Relationships with the police had also improved after the incident was discussed at the joint liaison meeting where lessons were shared and learnt.
We reviewed 26 incidents at Netherthorpe House and found that these were also investigated. We saw that where there were recurring issues such as problems with the telephone system these had been placed on the risk register.
Staff had the option for incidents to be sent to other relevant people within the trust. This could include senior managers or safeguarding leads. Incidents were monitored through the trust governance meetings.
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Is the service effective?
Assessment of needs and planning of care
Staff completed a comprehensive mental health assessment of each patient. We looked at 10
patient records at Netherthorpe House and found that all had received a full mental health
assessment.
Staff had close links with GPs and were aware of medications and health issues. The service did
not have the facilities to carry out physical healthcare checks.
Staff described how they were working with patients to identify their needs. Patients were offered
three sessions, which covered an assessment and two brief interventions. However, none of the
records reviewed contained a written care plan.
Staff did not always know the patients background and full risk assessment when completing an
assessment. The service had introduced a new system for booking appointments, which meant
that staff did not always have time to read patients notes. Managers had offered to help with this
by pulling together a summary for each patient due to be seen that day.
We observed three assessments where staff had to apologise for not knowing the patients full
background. Staff expressed frustration on the system, which they often found unsafe.
In the 10 records reviewed at the health-based place of safety, we found that patients were being
assessed and were receiving physical health checks. However, there were some incomplete 136
records where physical health and observations had not been recorded. Managers were
monitoring issues through a monthly audit of the records. Managers had introduced new
processes to ensure that staff were recording correctly. The team had made significant progress in
terms of recording since the last inspection.
There had been 165 detentions into the health-based place of safety in the last six months.
December 2017 20
January 2018 17
February 2018 23
March 2018 42
April 2018 21
May 2018 42
It was acknowledged that this number was high and that the reasons were not fully understood.
The trust was investigating this since it was expected street triage should reduce the number of
detentions. There had been a total of 504 street triages in the previous six months. Police officers
were now calling ahead to the health-based place of safety to discuss patients and where possible
were utilising street triage.
Best practice in treatment and care
Patients were having an assessment of their needs and interventions were being delivered Staff
were providing crisis interventions that involved an assessment and two brief interventions.
Patients had access to medication through the consultant who worked closely with GPs. Patients
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had access to psychological therapies. The service worked closely with GPs to ensure that
patient’s physical health needs were being met. However, staff felt that three appointments limited
the work they could do with patients. Services in the community had reduced so signposting was
not always an option. We were given an example of where the recovery team had declined a
referral, as the patient was not ready for recovery. The worker then had nowhere to refer the
patient for extra support. Housing and employment issues were being discussed and support
offered from the teams support worker. However, this was one post and staff felt that they could
not always cover all aspects of housing and employment during three sessions.
Monthly audits were being carried out at the health based place of safety. These assisted the
manager to deal with any issues in terms of recording. However, staff at Netherthorpe House were
not participating in benchmarking and quality improvement.
This core service participated in the following clinical audits as of their clinical audit programme in
the 12 months leading up to the submission of the provider information return.
Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
Collaboration
with Primary
Care Clinicians
Service users
on CPA
Provider
wide Clinical on-going
Changes made following
previous audit round:
provide guidance to staff
on annual reviews of care.
Changes to care plan form.
Creation of a 'clinical
review for GP' IT system
solution.
Record keeping
audit 2016/2017 Trust wide
Provider
wide Clinical on-going
From data collected so far:
Further clarity provided to
staff on use of
abbreviations - to be
incorporated into the
relevant policy.
Audit of risk
assessments
2016/2017
Trust wide Provider
wide Clinical audit March 2017
Local action plans to
address identified issues.
Audit tool to be revised to
give clearer results.
Re-audit to be undertaken
in 2017/18.
Audit of risk
assessments
2017/2018
Trust wide Provider
wide Clinical audit ongoing Await findings
Audits of care
plans Trust wide
Provider
wide Clinical audit
January
2018
Agreed need for frequent
small scale audits.
Findings being shared with
teams.
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG43
Transition from
children’s to
adults’ services
Trust wide Provider
wide Clinical audit June 2017
Findings fed into
Commissioning for Quality
and Innovation and other
related joint work with child
and adolescent mental
health services to improve
transitions
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for young
people using
health or social
care services
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG13
Workplace
health:
management
practices
Trust wide Provider
wide Clinical audit
September
2017
Review practices against
guidance as necessary in
future
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG58
Coexisting
severe mental
illness and
substance
misuse:
community
health and
social care
services
Trust wide Provider
wide Clinical audit
December
2017
Action plan under
development
Skilled staff to deliver care
All services had a full range of specialists within the teams including psychiatrists, psychologists,
nursing staff, support workers, occupational therapists, and social workers.
Staff were experienced, qualified and had the necessary skills to deliver effective care and
treatment to meet the needs of their patients. Staff had completed mandatory training although
there were capacity issues at Netherthorpe House where staff felt that they were unable to access
specialist training for their individual role. Staff had been given an induction into the new team but
felt that this did not reflect the roles they were now doing.
Managers provided staff with supervision and appraisals. The trust’s target rate for appraisal
compliance is 90%. As at 31 January 2018, the overall appraisal rates for non-medical staff within
this core service was 98%.
The rate of appraisal compliance for non-medical staff reported during this inspection was higher
than the 79% reported at the last inspection.
Team name
Total number of
permanent non-medical
staff requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an appraisal
% appraisals
Liaison Psychiatry 36 36 100%
Out of Hours Service 15 15 100%
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Team name
Total number of
permanent non-medical
staff requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an appraisal
% appraisals
SPA/Emotional Wellbeing 33 34 97%
Liaison & Diversion Service 7 8 88%
Core service total 93 91 98%
Trust wide 1440 1495 96%
The trust’s target rate for appraisal compliance is 90%. As at 31 January 2018, the overall
appraisal rates for medical staff within this core service was 100%.
No data for the rate of appraisal compliance for medical staff was reported at the last inspection.
Team name
Total number of
permanent medical staff
requiring an appraisal
Total number of
permanent medical
staff who have had
an appraisal
%
appraisals
Liaison Psychiatry 5 5 100%
SPA/Emotional Wellbeing 3 3 100%
Core service total 8 8 100%
Trust wide 56 57 98%
The trust’s measure of clinical supervision data is sessions delivered with a target of 66%.
Between 1 March 2017 and 28 February 2018 the average rate for non-medical staff across all four teams in this core service was 94%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it is important to understand the data they provide.
The rate of clinical supervision reported during this inspection was higher than the 60% reported at
the last inspection.
Team name Clinical supervision
sessions required
Clinical
supervision
delivered
Clinical
supervision rate
(%)
Liaison & Diversion Service 48 48 100%
Liaison Psychiatry 310 308 99%
SPA/Emotional Wellbeing 28 32 88%
Out of Hours Service 135 107 79%
Core service total 525 491 94%
Trust Total 3420 2183 64%
Between 1 March 2017 and 28 February 2018 the rate for medical staff in this core service was 25%, all staff were within the Liaison Psychiatry team.
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Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it is important to understand the data they provide.
Team name
Clinical supervision
sessions required
Clinical
supervision
delivered
Clinical
supervision rate
(%)
Liaison Psychiatry 12 48 400%
Core service total 12 48 400%
Trust Total 91 250 36%
Multidisciplinary and interagency team work
Multidisciplinary team meetings at Netherthorpe House were well attended but their effectiveness
was limited. Netherthorpe House held multidisciplinary meetings every Tuesday and Thursday
morning. There was no clear focus. Some patients discussed had not been seen by the staff
discussing them. Staff were often unable to attend multidisciplinary meetings due to the
introduction of new assessment times. However, there was close working with the Home
Treatment Team and joint assessments were available to patients. The out of hour’s team started
at 4pm to allow for a handover period from the single point of access.
Staff at the health based place of safety worked closely with the police, approved mental health
practitioner service, and ambulance service. Joint police liaison meetings took place and were well
attended by all agencies. Relationships were improving with the police who were now calling the
ward to discuss a patient before bringing them to the health-based place of safety.
Joint liaison meetings took place each quarter. The aim of the group was to ensure good
coordination and dialogue between statutory agencies who share functions and responsibilities
under the Mental Health Act 1983. The group was well attended and included representatives from
all agencies including the police, ambulance, local authority, acute hospital, and the trust.
Discussions took place around the health based place of safety, street triage and incidents on
inpatient wards requiring police attendance.
The trust was working closely with South Yorkshire police around training on knowledge and skills
when dealing with a mental health issue. The training had allowed both trust staff and police
officers the opportunity to learn about each other roles and responsibilities.
Figures showed that December 2017 – May 2018 165 people had been detained under section
136 of the Mental Health Act, in the health based place of safety. The service felt that this was
high and discussions had started take place to identify possible reasons.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
As of 28 February 2018, 67% (two out of the three) of the eligible workforce had received training in the Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient and all community staff and renewed every three years.
The training compliance reported during this inspection was higher than the 31% reported at the last inspection.
Staff had a good understanding of the Mental Health Act. Care and treatment was discussed with patients. Staff had access to administrative support and legal advice on the implementation of the
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Mental Health Act and its code of practice. Staff knew who their Mental Health Act administrators were. Policies and procedures were available.
However, the trust was not managing Mental Health Act assessments. Anyone identified as needing a Mental Health Act assessment was referred to the service at Netherthorpe House. At the time of the inspection, the trust had 13 people awaiting a Mental Health Act assessment. Bed managers monitored the list daily and senior managers were available for support.
Patients detained at the health-based place of safety had their rights explained to them and this was audited monthly. Patients had access to independent mental health advocacy services.
The health-based place of safety safely stored detention paperwork, consent to treatment forms, approved mental health professional reports, and second opinion approved doctor reports. Copies of Mental Health Act documentation were scanned onto the electronic patient care record, which meant all staff could access them when needed.
Good practice in applying the Mental Capacity Act
As of 28 February 2018, 95% of the eligible workforce had received Level 1 Mental Capacity Act
training and 91% of those eligible had received Level 2 training. The trust stated that this training
is mandatory for all core services for inpatient and all community staff and renewed every three
years.
The training compliance reported during this inspection was higher than the 22% (Level 1) and 0% (Level 2) reported at the last inspection.
Relevant policies and procedures reflected recent guidance and staff had access to these on the intranet.
Staff understood and could explain the five principles of the Mental Capacity Act. Staff could give examples of when they would need to assess someone’s capacity. The team would assume capacity unless anything suggested otherwise. Staff supported patients to make decisions about their care and treatment and other decisions affecting their lives.
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Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
Staff attitudes and behaviours towards patients were discreet, respectful, and responsive. We
observed staff being flexible in terms of home visit appointment times. We observed three
assessments at Netherthorpe House and found the staff to be caring and respectful towards
patients. However, due to the appointment system we saw that a patient had to wait in the waiting
room for up to 30 minutes after their appointment time.
The staff rooms were busy and noisy and faced a main road. The volume of calls meant that
several conversations could be happening at the same time. Staff sometimes found it hard to hear
what patients were saying and had difficulty concentrating in the open plan office.
Staff were attempting to signpost patients to community and other trust services. However, due to
the introduction of three sessions patients were often not ready to be referred. The three sessions
involved an assessment and two brief interventions. Staff were aware of services in the
community and where possible were making referrals.
We spoke with seven patients who all said that staff treated them well and behaved appropriately
towards them.
The patients we spoke with at the health-based place of safety said that staff were kind to them
but they did not always understand why they were there. The patients we spoke with had been
detained under the Mental Health Act and were now on Maple ward. It was difficult to interview
these patients since they were unwell at the time. We were unable to speak to any patients who
had used the health-based place of safety and were now back in the community.
Involvement in care
Involvement of patients
We reviewed 10 patient records at the Netherthorpe service and found that none of these
contained a care plan. However, we saw that patients were involved in assessments and in
planning their care. Patients were given an information leaflet when they accessed the service and
could give feedback through the friends and family test.
Patients who had accessed the health based place of safety were given feedback forms to
complete and results were mainly positive. However, there was low uptake and the service was
considering attempting to gain feedback after the patients had left and were more able to reflect on
their experience.
Patients had access to advocacy and we saw in records that patients had accessed this.
Involvement of families and carers
Staff involved and informed families where possible. We spoke with three carers who spoke highly
of the service. They felt involved in discussions about treatment. Where patients gave consent,
families were involved in assessments and in discussions around treatment options. Families
would often call the crisis number either during the day or out of hours if they were concerned
about a loved one.
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Carers were given information on how to access carers assessments and also support for
themselves.
Families were able to give feedback as part of the friends and family test.
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Is the service responsive?
Access and waiting times
The service had a set target for time from referral to triage/assessment. The clinical
commissioning group had set the target. All urgent referrals had to be assessed within four hours
and non-urgent referrals within three weeks. The service was meeting the target for urgent
referrals but patients were currently waiting seven to nine weeks for a routine assessment.
The telephone line was not fit for purpose. The service was unable to monitor the volume of calls and how long people had been waiting. This had been identified and escalated through the mobilisation meetings. The management team had investigated the issue which was on the risk register. The trust had put mitigation in place which included the recruitment of an additional two dedicated telephony staff. The existing telephony system had been improved to include a series of line management escalatory call groups. This meant that calls unanswered within eight rings would be escalated. An answer phone facility had also been added to the telephone line. However, staff reported not to have enough capacity to review the answerphone during the day. The trust had plans to pilot a new telephone system and this was being driven at a senior level.
The single point of access had a waiting list of approximately 400 patients. The team had come
together in January 2018 and had inherited the list from the reconfiguration. Everyone on the list
had been triaged and sent a letter to say that they were currently on a waiting list. The letter
contained numbers to call if in further crisis.
The team consisting of psychiatrist, senior practitioners and managers, worked together to review
the waiting list weekly and any patient who had not made contact in the last year was removed
from the list. Patients and their GP were sent a letter informing them of this decision. The clinical
commissioning group were monitoring the trust on the waiting list and regular performance
meetings were taking place.
The team took active steps to make contact with patients that did not arrive for their appointment
by phoning them to check their wellbeing and informed patient GPs. If they did not attend after
three appointment times, they were removed from the service waiting list.
Appointment times for routine assessments were not flexible to reflect patient choice. They were
held every morning at 9.30 and 11am. There were high do not attend rates for assessments and
the trust had introduced a double booking system. We observed a situation where both patients
arrived for the appointment and so one had to wait to be seen.
The trust were recording the length of time people were waiting for an assessment in the health
based place of safety. Of the people accessed in the health-based place of safety, 53 were
assessed within two hours, 94 between two and 16 hours, and five between 16 and 24 hours. One
patient waited over 24 hours. Guidance introduced in December 2017 reduced the time someone
could be detained under section 136 from 72 hours to 24 hours with the possibility of a further 12-
hour extension in specific circumstances.
The facilities promote comfort, dignity and privacy
Both services had a range of rooms to support treatment and care. However, some of the
interview rooms at Netherthorpe House did not promote comfort, dignity, and privacy. Some of the
interview rooms faced a noisy main road. The noise from the main road made it difficult to hear
during assessments. The main office was also very busy which meant that staff could not always
hear a patient on the telephone. There were often several conversations happening at the same
time with people typing notes in the background.
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The health-based place of safety met the national standard. This consisted of two bedrooms and
an assessment room. Patients had access to food and drink and a clock was visible.
Patients’ engagement with the wider community
Where possible staff supported patients with issues around housing and employment. The
assessment process identified these issues. A support worker picked up these issues, however,
this was one post for the whole team, and staff felt that they did not have the time to effectively
deal with all issues. Social work assessments were taking place to identify any social needs and
there was access to social care funding.
Community resources such as support groups were available. However, some were no longer
taking referrals due to capacity.
Patients were encouraged to maintain relationship with family and friends and where possible
families were given information on support agencies.
There were good links with the police and the street triage was working with people in their own
communities.
Meeting the needs of all people who use the service
The service at Netherthorpe House had disabled access and patients could be seen in the community or their own homes if required. Information leaflets were available in different languages and formats and the service had access to interpreters.
The out of hours and street triage had identified core hours for activity and had shaped staffing around this. The team had been looking at response times to phone calls with the use of the answering machine, staff from the out of hours team had the capacity to do this.
Information leaflets were available in other languages and the staff had access to interpreters and signers.
Listening to and learning from concerns and complaints
Patients knew how to complain or raise concerns. There was information available to patients on
how to make a complaint and they were supported to do this. The core service had only received
one complaint between 1 March 2017 and 28 February 2018, which was not upheld. It was not
clear if patients who had been unable to access the service were made aware of their right to
complain.
The number of either partially or fully upheld complaints reported during this was lower than the one reported at the last inspection.
Team name Total
Complaints
Fully
upheld
Partially
upheld
Not
upheld
Referred to
Ombudsman
Upheld by
Ombudsman
Liaison
Psychiatry
Service
1 0 0 -
This core service received three compliments during the last 12 months from 1 March 2017 to 28
February 2018, which accounted for less than 1% of all compliments received by the trust.
20171116 900885 Post-inspection Evidence appendix template v3 Page 175
Is the service well led?
Leadership
Leaders had the skills, knowledge, and experience to perform their roles. The operations manager
at Netherthorpe House understood the challenges faced by staff. The team was new and the
manager was aware of the issues with waiting lists, telephone line and staff morale. Leaders were
visible in the service. However, staff at Netherthorpe House did not feel supported by senior
leaders.
Staff felt that the trust had underestimated the capacity of the service, which had resulted in a
substantial waiting list. Staff felt that systems were introduced that did not meet the needs of the
service. Staff had raised concerns about the introduction of the new assessment appointment
times and felt that they were not heard. Staff morale was generally low.
However, senior managers were aware of the issues at Netherthorpe and had plans in place to
improve the service. Weekly mobilisation meetings were taking place and there were plans to
relocate the service. Senior managers held weekly sessions with staff and were visible at the site.
The manager at Maple ward managed the health-based place of safety and could demonstrate
good leadership. The trust had acknowledged the staffing issues and measures had been put in
place to recruit more staff.
Vision and strategy
Staff knew and understood the trusts vision to improve the mental, physical, and social wellbeing of the people in communities. The values of respect, compassion, partnership, accountability, fairness, and ambition were applied to daily work. However, staff did not feel that the trust had successfully communicated the vision for the new service and that their daily work did not reflect the service they thought they would be delivering. The trust had a vision for a crisis hub, which would locate the crisis, and health based place of safety together. A working group had responsibility for ensuring these developments were in place for the autumn 2018.
Culture
Staff felt respected, supported, and valued by managers at a local level. However, they did not feel respected or valued by the wider trust. This was mainly due to fact that they perceived the trust had poorly handled the reconfiguration of the service. Staff did not feel positive about the service they were offering and felt that at times it was unsafe. Staff felt able to raise concerns but felt that these concerns were not always listened to.
Staff knew how to use the trust’s whistleblowing procedures and could access them via the trust’s website. Staff also knew whom the trust’s freedom to speak up guardian was and what their role was in respect of supporting staff to speak out and raise concerns. We spoke with the service leads who confirmed staff had approached the guardian about their concerns over the reconfiguration exercise.
The trust had a performance management system in place, which included procedures for managers who needed to address poor staff performance. Staff confirmed that the manager supported them if there were ever difficulties within their team.
The trust promoted equality and diversity in its day-to-day work and in providing career progression. The trust had equality and diversity policies in place, which were available to all staff
20171116 900885 Post-inspection Evidence appendix template v3 Page 176
via the trust’s intranet. Discussions during staff supervision and appraisals focussed on issues around equality and diversity.
There was some sickness within the team at Netherthorpe House and some use of agency for social workers.
Staff had access to support for their own physical and emotional health needs. This included support from the trust’s workplace health and wellbeing group, smoking cessation support, and an occupational health service.
During the reporting period, there were zero cases where staff have been either suspended, placed under supervision, or were moved to a different team within this service.
The number of staff placed under supervision, suspended or moved team during this inspection was similar than those reported at the last inspection (1 suspended) between 18 September 2014 and 27 September 2016. Please note, this may not be comparable depending on the type of restriction detailed at the previous inspection.
Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these should be noted.
Governance
Staff received regular appraisals and supervision. Staff knew how to report incidents, handle
complaints and used lessons learned from investigating incidents and complaints to improve
practice.
Staff understood arrangements for working with other teams, both within the provider and
externally, to meet the needs of the patients. However, staff at the Netherthorpe House said
opportunities to signpost had decreased due to capacity within the voluntary sector. Staff worked
with colleagues within the trust’s recovery and home treatment teams and shared information
through electronic systems, face-to-face meetings, and e-mail. Staff knew how to identify possible
signs of abuse, how to make a safeguarding alert and did so when appropriate.
Staff had a good understanding of the Mental Health Act and Mental Capacity Act and a central
team within the trust monitored staff compliance with the acts and provided advice and guidance
to staff when required.
We spoke with seven people who used the service and their feedback was positive. They said
staff were kind, caring and respectful, involved patients and carers in decisions about their care
and treatment gave patients and carers opportunities to provide feedback and understood their
individual needs.
The services monitored a range of information including referral sources, waiting times, and
response times. However, there were a significant number of people waiting to access the crisis
service and 13 people waiting for a Mental Health Act assessment. The telephone line was not fit
for purpose and so the service was unable to monitor the numbers of people trying to access the
service.
Staff at Netherthorpe House were not completing audits and this was linked to the volume of work.
The staff at the health based place of safety did monthly audits of the 136 detentions and
associated paperwork. However, the trust did not always record how long a patient had waiting for
an assessment.
Staff understood the need to work closely with other trust services such as the home treatment
team, recovery teams to meet the needs of patients. Where possible joint working took place.
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Management of risk, issues, and performance
Staff maintained and had access to risk registers. Staff at Netherthorpe House had escalated
concerns in relation to waiting times, the telephone system and the reconfiguration of admin staff.
Other issues included bed management, and lack of police attendance at Mental Health Act
assessments. All the issues raised by the services were on the risk register. Senior managers
understood the issues and were working on ways to ensure the issues were dealt with. However,
staff working within the centralised approved mental health practitioner team felt that the number
of people awaiting a Mental Health Act assessment was a concern.
Information management
The services used the trusts electronic system to record patient information. The system was
effective and easy to use. Staff at the health-based place of safety had access to a tablet so that
they could record patient’s assessments and risk plans whilst in the place of safety. The staff at
Netherthorpe House had a hot desk policy; this could be problematic when having to log off whilst
away from desk. Staff would sometimes come back and have to find another desk and information
could be lost.
Information governance training was a mandatory requirement for staff within the trust. This
training included the need to ensure that all staff maintained patient confidentiality at all times.
Managers did not have all the information they needed on the performance of the service.
Managers were unable to know how many people were unable to access the crisis service. The
service managers used key performance indicators to monitor compliance in relation to mandatory
training and other progress within their teams. However, since the team was new the manager
was still pulling together staffing information from previous teams.
Engagement
Staff, patients, and carers had access to up-to-date information about the services they used and
wider trust through social media, emails, newsletters intranet, and internet. Patients and staff could
meet with members of the senior leadership team and governors to give their feedback and ideas
for shaping the service. Although the staff at Netherthorpe House felt that they were not listened
to, we saw that senior managers did visit the service frequently and were aware of the concerns.
The trust had engaged people who used the service and other stakeholders in the reconfiguration
exercise during feedback sessions, presentations, and drop in sessions. Staff had been involved
in sessions but felt that decisions had already been made.
Learning, continuous improvement and innovation
The reconfiguration was a whole system redesign improvement programme introducing a new way of working. Staff had been engaged in the process through to options appraisal, recommendation and mobilisation. The service model for the single point of access was refined in response to feedback from staff during the engagement and consultation phases. However, some staff felt that the current service did not reflect the service designed during the reconfiguration. Staff were under pressure daily to deal with the volume of calls and assessments. They were doing this alongside work to reduce the waiting list. Staff were not participating in any research.
Innovations were planned with the development of a crisis hub to bring together crisis and health based place of safety. Senior managers gave an overview of developments and these were to be in place by autumn 2018.
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NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.
The table below shows which services within this core service have been awarded an accreditation together with the relevant dates of accreditation.
Accreditation scheme Service accredited Comments and date of accreditation / review
Psychiatric Liaison Accreditation
Network (PLAN)
Liaison Psychiatry 21st March 2017- 2020
20171116 900885 Post-inspection Evidence appendix template v3 Page 179
Wards for people with a learning disability or autism
Facts and data about this service
Location site name Ward name Number of beds Patient group (male,
female, mixed)
Assessment & Treatment Service
Service – Firshill Rise
Firshill Rise
Assessment &
Treatment
Service
7 Mixed
Firshill Rise assessment and treatment service is a mental health ward for adults with a learning
disability or autism provided by Sheffield Health and Social Care NHS Foundation Trust. The
service provides care and treatment to male and female patients over the age of 18. The ward can
provide care and treatment for up to seven patients. It has six bedrooms and one self-contained
flat. Patients are admitted to the service because they have severe mental health problems and/or
because they are presenting challenging behavior, which cannot be supported in the community or
in mainstream adult inpatient mental health services.
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Is the service safe?
Safe and clean care environments
Safety of the ward layout
The service had a part-time buildings manager who undertook environmental risk assessments including health and safety assessments and fire risk assessments. Clinical staff carried out regular risk assessments of the ward areas. Staff took action in response to incidents involving environmental risks. The last ligature risk assessment was completed in October 2017. The trust reported that the ward presented a high level of ligature risk due to the acuity of patients and remaining ligature anchor points in the self-contained flat area, which including taps which were not anti-ligature taps and had handles on cupboard doors. The accessible bedroom also had an overhead hoist.
In areas regarded as high risk, such as patient bedrooms, the trust had installed anti-ligature fittings. The trust had taken the following actions to mitigate ligature risks: risk assessments and observations levels where ligature risks remained; removal of items that may be used as ligatures.
The layout of the ward did not allow staff to observe all parts of the ward; staff mitigated these risks by observing patients at regular frequencies.
The ward was mixed sex. All bedrooms contained en-suite toilet and bathing facilities and female patients had access to a female only lounge. Over the 12-month period from 1 March 2017 to 28 February 2018 there were no mixed sex accommodation breaches within this core service.
Staff carried personal alarms and nurse call points were available in all bedrooms for patients to call for assistance from staff when required.
Maintenance, cleanliness and infection control
The ward was clean and had good, well-maintained furnishings. The ward had a cleaning
schedule and dedicated housekeeping staff supervised by the buildings manager. Cleaning
records were up to date and demonstrated that staff cleaned the ward regularly.
Staff had effective processes in place to reduce the risk and spread of infection, including
handwashing, with signage in appropriate areas and antibacterial hand gel dispensers placed in
communal areas and toilets. Staff carried out regular infection control audits and had action plans
in place to maintain standards.
At the last comprehensive inspection in November 2016, patients had access to a clinic room
located away from the ward area. This meant staff stored patient medication in the staff office and
they carried out health checks in patient bedrooms. We were concerned that this could have
increased the risk of infection to patients. However, the trust had created a clinic room on the
ward, which meant staff could store patient medication away from the staff office and could carry
out patient health checks on the ward in a designated room.
For the most recent Patient-led Assessments of the Care Environment (PLACE) assessment
(2017), the location scored higher than the similar trusts for two of the three applicable aspects
overall and similar to other trusts for cleanliness.
The table below shows the Patient-led Assessments of the Care Environments assessment score
for 2017:
Site name Core service(s)
provided
Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
20171116 900885 Post-inspection Evidence appendix template v3 Page 181
Firshill Rise
MH – Wards for
people with learning
disabilities or autism
98.6% 98.2% N/A 91.1%
Trust overall 99% 97.8% 91.1% 91.8%
England average (Mental
health and learning
disabilities)
98% 95.2% 84.8% 86.3%
Seclusion room
Since our last inspection, the trust had removed one of the patient bedrooms and built a seclusion
room. Prior to this, the ward did not have seclusion facilities. The seclusion room allowed staff
clear observation of patients and had a two-way communication system in place. Patients in the
seclusion room had access to toilet and washing facilities. The room had air conditioning, which
allowed staff to control the temperature in line with patient need. Patients could see a clock and
the room had natural light. Staff told us that if they secluded patients who could not read the time
from the clock, they encouraged them to ask staff for the time.
Clinic room and equipment
The ward had a newly refurbished fully equipped clinic room with an examination couch and
emergency drugs, which staff checked regularly. Staff had access to resuscitation equipment,
which they stored in the staff office. Staff checked and maintained this equipment.
Safe staffing
Nursing staff
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 January 2018 24.2 N/A
Total number of substantive staff leavers 1 February 2017 to 31 January 2018
2.8 N/A
Average WTE* leavers over 12 months (%) 1 February 2017 to 31 January 2018
11% 13%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31March 2018 4 N/A
Total vacancies overall (%) At 31March 2018 12% NA
Total permanent staff sickness overall (%) Most recent month (At 31 January 2018)
14% 5%
Average sickness rate over 12 months 1 February 2017 to 31 January 2018
14% 5%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 March 2018 7 N/A
Establishment levels nursing assistants (WTE*) At 31 March 2018 18 N/A
Number of vacancies, qualified nurses (WTE*) At 31 March 2018 1 N/A
20171116 900885 Post-inspection Evidence appendix template v3 Page 182
Substantive staff figures Trust target
Number of vacancies nursing assistants (WTE*) At 31 March 2018 3 N/A
Qualified nurse vacancy rate At 31 March 2018 14% N/A
Nursing assistant vacancy rate At 31 March 2018 17% N/A
Bank and agency Use
Shifts bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 March 2017 and 28
February 2018 698 (41%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses)
1 March 2017 and 28
February 2018 447 (26%) N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses)
1 March 2017 and 28
February 2018 104 (6%) N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 3602 (58%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 665 (11%) N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants)
1 March 2017 and 28
February 2018 361 (6%) N/A
*Whole-time Equivalent
This core service reported an overall vacancy rate of 14% for registered nurses at 31 March 2018.
The vacancy rate for registered nurses was higher than the 0% reported at the last inspection.
This core service reported an overall vacancy rate of 17% for registered nursing assistants.
The vacancy rate for nursing assistants was lower than the 20% reported at the last inspection.
This core service has reported a vacancy rate for all staff of 12% as of 31 March 2018. This was similar to the rate reported at the last inspection (between 1 August 2016 and 31 July 2017).
Registered nurses Health care assistants Overall staff figures
Ward/Tea
m
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Vacanci
es
Establishm
ent
Vacan
cy rate
(%)
Firshill
Rise
1 7 14% 3 18 17% 4 33 12%
Core
service
total
1 7 14% 3 18 17% 4 33 12%
Trust
total 32 433 7% 15 353 4% 68 1339 5%
NB: All figures displayed are whole-time equivalents
Between 1 March 2017 and 28 February 2018, bank staff filled 41% of shifts to cover sickness, absence or vacancy for qualified nurses.
In the same period, agency staff covered 26% of shifts for qualified nurses. Six percent of shifts were unable to be filled by either bank or agency staff.
Ward/Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by
bank or agency staff
20171116 900885 Post-inspection Evidence appendix template v3 Page 183
Firshill Rise 1721 698 (41%) 447 (26%) 104 (6%)
Core service
total
1721 698 (41%) 447 (26%) 104 (6%)
Trust Total 32,394
4977
(15%)
7252
(22%)
900
(3%)
*Percentage of total shifts
Between 1 March 2017 and 28 February 2018, 58% of shifts were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.
In the same time-period, agency staff covered 11% of shifts. Six percent of shifts were unable to be filled by either bank or agency staff.
Ward/Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by bank
or agency staff
Firshill Rise 6189 3602 (58%) 665 (11%) 361 (6%)
Core service
total 6189 3602 (58%) 665 (11%) 361 (6%)
Trust Total 59,514 21,770
(37%)
5623
(9%)
1760
(3%)
* Percentage of total shifts
Senior managers set the minimum daily staffing levels, but the ward manager could adjust these
as needed based on the needs of the ward and patient acuity levels. At the last comprehensive
inspection in November 2016, the staffing level was two registered nurses and three support
workers on duty during the day and one registered nurse and two support workers on duty
overnight. However, managers had increased staffing levels to two registered nurses and five
support workers during the day and one registered nurse and four support workers at night. These
levels were above the minimum staffing levels set out by the trust. Managers of the service had
put in a business case to keep staffing at the current levels on a more permanent basis due to
patient acuity levels.
The ward manager and the deputy could be counted into the staffing numbers and had been
covering shifts to fill registered nurse shifts. The service had recently recruited two new registered
nurses. There was always at least one registered nurse present on the ward and managers could
deploy agency staff or bank staff to cover shortfalls. The service had a high rate of bank staff to
cover shifts but these staff were already employed by the trust and undertook additional work at
the service when needed.
We had concerns that new staff and agency staff appointed to work on the ward did not always
complete an induction before starting work on the ward. Some staff told us they felt unsafe on the
ward because of this. Following our inspection, we asked the service to provide further information
about this. The data they supplied showed that in the three months prior to our inspection,
managers had recruited three new permanent members of staff to work on the ward. Of these, two
staff had not received an induction prior to commencing their first shift. They were mostly up-to-
date with their mandatory training including training in managing aggression but two staff had not
completed clinical risk assessment training, two had not completed Mental Capacity Act level two
training, two had not completed medicines management training and two had not completed rapid
tranquilisation training. None of them had completed their mandatory training in the Mental Health
Act. The data also showed the hospital had appointed three new agency staff and none of them
had completed an induction prior to starting their shifts.
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As part of our inspection, we interviewed five staff on duty including a mixture of support workers
and registered nursing staff. Four of the staff we spoke with told us they thought the service was
short of staff, which resulted in them regularly having to cancel patient leave and activities. We
also spoke with three patients as well as the advocacy service who regularly visited patients on
the ward. One patient and the advocacy service told us that the provider cancelled activities
regularly because there were not enough staff to facilitate them. We asked the provider for
information about how many episodes of leave they cancelled because of staff shortages. They
reported that in the three months prior to our inspection, staff had to cancel four episodes of
patient leave due to staff shortages.
Data provided prior to the inspection showed that between 1 March 2017 and 28 February 2018,
the service could not cover six percent of shifts with bank or agency staff. On the day of the
inspection, we could see that two support staff had reported in sick so there were two nurses and
three support workers on duty. Staff told us they may have to cancel activities and patient leave
but the number and grades of staff on duty was still within their minimum safe staffing levels.
Two staff we spoke with told us that a minimum of three staff trained to deliver restraint and
seclusion should be on duty at each shift but that this did not always happen. Between 5 March
2018 and 11 June 2018, there were 13 shifts that fell below the minimum of three RESPECT
trained staff on shift. RESPECT training included training in positive behavioural support and
restraint techniques. This represented 4% of the total shifts during this time period. The service
was a standalone unit, which meant that it did not have any additional support from staff in other
services to restrain and seclude patients where this was necessary.
This core service had 2.8 (11%) staff leavers between 1 March 2017 and 28 February 2018. This was lower than the 24% reported at the last inspection (between 1 August 2016 and 31 July 2017).
Ward/Team Substantive staff
Substantive staff Leavers Average % staff leavers
Firshill Rise 24.2 2.8 11%
Core service total 24.2 2.8 11%
Trust Total 1351.6 129.6 8%
The sickness rate for this core service was 14% between 1 February 2017 and 31 January 2018.
.
Ward/Team Total % staff sickness
(at latest month)
Ave % permanent staff sickness
(over the past year)
Firshill Rise 14% 14%
Core service total 14% 14%
Trust Total 8% 7%
Managers told us their rates of sickness absence were higher than the trust average due to staff
stress and assaults on staff. However, managers had conducted a stress audit and introduced
initiatives to reduce the number of assaults on staff in an attempt to reduce staff absence.
20171116 900885 Post-inspection Evidence appendix template v3 Page 185
The below table covers staff fill rates for registered nurses and care staff between November 2017 and February 2018.
Firshill Rise had a fill rate of over 125% for nurses for all day shifts reported.
Key:
> 125% < 90%
N-Nurses
C- care staff
Medical staff
Between 1 March 2017 and 28 February 2018, no shifts were filled by bank staff to cover
sickness, absence or vacancy for medical locum shifts.
In the same time period, agency staff covered 22 shifts. Zero shifts were unable to be filled by
either bank or agency staff.
Ward/Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by bank
or agency staff
Firshill Rise Not provided 0 22 0
* Percentage of total shift
There was adequate medical cover provided by a psychiatrist and specialty doctor. Staff could
speak with an on-call psychiatrist, for example, at night if they needed to. The service covered
planned and unplanned absences using responsible and approved clinicians from other parts of
the trust, for example, from the community learning disabilities team.
Mandatory training
The compliance for mandatory and statutory training courses at 28 February 2018 was 89%. Of the training courses listed four failed to achieve the trust target and of those, three failed to score above 75%.
The training compliance reported for this core service during this inspection was higher than the 81% reported at the last inspection.
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Day Night Day Night Day Night Day Night
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
November 2017 December 2017 January 2018 February 2018 Firshill
Rise
188.1 153.4 96.8 243.1 174.5 133.7 100.0 225.4 151.3 118.0 100.0 173.2 148.7 118.7 96.4 176.6
20171116 900885 Post-inspection Evidence appendix template v3 Page 186
Training course This core service %
Trust target % Trustwide mandatory/ statutory training total %
Immediate Life Support 100% 80% 88%
Safeguarding Children (Level 3) 100% 80% 91%
Mental Capacity Act Level 2 100% 80% 85%
Rapid Tranquilisation 100% 80% 88%
Clinical Risk Assessment 100% 80% 91%
Health and Safety (Slips, Trips and
Falls) 100% 80%
97%
Medicine management training 100% 80% 87%
Respect Level 2 100% 80% 80%
Domestic Abuse Level 2 96% 80% 85%
Hand Hygiene 96% 80% 94%
Safeguarding Adults (Level 2) 96% 80% 87%
Mental Capacity Act Level 1 94% 80% 94%
Safeguarding Children (Level 2) 94% 80% 85%
Autism Awareness 92% 80% 88%
Fire Safety 2 years 92% 80% 96%
Respect Level 3 82% 80% 83%
Dementia Awareness (inc Privacy &
Dignity standards) 80% 80%
85%
Equality and Diversity 77% 80% 95%
Adult Basic Life Support 73% 80% 81%
Information Governance 69% 80% 80%
Mental Health Act 67% 80% 83%
Core Service Total % 89% 88%
At the last comprehensive inspection in November 2016, we told the service they should ensure
that staff completed mandatory training for autism awareness, dementia and Deprivation of Liberty
Safeguards. Data provided for this inspection showed that managers provided staff with
mandatory training and most were up-to-date with this. When we spoke with staff, they confirmed
they received mandatory training and we saw that each month, managers reviewed training data
to track staff compliance.
In four mandatory training courses, we saw that staff compliance rates fell below the trust target of
80% and for three courses, compliance rates fell below 75%, the rate that CQC consider the
minimum compliance level. The courses that fell below 75% were adult basic life support,
information governance and the Mental Health Act. However, managers had clearly identified
which staff needed to complete their mandatory training and had booked them onto future course
dates.
Assessing and managing risk to patients and staff
Assessment of patient risk
All six patients’ care and treatment records we looked at contained a comprehensive risk
assessment using a trust wide tool called the detailed risk assessment and management plan.
Staff carried out risk assessments on admission to the service and updated these regularly.
Management of patient risk
Staff responded to changes in risk profile by using a clinical progress tracker. At every shift staff
recorded patient behaviours, which they then shared with multi-disciplinary team twice per week
and at handovers. The tracker was colour coded, green for adaptive behaviours, amber for early
20171116 900885 Post-inspection Evidence appendix template v3 Page 187
signs of unease, and red for moderate to severe signs of risk or poor mental state. Each patient’s
colour coded tracker was visible to staff on an electronic screen located in the team office.
We saw how staff followed policies for observing patients and for searching patients as
appropriate. For example, staff told us they had to search a patient’s room when a risk item went
missing from one of the communal areas. We saw from records that staff conducted patient
searches only in response to risks based on individual assessment, for example, where they
suspected a patient had brought a cigarette lighter back onto the ward.
Staff told us they did not have any blanket restrictions on patients’ freedom and we did not identify
any at our last comprehensive inspection in November 2016. At this inspection, we found there
were restrictions affecting all patients that were not based on individual risk assessments,
including access to outside areas and access to hot drinks and snacks. The kitchen on the ward
was primarily used for preparing food for the ward, but staff told us that there was a kitchen on the
first floor where patients were supported to prepare meals as part of their treatment. Patients had
access to hot drinks on request. The doors to the garden were locked and there was a notice
advising patients if they wanted access to the garden, they had to ask a member of staff to open
the doors. We were told by someone who visited the ward regularly that there was not always
enough staff to facilities access to the garden at times when patients might want to go. None of the
patients we spoke with at the inspection raised this issue.
The laundry, the craft room and the ward kitchen were all subject to supervised access only, unless patients had been assessed as not presenting a risk in these areas. Access to risk items such as razors or glassware were individually risk assessed by staff for each patient. Staff kept these restrictions under review at their monthly governance meetings. The hospital had a no smoking policy and at the time we carried out our inspection, there were no
patients that smoked.
At the time we carried out our inspection, none of the patients in the service were informal. Staff
told us they would communicate with informal patients personally so they understood they could
leave by asking a member of staff to open the doors.
Use of restrictive interventions
This core service had 40 incidents of restraint (on 25 different service users) and zero incidents of
seclusion between 1 March 2017 and 28 February 2018.
The below table focuses on the last 12 months’ worth of data: 1 March 2017 and 28 February
2018.
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
Firshill Rise 0 40 25 0 (0%) 6 (15%)
Core service
total 0 40 25 0 (0%) 6 (15%)
There were no incidents of prone restraint. There have been no instances of mechanical restraint over the reporting period.
The number of restraint incidents reported during this inspection was higher than the zero reported at the time of the last inspection.
At our last comprehensive inspection in November 2016, we told the provider they should ensure that all staff were competent and trained in the use of interventions when dealing with aggression
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and violence. The service used an approach called RESPECT, which utilised a philosophy of support and empowerment. Staff were trained in how to use de-escalation techniques with patients and use physical interventions which did not cause pain or panic. Data provided by the service indicated that most staff had received training in RESPECT interventions. Staff used restraint only as a last resort where attempts at verbal de-escalation had failed. We saw that staff encouraged patients to use a room, called the green room to help patients calm themselves down. Staff had found this helpful when patients became agitated and patients were free to leave the room at any time.
The consultant nurse from the community team facilitated regular workshops with staff to help them deal with challenging behaviour from patients. Managers told us they had held three of these workshops over the previous six months and they had another planned immediately following our inspection.
Staff used rapid tranquilisation rarely and only when patients’ behaviour had become extremely challenging and other attempts at de-escalation had failed. The service had a policy and staff received appropriate training to carry out physical health monitoring after administering medication in this way to patients.
The provider reported zero incidents of seclusion between 1 March 2017 and 28 February 2018.
However, in June 2018, there was one episode of seclusion, which had commenced the day prior
to our inspection visit. The service had a seclusion policy in place and had arranged for a nurse to
be on-call so staff could carry out nursing reviews during the night shift. As part of our inspection,
we looked at the one seclusion record and found staff kept seclusion records appropriately.
However, we saw one example where a patient in seclusion did not have a medical review at the
appropriate time because no doctors were available at the right time. Staff told us this was very
unusual and they would report this as an incident.
In this location, there were zero instances of long-term segregation over the 12-month reporting
period.
Safeguarding
A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional.
Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.
This core service made 116 safeguarding referrals between 1 February 2017 and 31 January 2018.
Staff participated in safeguarding training, which included both adults and children. Staff had a good understanding of what constituted abuse and how to recognise it. Support workers sought support from nursing staff where necessary. Staff worked in partnership with social care agencies to progress safeguarding enquiries. The service had comprehensive safeguarding policies, which
Referrals
Adults Children Total referrals
116 0 116
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included safe procedures for children visiting the ward. Staff did not allow persons under the age of 18 years onto the ward area but there was a separate visiting room.
At inspection, staff showed us data to confirm that staff had raised 116 safeguarding alerts concerning 17 different individuals.
Staff access to essential information
Staff used an electronic system to record most patient care. In the records we reviewed, staff
recorded information in different places but the information was available to all relevant staff
including agency and bank staff. The manager told us they were implementing new templates onto
the electronic system, which would streamline care planning and ensure staff recorded information
in a consistent place.
The service controlled staff access to electronic records by ensuring staff had individual
passwords. Staff stored other patient information securely locked in the team office and clinic
rooms.
Medicines management
At our last comprehensive inspection in November 2016, staff stored patient medication in the
team office because the clinic room was off the ward area. At this inspection, the trust had
extended the ward to create an air-conditioned clinic room where staff stored and administered
patient medicines. Staff maintained patient medicines charts electronically and a pharmacy
technician from the trust audited medicines management practices weekly. Where the audit
identified deficits, they highlighted this to the nurse in charge who took immediate action. For
example, we saw how, in response to an incident relating to storing medications at the right
temperature, staff had placed a sign on the air conditioning unit in the clinic room reminding staff
not to switch it off.
We checked all the medication records for patients and found staff managed medication
appropriately.
Staff maintained a record of clinic room and medication fridge temperatures. These showed staff
recorded temperatures consistently and staff took action when they were out of range. Medicines
audit reports were presented and discussed at monthly governance meetings and managers put
action plans in place to address areas identified for improvement by the pharmacist.
Track record on safety
Providers must report all serious incidents to the Strategic Executive Information System within two working days of an incident being identified.
Between 1 March 2017 and 28 February 2018 there were no Strategic Executive Information System incidents reported by this core service.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with Strategic Executive Information System.
The number of serious incidents reported during this inspection was the same as the zero reported at the last inspection.
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Reporting incidents and learning from when things go wrong
The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths.
In the last two years, there have been zero ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.
Staff knew how to report incidents and had access to an electronic reporting system. We saw examples where staff completed incident reports including minor incidents and near misses. At the last comprehensive inspection in November 2016, we told the trust they should ensure that the manager reviewed incidents so they had an overview of what was happening on the ward. At this inspection, we found the figure for outstanding incidents had reduced but there was still a back-log of 71 incidents waiting for manager review. Following the inspection, the trust told us that whilst these incidents had not received management reviews they had all been read at time of entry, and key findings and themes were discussed at handover, safety huddles and in multidisciplinary meetings. We did see evidence that staff discussed incidents involving patients at handover meetings and multidisciplinary meetings.
We saw evidence that staff investigated incidents appropriately and put measures in place to improve practice. For example, managers had built a safety huddle into every shift handover to improve staff and patient safety. At each handover, staff discussed incidents of physical assault on staff and patient-to-patient assaults. Staff also discussed any incidents of observation breaches. Each day, staff put up a poster in the team office identifying the number of days since the last assault incident or breach of observation or dysphagia protocol.
We did not see evidence that staff were involved in reviewing and learning from incidents in the wider trust. Staff talked of receiving emails regarding incidents but these were limited to incidents, which took place within the service. Following serious incidents, managers told us they offered debrief to staff and patients, and we saw examples of this. However, sometimes they struggled to complete these in a timely manner. In the team meeting in May 2018, managers acknowledged difficulties in providing debrief for staff and told us they struggled to support staff to have time out from direct duties in order to reflect and de-brief following incidents. None of the staff we spoke with at our inspection raised this as a concern.
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Is the service effective?
Assessment of needs and planning of care
We reviewed the care and treatment records for six out of seven patients on the ward. Each
record contained a comprehensive assessment of their mental and physical health including a
communication assessment, psychological assessment and social and adaptive functioning. Each
patient had a number of care plans in place including a person-centred care plan, a positive
behaviour support plan, a physical health care plan, and a communication plan. However, we
found one patient with challenging behaviour who required a specialist communication
assessment, which staff had not progressed. At the end of our visit, we asked managers to
prioritise this. Following the inspection, we received confirmation that the patient’s communication
needs had been reviewed by a lead speech and language therapist in the trust.
Staff ensured patient care plans, were personalised, and contained clarity about the aims of the
treatment. Care plans were recovery orientated because they were strengths based and covered
the full range of patient need. Staff updated care plans as needed and following review by the
multidisciplinary team.
Best practice in treatment and care
This core service participated in the following clinical audits as part of their clinical audit
programme in the 12 months leading up to the submission of the provider information return.
Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
Capacity &
consent
recording in
Firshill Rise ATS
Firshill Rise ATS
MH - Wards
for people
with learning
disabilities or
autism
Clinical On-going
Awaiting findings
Assessment of
NICE Guidance:
QS142 Learning
disabilities:
identifying and
managing
mental health
problems
Learning
disability
services
MH - Wards
for people
with learning
disabilities or
autism
Clinical On-going Awaiting findings
Greenlight
Toolkit Audit
Learning
disability
services
MH - Wards
for people
with learning
disabilities or
autism
Clinical Not
provided
Green light meeting used
to develop and track action
plan.
Re-audit in 2018
Collaboration
with Primary
Care Clinicians
Service users
on CPA
Provider
wide
Clinical on-going Changes made following
previous audit round:
provide guidance to staff
on annual reviews of care.
Changes to care plan form.
Creation of a 'clinical
review for GP' IT system
solution.
Record keeping
audit 2016/2017
Trust wide Provider
wide
Clinical on-going From data collected so far:
Further clarity provided to
staff on use of
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abbreviations - to be
incorporated into the
relevant policy.
Audit of risk
assessments
2016/2017
Trust wide Provider
wide
Clinical audit March 2017 Local action plans to
address identified issues.
Audit tool to be revised to
give clearer results.
Re-audit to be undertaken
in 2017/18.
Audit of risk
assessments
2017/2018
Trust wide Provider
wide
Clinical audit On-going Await findings
Audits of care
plans
Trust wide Provider
wide
Clinical audit January
2018
Agreed need for frequent
small scale audits.
Findings being shared with
teams.
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG43
Transition from
children’s to
adults’ services
for young
people using
health or social
care services
Trust wide Provider
wide
Clinical audit June 2017 Findings fed into
Commissioning for Quality
and Innovation and other
related joint work with child
and adolescent mental
health services to improve
transitions
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG13
Workplace
health:
management
practices
Trust wide Provider
wide
Clinical audit September
2017
Review practices against
guidance as necessary in
future
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG58
Coexisting
severe mental
illness and
substance
misuse:
community
health and
social care
services
Trust wide Provider
wide
Clinical audit December
2017
Action plan under
development
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Staff delivered treatment in line with National Institute for Clinical Excellence, for example, all patients had a named worker to co-ordinate their care. Patient assessments and on-going monitoring identified possible triggers, environmental factors, and functions of the behaviour.
Staff reviewed patients’ medication in line with new guidance produced by NHS England aimed at reducing the over-medication of patients with a learning disability, autism or both.
Staff ensured patients had access to on-going physical healthcare through the health care plan. They supported patients to live healthier lives by providing them with advice and support around, for example, diet and exercise.
Staff participated in clinical audit and benchmarked themselves against other services where appropriate. For example, they compared their incident reporting with other services in the trust and developed initiatives aimed at reducing the number of assaults on staff. Staff participated in an audit aimed at improving access for patients with a learning disability and autism to access mainstream health services.
The psychology team were developing an approach to evidence clinical progress and outcomes with all patients. Key measures included quality of life scores, psychological distress, problem behaviour, psychiatric problems and depression. The team used recognised and evidence based tools for example, they used the CORE-LD assessment and the Glasgow depression scale, both of which were designed to be used with patients with a learning disability. Whilst the approach was still under development, the team had produced a report to show over 70% of the patients profiled had improved psychiatric symptomology, decreased challenging behaviour and decreased levels of psychological distress.
Skilled staff to deliver care
Patients had access to a full range of specialists including, where appropriate, practitioners from
across the trust who could be brought in on a sessional basis. The multi-disciplinary team
consisted of nurses, support workers, an occupational therapist, psychologists, a pharmacist,
psychiatrist and speciality doctor and a speech and language therapist. The team also worked
closely with staff from the trust’s community intensive support service and the community learning
disability team.
The hospital had a policy that new staff on the ward had an appropriate induction and this included
agency and bank staff. However, two people we spoke with told us not all agency and bank staff
had received training in supporting people with learning disabilities and autism and did not always
know how to interact appropriately with patients. When we asked the service about this, they told
us agency staff received basic autism awareness training and regular staff received more in-depth
training and guidance in positive behaviour support. At our inspection visit, we did speak with one
agency member of staff who confirmed they had completed their induction training and knew how
to interact with patients. We did not see any examples where staff interacted inappropriately with
patients.
Notes from team meetings indicated that support staff could participate in non-mandatory training
including physical observations, blood glucose monitoring and care planning. One support worker
we spoke with told us it was difficult for them to get time away from the ward to complete non-
mandatory training.
The trust’s target rate for appraisal compliance is 90%. As at February 2018, the overall appraisal
rates for non-medical staff within this core service was 93%.
The rate of appraisal compliance for non-medical staff reported during this inspection was higher
than the 64% reported at the last inspection.
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Ward name
Total number of
permanent non-medical
staff requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an appraisal
% appraisals
Firshill Rise 28 26 93%
Core service total 28 26 93%
Trust wide 1495 1440 96%
The trust’s target rate for appraisal compliance is 90%. As at February 2018, no permanent
medical staff within this core service required an appraisal.
The trust’s target for clinical supervision was 66%
Between 1 March 2017 and 28 February 2018, the rate across this core service was 56%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. The rate of clinical supervision reported during this inspection was lower than the 64% reported at
the last inspection.
Ward name Clinical supervision
sessions required
Clinical
supervision
sessions delivered
Clinical
supervision rate
(%)
Firshill Rise 81 45 56%
Core service total 81 45 56%
Trust Total 3420 2183 64%
Managers told us they provided supervision to staff regularly but over recent months, they had not
done this due to pressure of work and having to provide nursing cover on shift. As part of our
inspection, we interviewed five staff on duty including a mixture of support workers and qualified
nursing staff. Two of the nursing staff we spoke with had been provided with supervision but the
support workers we spoke with told us they had not had regular supervision. Managers told us
supervision rates going forward would improve because they had recruited more nursing staff to
act as supervisors.
Staff had access to team meetings but recently, these had been cancelled in February and March
2018. Support workers told us they did not always have time to attend meetings and when we
reviewed minutes from the team meetings for January, April and May 2018. We saw poor
attendance by support and nursing staff from the ward and there was a lack of clarity about the
dates and frequency of future meetings.
Multi-disciplinary and interagency team work
Staff held weekly multidisciplinary meetings and daily handover meetings. The multidisciplinary
team invited support staff to attend but they told us it was difficult for them to get time away from
direct duties to attend meetings. Support staff told us they did not feel involved in decision-making
and did not feel listened to. This finding was supported when we looked at the team meeting
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minutes for May 2018 where managers noted that staff did not feel involved in multidisciplinary
meetings and the minutes of these meetings were not always clear. Managers were aware of the
issues and had some ideas to address this including the introduction of collaborative care planning
and ways of making multidisciplinary decisions easier for staff to access.
As part of our inspection, we observed a handover meeting where staff discussed each patient
including any significant incidents within the previous 24 hours. Staff found handovers an effective
way of sharing information about patients’ changing needs and risks.
The team had effective relationships with local community services and external care coordinators.
We observed a planning meeting where staff met with the relevant support agencies and others
involved with the care of the patient to plan their future support needs.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
As of 28 February 2018, 67% of the workforce in this core service had received training in the Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient and all community staff and renewed every three years.
The training compliance reported during this inspection was lower than the 100% reported at the last inspection.
We spoke with the service that provides advocacy support to patients at the hospital and they told
us staff knowledge concerning the Mental Health Act was inconsistent and they had arranged to
provide some advocacy training for staff. However, we found the staff we spoke with at inspection
had a good working knowledge of the Mental Health Act. Managers had clearly identified which
staff needed to complete their mandatory training and had booked them onto future course dates.
The trust had appropriate Mental Health Act policies in place, which reflected current guidance.
Staff could access relevant policies on the trust’s intranet and had access to support and guidance
from Mental Health Act administrators at the trust.
Patients had access to information about independent mental health advocacy including easy-read
versions of information concerning their rights. An advocate visited once per week and referrals to
the advocate was part of the admissions process. Staff had put posters and leaflets up in ward
areas about patient access to the advocacy service.
One patient out of three we spoke with told us staff had sometimes cancelled their section 17
leave due to their unavailability. When we asked the hospital about this, they told us that in the
three months prior to our inspection staff had to cancel four episodes of patient leave due to staff
shortages.
At the time of our inspection, all seven patients were detained under the Mental Health Act. We
reviewed the care and treatment records for six patients. All six patients received support from an
independent mental health advocate and staff had explained to them their rights at regular
intervals. At our last comprehensive inspection in November 2016, we told the trust they should
ensure that the use of advocacy is consistently recorded in patient notes, and that advocates are
routinely invited to take part in decision-making processes to support the patient. At this
inspection, staff had documented advocacy involvement and the date they explained patients’
rights in the care record. We saw in patient notes that an advocate was present at care reviews
and other appropriate meetings to support the patient.
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Each month, the ward manager completed an audit of Mental Health Act paperwork including
consent to treatment. As part of the inspection, we looked at recent audits and found that overall
staff applied and monitored the use of the Mental Health Act correctly.
Good practice in applying the Mental Capacity Act
As of 28 February 2018, 94% of the workforce in this core service had received training in the
Mental Capacity Act Level 1 and 100% of the workforce had Mental Capacity Act Level 2. The
trust stated that this training is mandatory for all core services for inpatient and all community staff
and renewed every three years.
The training compliance reported during this inspection was higher than the 57% reported at the last inspection.
The trust had an up to date policy on the Mental Capacity Act, including Deprivation of Liberty
Safeguards. Staff were aware of the policy and that they could access it through the intranet.
Staff had a good understanding of the principles of the Act and supported patients to make their
own decisions as much as possible.
At the last comprehensive inspection in November 2016, we told the provider they should ensure
that staff carry out assessments of patients’ capacity to make decisions, thoroughly and in line with
the Mental Capacity Act code of practice. At this inspection, we saw examples where staff had
carried out and documented capacity assessments and best interest decisions as appropriate with
patients.
When staff needed advice or guidance concerning patient capacity, staff could speak with the
deputy ward manager who acted as the lead for mental capacity. The hospital’s lead psychologist
and consultant psychiatrist also provided support and guidance to staff concerning mental capacity
and best interest decision-making.
The lead psychologist carried out an audit of the hospital’s adherence to the Mental Capacity Act
in March 2018. They audited seven records and found some areas of good practice as well as
some practices which required improvement. Staff discussed the results from the audit in the
governance meeting. As a result of the audit, managers had identified recommendations and next
steps. These included reminding staff about the use of capacity assessment forms and using
standard headings in patient care plans to record capacity. Managers also had an action to make
their library of resources more accessible to staff at the point they needed them. Managers told us
they intended to carry out a re-audit in the following three months.
The trust told us that zero Deprivation of Liberty Safeguard applications were made to the Local Authority for this core service between 1 March 2017 and 28 February 2018.
CQC received no direct notifications from Trust between 1 March 2017 and 28 February 2018.
The number of Deprivation of Liberty Safeguard applications made during this inspection was zero. This was the same as the amount reported at our last inspection.
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Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
We observed staff interacting with patients on the ward. Staff were respectful and provided
patients with appropriate emotional support when they needed it. All three of the patients we
spoke with told us that staff demonstrated a caring approach and were interested in their well-
being. They told us staff treated them well and behaved appropriately towards them. Two of the
patients we spoke with told us that staff were ‘fantastic’, ‘brilliant’ and could not do enough for
patients. Patients told us staff would knock on their door before entering their room.
Staff had strong links with other services and supported patients to access them as appropriate.
For example, we saw how staff supported a patient to access a local community learning disability
and autism service.
Staff recorded each patient’s cultural, social and religious needs and we saw examples of staff
supporting a patient to access a local church of their choosing. Each patient had a personalised
support plan, which described their communication needs and how they wanted to be cared for,
particularly at times of crisis.
When we interviewed staff, they told us they could and would raise concerns to managers about
any disrespectful or abusive behaviour they saw towards patients. Staff told us they would not be
worried about any consequences of raising concerns and thought managers would act swiftly to
deal with any concerns.
Staff knew how to maintain confidentiality. Each patient had a written agreement in their record
showing which people and organisations staff could share patient information with. Staff
understood the importance of patient confidentiality and showed an awareness of the boundaries.
The last Patient-led Assessments of the Care Environment (PLACE) score for privacy, dignity and wellbeing at this location scored higher than similar organisations.
Site name Core service(s) provided Privacy, dignity
and wellbeing
Firshill Rise MH – Wards for people with learning disabilities or
autism 93.8%
Trust overall 96.6%
England average (mental health
and learning disabilities) 90.6%
Involvement in the care
Involvement of patients
Staff provided easy-read information for patients to help orient new patients to the ward and
patients told us that staff provided information to them at admission using language they could
understand.
We reviewed the care plans for six patients in the hospital. All six records showed that staff had
involved patients in their care plans and gave them a copy where they wanted one. We saw
evidence that a patient had written into their own care and risk plans using their own language.
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Staff encouraged patients to fill out a ‘my questions for the team’ sheet about what help they
needed or whether they would prefer to speak personally with the ward manager or the
responsible clinician.
The hospital employed a speech and language therapist who carried out assessments and made
recommendations for patients with communication difficulties. The therapist met with each
patient’s named nurse to produce a personalised communication plan which included easy-read
information where appropriate.
Patients had the opportunity to be involved in decisions about the service through community
meetings. The patient ‘get together’ group met monthly and included an opportunity for patients to
express new ideas and things they would like to get involved in. Some patients also took part in
recruiting new staff by being part of the interviewing process.
Staff told us they looked at advanced decision making as part of the Mental Capacity Act audit and
would support patients to make advanced decisions where appropriate.
Involvement of families and carers
We examined the care and treatment records of six patients at the hospital and found that staff
involved families and carers in the care plan. There was evidence that carers were involved in
care review meetings and one carer we spoke with told us staff updated them weekly on the
progress of their relative. However, except for one carer who we spoke with who told us staff did
involve them and they felt supported by the service, the other relatives and carers we spoke with
in the focus group prior to the inspection and on the inspection visit felt that staff did not provide
them with the appropriate support, and described involvement and communication as poor.
The service produced an information booklet specifically for patients’ carers and families
containing detailed information regarding the treatment on offer at the hospital. Staff told us the
information was based closely on national guidance issued by NHS England. The booklet stated
that staff would offer families independent advocacy support within one week of admission and
that staff would ask regularly if carers needed additional support. Some staff at the hospital told us
this information had only just been put together by the trust and therefore had not been available
to many carers.
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Is the service responsive?
Access and discharge
Bed management
The trust provided information regarding average bed occupancies for wards in this core service between 1 March 2017 and 28 February 2018.
Ward name Average bed occupancy range (1 March 2017 and 28
February 2018) (current inspection)
Firshill Rise 72.5 – 94.76
The trust provided information for average length of stay for the period 1 March 2017 and 28 February 2018.
We are unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the time-period that was covered.
The staff were proud of the work they had done to reduce the average length of stay of patients at the hospital. They told us that one of their biggest challenges was to help patients progress and not be in hospital longer than necessary. Following our inspection, ward managers provided us with data to show that in 2016, the average length of stay of a patient was 122 days but this had reduced to 85 days in 2017.
Ward name Average length of stay range (1 March 2017 and 28
February 2018) (current inspection)
Firshill Rise 1 - 265
This core service reported three out of area placements between 1 March 2017 and 28 February 2018.
The placement that lasted the longest amounted to 2027 days.
All of the out of area placements were due to alternative providers better suiting the patients’ care or personal needs.
Number of out of
area placements
Number due to
specialist needs
Number due to
capacity
Range of lengths
(completed
placements)
Number of ongoing
placements
3 3 - 1044 - 2027 0
This core service reported no readmissions within 28 days between 1 March 2017 and 28 February 2018. Staff held discharge meetings with the patient and community providers to ensure patients had a smooth transition to appropriate community services. As part of our inspection, we observed a discharge meeting about a patient who was ready to leave the ward. We saw how staff had good liaison with community support staff to ensure robust support was in place when the patient left the hospital. This meant staff focussed on reducing patient readmissions as much as possible. The ward had a ‘tree of hope’ where patients getting ready for discharge could write messages on a leaf about what they had learned.
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Discharge and transfers of care
Between 1 March 2017 and 28 February 2018 there were 12 discharges within this core service. This amounts to 1% of the total discharges from the trust overall (804).
Staff planned patients’ discharge as part of the assessment process and reviewed these as part of
multi-disciplinary meetings. The team completed care and treatment reviews with patients to make
sure they had the right support to be able to live safely in the local community. From the period, 1
April 2017 to 31 March 2018, staff carried out nine reviews on seven patients. Of those patients,
four patients were discharged to onward placements, two patients remained in active treatment
and one patient was transferred to locked rehabilitation unit.
Since the last comprehensive inspection, the trust had built an appropriate seclusion facility on the ward so staff could support patients where their behaviour escalated, rather than transferring them to another ward or service.
There were 27 delayed discharges between 1 March 2017 and 28 February 2018. Due to delayed discharges being reported on month by month basis patients can be captured multiple times within the data.
Referral to assessment and treatment times was not provided for this service. We saw that where
possible, patients had a care and treatment review prior to admission. The hospital told us the
reviews were designed to determine whether in-patient care was the most appropriate treatment
and to ensure that all community alternatives had been explored.
Facilities that promote comfort, dignity and privacy
The 2017 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at this location scored higher than similar trusts.
Site name Core service(s) provided Ward food
Firshill Rise MH – Wards for people with learning disabilities or
autism 99%
Trust overall 96.4%
England average (mental health and learning disabilities) 91.5%
The ward was located in a purpose-built building called Firshill Rise. The building had many
unique design features including the colour scheme, which met the King’s Fund ‘enhancing the
healing environment’ standards. Patients had their own bedrooms all with en-suite facilities. The
hospital had one self-contained flat designed to aid and support independent living.
Patients told us they could personalise their bedrooms and had somewhere secure to store their
possessions. Staff told us they were looking to install safe boxes in patient rooms so they could
store their money. In the meantime, staff looked after patients’ money and kept records when
patients wanted take money out.
Staff and patients had access to four comfortable lounges including a female only lounge, an
activities room, a therapy kitchen, a multi-faith room, a fitness room and a de-escalation suite.
Since the last comprehensive inspection, the hospital had built a clinic room and a sensory room
on the ward so patients did not have to move off the ward to access these facilities. The trust had
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also built a seclusion room for use in appropriate circumstances with patients with challenging
behaviour. Patients had access to a garden area with some interactive games. The hospital had a
dedicated meeting room where patients could meet visitors.
Patients were allowed their mobile phones on the ward and this was individually risk assessed and managed. Patients had personal access to the internet on the ward if they had their own laptop or electronic device. Staff gave patients a Wi-Fi password. Patients were also able to use the ward cordless phone on request. The patients we spoke with told us they liked the food. None of the patients staying in the hospital
had unsupervised access to the kitchen and had to ask staff if they required drinks or snacks
outside meal times. Staff placed notices on kitchen doors to prompt patients to ask staff if they
required these.
Patients’ engagement with the wider community
The occupational therapist worked with support staff to provide some activities for patients aimed
at education including cooking and gardening skills. Occupational therapy staff worked with some
patients to access college and voluntary work opportunities.
We saw evidence in care records that staff encouraged patients to maintain contact with their families and carers. However, we saw a sign on the ward about visiting times for carers being limited to certain times of the day. When we asked staff about this, they told us that relatives and carers could visit outside these times provided they advised staff in advance. They gave us an example where they had been able to facilitate visits for a carer who could not make the stated times. None of the patients or carers we spoke with raised concerns about visiting times. The ward manager was the main point of contact for carers and we found no carer’s forums in place. Staff told us they intended to develop this area and had produced a detailed information booklet aimed at families and carers.
Meeting the needs of all people who use the service
The ward had wheelchair access throughout and staff carried out mobility assessments where
patients needed it. Staff had access to hoists and other equipment to support patients with mobility
needs.
Patients told us staff provided information about how to complain and we saw information in the ward areas about local services including information about patients’ rights. This information was available in easy read format. We found some of the activities and materials available for patients were not always age appropriate and were more suitable for young children. Staff told us they had access to interpreter facilities through the trust. They told us the trust could produce information in different languages and different formats where required. They gave us an example of how they supported a patient with reduced hearing. Some staff had been trained to use British sign language with patients. The ward employed housekeeping staff to prepare meals on site. Staff told us there was a menu review taking place in the hospital led by occupational therapy staff and supported by a dietician from the trust. Staff could prepare meals according to patients’ dietary requirements. For example, staff told us that they had a patient who would only eat fish. Staff ensured patients had a choice about the food they ate including any religious requirements they had. Patients had access to a
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multi-faith room and we saw examples where staff supported patients to access a local church of their choice.
Listening to and learning from concerns and complaints.
This core service received two complaints between 1 March 2017 and 28 February 2018. Both
were still under investigation at the time of the provider information request submission.
The patients we spoke with told us they knew how to make a complaint and raise concerns. We
saw information on the ward about the hospital’s complaints procedure and patients could raise
issues in community meetings. However, we saw in the community meeting notes on 24 April
2018 that patients had asked for the television in one of the patient lounges to be fixed but this had
not been done when we carried out the inspection two months later. Following our inspection, we
asked the provider to attend to this and they confirmed they would. Staff told us they knew that
patients could make a formal complaint and they knew the process to enable them to do this.
We saw that managers discussed complaints as a standing item at monthly governance meetings
but when we reviewed notes from team meetings, we could not see that managers had cascaded
any information to staff regarding the outcome of formal complaints. For example, the hospital had
partially upheld a complaint made by a patient’s family at the end of March 2018. When we
reviewed the notes from the team meetings for April and May 2018, we could not see that staff
had received any feedback about this complaint. However, we noted that at their governance
group in May 2018, managers had an action to provide feedback to the team about the outcome of
the complaint and we could see that on the day of our inspection, some staff had participated in a
workshop aimed at learning from the complaint. At the time of our inspection, the service had one
outstanding complaint that the trust had investigated and were in the process of responding to this.
Some of the carers we spoke with told us they had complained informally but had not received a
satisfactory response. When we raised this with managers, they told us the service had received
some negative feedback from carers through the feedback box based in the reception area.
Managers told us they had offered some carers the opportunity for meetings between themselves
and nursing staff to discuss concerns.
This core service received zero compliments during the last 12 months from 1 March 2017 and 28
February 2018.
Following the inspection, staff provided evidence that in June and July 2018, the service received
five compliments. These included compliments from carers, patients and other organisations.
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Is the service well led?
Leadership
A ward manager managed the ward with support from two deputy managers. At each shift, staff
had support from a nurse in charge. The manager we spoke with was not a specialist learning
disability nurse but had received training in positive behaviour support approaches from the nurse
consultant who provided clinical leadership to the service. A psychiatrist and a consultant clinical
psychologist provided further clinical leadership.
The leaders had a good understanding of the services they managed and could explain how the
team worked together including some of the challenges they faced. They worked closely with staff
and patients to provide direct care. The ward manager had been providing nursing cover for a
significant number of shifts and had a good understanding of the needs of the service. During our
visit, we saw managers interacting with staff and patients to deliver treatment.
Managers told us they had opportunities to develop their leadership skills but some of them had
not been able to take full advantage of them due to staffing levels. However, the service had
recently recruited permanent nursing staff and some managers were hopeful that a more settled
period would follow. We did not see evidence that staff below manager level had access to
leadership development opportunities.
Vision and strategy
The staff we spoke with knew what the trust’s vision and values were as these were visible on the
intranet and available to all staff. Staff told us there were clear links to the trust’s vision and values
in their annual performance appraisals.
Staff could tell us what the vision and values meant for them in delivering positive outcomes with
patients and their families. When we observed staff working with patients and with colleagues, we
could see that they demonstrated the trust’s values, for example respect, compassion and
partnership.
Managers told us that front-line staff had the opportunity to contribute to service development
through attendance at local governance meetings but the staff we spoke with told us they found it
difficult to get time away from delivering front-line care. Managers confirmed that one of their
biggest challenges was supporting the team with time away from the ward to get involved in
development multidisciplinary and other meetings.
Staff told us they were part of a new crisis and emergency care network within the trust and were
working closely with their colleagues on improving quality of care. Most of the staff we spoke with
were positive about being part of the new structure but some staff we spoke with thought it would
lead to a reduction in the quality of care provided by the service. Managers were in discussion with
local commissioners about staffing levels, bed numbers and reinvesting resources into a
community intensive support function for patients.
Culture
Managers told us one of their biggest challenges was supporting the team with time away from delivering direct care and reducing the risks to staff stress and low morale. They had conducted a staff stress survey in October 2017, which identified high levels of stress across a number of domains including demands, control, and support. Managers told us that they treated the results with some caution because staff selected themselves for participation and less than a third of the
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workforce took part. When we spoke with staff, they told us the work was stressful and they did not get enough time away from delivering direct care.
Based on the results of the stress survey managers had put some key actions in place, including increased access to reflective sessions, the implementation of acceptable behaviour agreements with patients, staff meetings, and workplace well-being support. When we spoke with staff and looked at notes from meetings, we could see that managers had plans in place to implement regular reflective practice sessions with staff and had discussed implementing behaviour agreements with patients but these initiatives were not yet in place when we inspected the service. We did see evidence that managers had communicated with staff about health and well-being support. The trust had information on the intranet for staff about networks and support groups, personal and professional development, physical, and mental health wellbeing groups. Some of the staff we spoke with did not feel positive about working for the provider and felt they were not involved much in decision-making. They did not feel listened to by members of the multidisciplinary team regarding patient care. Managers we spoke with were aware of these issues and carried out a teamwork and safety survey every three months. They monitored the results through local governance meetings and had a management action plan covering a broad range of staff support issues. The staff we spoke with told us they felt able to raise concerns without fear of retribution and this was confirmed by the teamwork survey carried out by the hospital from December 2017 to February 2018. Although only 20% of the workforce took part in the survey, they reported that the service encouraged them to report safety concerns. Staff told us they knew how to use the whistleblowing procedures and knew there was someone in the trust who they could approach about speaking out. Managers could name the trust’s freedom to speak up guardian and explain the role they played. Some teams worked well together, for example, staff told us doctors and nurses worked well together, and managers valued nursing input. However, the latest team survey indicated that staff thought decision-making did not utilise all the input from relevant personnel and that the service did not resolve disagreements appropriately. Managers told us the trust supported them to deal effectively with conduct and capability issues within the teams and there were no reported cases of bullying or harassment within the teams. Managers told us they carried out annual appraisals with staff and these supported them to have conversations with staff about career development. The sickness absence rates for this core service were higher than the average for the provider. Managers attributed this to high levels of staff stress and assaults on staff from patients. Managers had introduced measures such as safety huddles and improved handovers as a way of reducing staff stress and assaults from patients.
During the reporting period, there were two cases where staff have been either suspended, placed under supervision or were moved to a different ward. Both were cases of suspension.
Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these should be noted.
Governance
Overall, the hospital had systems and procedures to ensure that premises were safe, clean, and
well managed. Staff carried out regular audits covering the full range of activities including the care
environment, medicines management, Mental Health Act and Mental Capacity Act, training,
patient records, supervision and appraisal. Managers monitored audit activities through their local
governance meetings each month. They ensured that staff were trained and that patients were
assessed, treated and discharged in line with trust protocols.
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When managers carried out audits, for the most-part, they acted on the results. For example, we
could see that they had put measures in place to reduce assaults on staff and they monitored
whether assaults were decreasing over time. Data supplied by the hospital identified that from
December 2017 to February 2018, the number of assaults on staff had fallen month by month from
a peak of 50 in November 2017.
Managers had recruited new staff and despite concerns from front-line workers, they operated
over and above their establishment levels for numbers of qualified nurses and support workers.
Managers had put forward a business case to keep staffing at these levels and were awaiting the
outcome of negotiations with service commissioners.
However, we found the hospital did not have effective systems in place to ensure support staff
received supervision. The support staff we spoke with told us they had not received supervision
and the trust reported low compliance rates. We also found that managers allowed some staff to
work on shifts where they had not completed an induction and on 13 shifts in the last three months
there were not always a minimum of three staff on duty trained to the required levels for managing
violence and aggression and restraint.
We found the hospital had a well-embedded incident reporting system and staff discussed patient
incidents at every handover meeting. We saw evidence that managers provided de-brief for
patients and staff following serious incidents. We also found evidence that systems for learning
from incidents and complaints had improved but managers had not embedded these processes
into the service. For example, we saw that some staff were involved in a workshop aimed at
learning from a recent complaint but we did not see evidence that managers routinely shared
lessons learned from non-patient incidents or from other parts of the trust with front-line staff.
We did not see evidence that learning from non-patient related incidents formed part of team
meetings and managers had 71 incidents still requiring manager review. This was something we
told the provider they should take action about at our last comprehensive inspection in November
2016. When we spoke with the provider, they told us that staff discussed incidents involving
patients at every handover and the psychology team monitored the frequency and severity of
incidents involving each patient. They showed us copies of their clinical tracker reports. However,
we could not see that staff had routine access to information concerning non-patient related
incidents. We could see from service action plans that managers had plans to address the amount
of incidents requiring review but the systems were not effective to stop this from occurring again.
Staff understood referral arrangements and care pathways with providers both internally and
externally. They had strong working relationships with other providers to meet the needs of their
patients.
Management of risk, issues and performance
Managers were aware of the high number of assaults on staff and had noted this on the local risk
register, which they monitored at monthly governance meetings. They also identified that the
service had been operating on high levels of agency and flexible staff and had escalated these
concerns to the relevant care network risk register located in the trust. The concerns identified on
the local risk register matched the concerns of staff in the service.
The trust acknowledged that, following a benchmarking exercise, they needed to carry out further
work to map staffing capacity to respond to incidents including the amount requiring review against
other clinical demands. Senior managers in the care network had set up a red flag escalation alert
when the numbers of non-reviewed incidents hit a threshold and local managers monitored
numbers through local governance meetings. The trust archived some incidents with an impact
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rating of lower than moderate. However, local managers still had 71 outstanding incidents to
review.
Information management
Staff had access to equipment and technology to carry out their role including desk space where
staff could use computers and telephones. The hospital had an electronic patient records system
and intended to introduce collaborative care planning to streamline care plans and make multi-
disciplinary decisions easier for staff to access.
Staff were aware of the importance of security and confidentiality in managing patient information.
They had received training in information governance and were familiar with the trust’s procedures
for managing and storing confidential data.
Engagement
Patients and carers had access to up-to-date information about the hospital through the trust’s
website, which had information for patients as well as information for families and carers. The
hospital had produced a new information pack with detailed information for families and carers and
the trust website provided information for staff about the work of the trust.
We saw that carers had access to a feedback box in the reception area of the building where the
hospital was located. Staff told us they had not received much feedback from this mechanism but
were looking at more meaningful ways to engage patients’ families and carers.
Learning, continuous improvement and innovation
Staff participated in a trust initiative to enable people with a learning disability and autism to access mainstream health services. They carried out several audits and took a number of actions to improve health outcomes and share good practice. These included improved awareness and training for staff on learning disability and autism and the development of accessible information and resources across the service.
Staff in this service were part of an initiative called STOMP which stood for ‘stop overmedication of people with a learning disability, autism or both’. Staff convened a stakeholders meeting with internal and external service providers to identify ways to reduce and stop the over prescribing of antipsychotic medication in learning disability services across Sheffield.
Staff in the service used a variety of quality improvement methods including, safety huddles and structured discussions for staff aimed at improving the emotional impact of assaults on staff well-being.
Providers are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.
There were no accreditations for this core service.
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Community-based mental health services for adults of working age
Facts and data about this service
Location site name Team name Number of clinics Patient group (male,
female, mixed)
Fulwood House
Community
Enhancing
Recovery Team
(CERT)
44 Mixed
Fulwood House Home Treatment
Team 44 Mixed
Fulwood House
Mental Health
Recovery Service
North
44 per week
(176 per month) Mixed
Fulwood House
Mental Health
Recovery Service
South
44 Mixed
Fulwood House
Early Intervention
in Psychosis
Service
44 Mixed
Sheffield Health and Social Care NHS Foundation Trust’s community services for adults of working age core service comprised five teams. During this inspection we inspected three teams based at two sites. These were the Mental Health Recovery Service North, the Home Treatment Team and the Community Enhancing Recovery Team.
The community service for adults of working age delivers three broad levels of treatment and support, which are tailored to the individual needs of each service user:
• Enhanced support - intensive and assertive treatment and support for service users who present with a high level of enduring and/or complex mental health needs who would otherwise disengage.
• Active Recovery - treatment and support to service users who present with enduring and/or complex mental health needs.
• Case Management - low level support for service users requiring less frequent contact, for example, service users collecting medication monthly with no other unmet needs or requiring regular but minimal contact to ensure that universal support is effectively meeting their needs.
The Home Treatment Team provides short term intensive mental health support to individuals who would otherwise require admission to hospital.
The Mental Health Recovery Service North provides multi-disciplinary care to people with complex mental health issues. It aims to promote an optimum level of recovery, independence and social inclusion for each individual.
The Community Enhancing Recovery Team is designed as an intensive rehabilitation and recovery team to deliver bespoke packages of care to people in their own homes as an alternative to hospital admission. The service provides support for people currently placed in locked rehabilitation hospitals, often outside of the city returning to Sheffield, living in their own accommodation.
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The community services for adults of working age had recently undergone a reconfiguration exercise at the time of our inspection. The aim of the reconfiguration was:
• to ensure quality of clinical and operational leadership
• to operate consistently across the City including standardised assessment and treatment in line with National Institute for Health and Care Excellence guidelines and quality standards
• to articulate and understand the definition of each component part of the service offer for staff, the people who used the services and referring agencies
• to ensure a well governed, performance managed operating system with leaders empowered to manage flow in community services
• to make the service financially affordable and sustainable over the next two operating years
• to ensure a consistently effective workforce through motivated staff with relevant skill sets
• investing in staff to bring about continuous service improvement.
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Is the service safe?
Safe and clean environment
Staff adhered to the service’s security arrangements. All visitors to the service were required to sign in and out and provide personal identification. There were no call alarms in the rooms at the service bases, however, patients were normally seen at their homes or alternative location of their choice.
The buildings were clean and tidy, furnishings were well maintained, and of a wipeable material which complied with infection control procedures. Health and safety documentation for the services, including certificates for gas, electrical, legionella, fire and other tests were in-date.
Staff undertook regular assessments of the environment and rectified any issues identified. For example, anti-ligature pull cords had recently been fitted in the disabled toilet and coat hooks had been removed from interview and activity rooms at the Mental Health Recovery Service North as they had been identified as potential ligature points. A ligature point is anything which could be used to attach a cord, rope or other material for hanging or strangulation. Signage was posted at both sites to show who the fire wardens and first aiders were.
Staff adhered to infection control procedures. Hand sanitising gel was available throughout the service and there were washing facilities throughout the service buildings. The services had their own domestic staff who regularly cleaned the environment. Equipment used to deliver care and treatment was clean and in working order with stickers to indicate when they had been serviced.
The Community Enhancing Recovery Team could access emergency medicines and equipment from the trust’s inpatient service when required.
The Home Treatment Team and Mental Health Recovery Service North shared a supply of stock emergency medication. These services could also order urgently required medication from the trust’s pharmacy department at short notice which could be either collected or delivered.
Safe staffing
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies). Any negative numbers indicate an over-establishment.
Substantive staff figures Trust target
Total number of substantive staff At 31 January 2018 213.2 N/A
Total number of substantive staff leavers 1 February 2017- 31 January 2018
34.6 N/A
Average WTE* leavers over 12 months (%) 1 February 2017- 31 January 2018
9% 13%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31March 2018 19 N/A
Total vacancies overall (%) At 31March 2018 8% NA
Total permanent staff sickness overall (%)
Most recent month (At 31 January 2018)
11% 5%
1 February 2017 to 31 January 2018
6% 5%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 March 2018 80 N/A
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Establishment levels nursing assistants (WTE*) At 31 March 2018 66 N/A
Number of vacancies, qualified nurses (WTE*) At 31 March 2018 -4 N/A
Number of vacancies nursing assistants (WTE*) At 31 March 2018 3 N/A
Qualified nurse vacancy rate At 31 March 2018 -5% N/A
Nursing assistant vacancy rate At 31 March 2018 5% N/A
Bank and agency Use
Shifts bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 March 2017 and 28
February 2018 188 N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses)
1 March 2017 and 28
February 2018 0 N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses)
1 March 2017 and 28
February 2018 7 N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 23 N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 0 N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants)
1 March 2017 and 28
February 2018 0 N/A
*Whole-time Equivalent
This core service reported there was a 5% over-establishment of registered nurses at 31 March 2018.
This core service reported an overall vacancy rate of 5% for nursing assistants.
The vacancy rate for nursing assistants was higher than the 1% reported at the last inspection.
This core service has reported a vacancy rate for all staff of 8% as of 31 March 2018. This was not comparable to the rate reported at the last inspection (between 1 August 2015 to 31 July 2016).
Registered nurses Health care assistants Overall staff figures
Team Vacanci
es
Establishme
nt
Vacanc
y rate
(%)
Vacanci
es
Establishme
nt
Vacan
cy rate
(%)
Vacanci
es
Establishme
nt
Vacan
cy rate
(%)
Adult
Home
Treatme
nt
-4 27 -15% -2 8 -25% 18 65 28%
MH
Recover
y North
2 13 15% 3 9 33% 9 34 26%
Early
Interventi
on
Service
2 18 11% 0 5 0% 5 41 12%
CERT -1 9 -11% 2 38 5% 1 57 2%
MH
Recover
y South
-3 13 23% 0 6 0% -14 36 -39%
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Registered nurses Health care assistants Overall staff figures
Core
service
total
-4 80 -5% 3 66 5% 19 233 8%
Trust
total 32 433 7% 15 353 4% 68 1339 5%
NB: All figures displayed are whole-time equivalents
Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by
bank or agency staff
Home
Treatment
Team
0 188 0 7
Core service
total 0 188 0 7
Trust Total 32,394
4977
(15%*)
7252
(22%*)
900
(3%*)
*Percentage of total shifts has only been provided for trust wide figures. The available shifts data was not
provided for this core service. We are therefore unable to provide proportions filled information for this core service.
Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by bank
or agency staff
Home
Treatment
Team
0 23 0 0
Core service
total 0 23 0 0
Trust Total 59,514 21,770
(37%*)
5623
(9%*)
1760
(3%*)
*Percentage of total shifts have only been provided for trust wide figures. The available shifts data was not
provided for this core service. We are therefore unable to provide proportions filled information for this core service.
This core service had 34.6 (9%) staff leavers between 1 March 2017 and 28 February 2018. This was slightly lower than the 11% reported at the last inspection (1 August 2016 and 31 July 2017).
Team Substantive staff
Substantive staff Leavers Average % staff leavers
West CMHT Senior Medical 0 1 60%
CMHT's Central 0 4.6 26%
South East CMHT 3.0 6 20%
North CMHT Admin 0 2 18%
West CMHT 1.4 4.4 18%
South West CMHT 1 4.8 15%
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Team Substantive staff
Substantive staff Leavers Average % staff leavers
South East CMHT Admin 0.8 1 11%
West CMHT Admin 0 1 8%
MH Recovery North 36.8 2.5 7%
North CMHT 2 2 6%
South West CMHT Admin 0.8 0.6 6%
CERT 58.3 3 5%
Early Intervention Service 32.3 1 4%
MH Recovery South 41.5 0.8 2%
Adult Home Treatment 34.6 0 0%
North CMHT Senior Medical 0.8 0 0%
South East CMHT Senior Medical 0 0 0%
South West CMHT Senior Medical 0 0 0%
Core service total 213.2 34.6 9%
Trust Total 1351.6 129.6 8%
The sickness rate for this core service was 6% between 1 February 2017 and 31 January 2018. The annual sickness rate was similar to the annual sickness rate of 6% reported at the last inspection in 31 July 2016.
Sickness absence figures for staff were high at the Mental Health Recovery Service North. They were an average of 14% in the 12 months prior to our inspection, twice the annual average figure for this core service, and had reached 20% in the final month. This was having an impact on staff morale and caseloads although there was no evidence this was affecting patient and staff safety. The reasons for sickness absence included work related stress as well as other more common health problems. Staff reported their caseloads were between 40 and 50 patients each because of other staff being absent due to sickness leave and were not manageable. Caseloads were monitored by managers during staff supervision sessions. Some staff members were on sickness absence due to work-related stress. However, the trust had been proactive by employing four agency staff members to cover sickness absences. Two of these staff had worked at the service for several months and were familiar with the way the service operated. The other two agency staff had recently joined the team and were still familiarising themselves with the service. Vacancy and sickness absence figures for the Home Treatment Team were also high at an average of 18% over the last 12 months, 11% higher than the annual average for this core service. However, at the time of inspection, some posts had been filled and staff said this had improved working practices and morale within the team.
Team Total % staff sickness Ave % permanent staff
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(at latest month) sickness (over the past year)
Adult Home Treatment 18% 18%
MH Recovery North 20% 14%
South East CMHT Admin - 13%
MH Recovery South 8% 11%
North CMHT 47% 10%
South East CMHT 44% 7%
Early Intervention Service 6% 6%
CERT 4% 5%
West CMHT 2% 5%
West CMHT Admin - 4%
South West CMHT 0% 3%
South West CMHT Admin 0% 3%
North CMHT Admin - 2%
North CMHT Senior Medical 0% 2%
CMHT's Central - 1%
South West CMHT Senior Medical - 1%
West CMHT Senior Medical - 1%
South East CMHT Senior Medical 0% 0%
Core service total 11% 6%
Trust Total 8% 7%
Managers at the services we inspected were unable to give a clear explanation as to how staffing numbers were calculated. They stated that this was because the staffing figures had had been calculated before they had started working in their teams. However, we had no concerns about the actual establishment levels of staff at either service and there were plans in place to recruit two nurses above actual establishment levels at the Mental Health Recovery Service North. The potential for an additional four care co-ordinators being established at the Mental Health Recovery Service North was being considered as part of the next round of staff recruitment to the service.
All three services had full time psychiatrists. They also had access to an additional psychiatrist from the trust to cover leave or sickness when required. For out of hours, the trust’s on call psychiatrists were utilised.
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Mandatory training
The compliance for mandatory and statutory training courses at 28 February 2018 was 87%. Of the training courses listed, six failed to achieve the trust target and of those, two failed to score above 75%. These were Respect level one training and intermediate life support.
The training compliance reported for this core service during this inspection was higher than the 57% reported at the last inspection.
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service %
Trust target % Trustwide mandatory/ statutory training total %
Mental Health Act 100% 80% 83%
Clinical Risk Assessment 98% 80% 91%
Fire Safety 3 years 98% 80% 96%
Health and Safety (Slips, Trips
and Falls) 97% 80% 97%
Equality and Diversity 96% 80% 95%
Mental Capacity Act Level 1 95% 80% 94%
Fire Safety 2 years 93% 80% 96%
Hand Hygiene 93% 80% 94%
Safeguarding Children (Level 3) 92% 80% 91%
Autism Awareness 88% 80% 88%
Respect Level 2 88% 80% 80%
Mental Capacity Act Level 2 85% 80% 85%
Safeguarding Adults (Level 2) 84% 80% 87%
Domestic Abuse Level 2 83% 80% 85%
Rapid Tranquilisation 82% 80% 88%
Medicine management training 82% 80% 87%
Information Governance 81% 80% 80%
Deprivation of Liberty
Safeguards Level 0 79% 80% 80%
Safeguarding Children (Level 2) 78% 80% 85%
Adult Basic Life Support 78% 80% 81%
Dementia Awareness (inc
Privacy & Dignity standards) 78% 80% 85%
Respect Level 1 68% 80% 66%
Immediate Life Support 50% 80% 88%
Core Service Total % 87% 80% 88%
However, compliance figures for mandatory training were low for staff at the Mental Health Recovery Service North at the time of our inspection, with 69% of clinical staff and 24% of social workers compliant with their mandatory training. Figures below 75% compliance included mandatory training in basic life support, health and safety, preventing falls, fire safety, Mental Capacity Act, dementia, autism awareness, domestic abuse and safeguarding. The low figures were partly because some of the staff members eligible for mandatory training were on long-term sickness absence.
Mandatory training compliance figures were also low at the Home Treatment Team in relation to dementia awareness, medicines management awareness, respect levels one and two and safeguarding children.
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However, compliance figures for the Community Enhancing Recovery Team were high and were 96% overall.
Assessing and managing risk to patients and staff
Assessment of patient risk
The trust had a risk assessment tool called the Detailed Risk Assessment and Management Plan. The tool recorded each patient’s history and included templates for making referrals to GPs and other health professionals. The Detailed Risk Assessment and Management Plan tool included the patient’s risk to themselves and others, details of any self-neglect, risk of exploitation, risks to dependants and other risks.
Staff at the Mental Health Recovery Service North did not regularly update risk assessments within patients’ records. We looked at 24 patient risk assessments; nine at the Mental Health Recovery Service North, seven at the Community Enhancing Recovery Team and eight at the Home Treatment Team. Risk assessments were in place for all patients at the Community Enhancing Recovery Team and Home Treatment Team and staff had updated regularly. However, seven of the nine risk assessments at the Mental Health Recovery Service North had not been updated for over six months. The service manager told us that they expected risk assessments to be updated every six months as a minimum. We also noted that a letter dated 18 April 2018 had been returned by a GP to say a patient was now under the care of a different GP surgery. However, staff had not changed the GP's details in the patient’s record, which could cause delays if staff needed to contact the GP urgently over concerns about the patient's physical health status.
The services made good use of crisis plans and advance decisions. Care records contained details of health professionals to contact when patients were in crisis and actions to take, for example, one patient’s crisis plan detailed the distraction techniques staff should use to calm the patient down. We saw evidence in patients’ care records that staff assisted patients who wanted to make advance decisions about their care and treatment choices when requested.
Management of patient risk
Staff responded promptly to sudden deterioration in a patient’s health. Staff consulted the multidisciplinary team and emergency psychiatrists when they identified any concerns. There were enhanced support teams within the Mental Health Recovery Teams who provided a crisis response and a higher level of support outside a patient’s scheduled planned care when required.
The services had good lone working practices. These included a buddying system, use of mobile phones, a signing in and out register and boards in the reception offices which gave details of the time and location of any external visits to patients.
Safeguarding
A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include physical, emotional, financial, sexual, neglect and institutional.
Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.
This core service made 1300 safeguarding referrals between 1 February 2017 and 31 January 2018, all of which concerned adults only.
Referrals
Adults Children Total referrals
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85
103110 109
130
119112
92
137
102
80
121
0
20
40
60
80
100
120
140
160
Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18
Total Safeguarding referrals
Staff knew how to raise safeguarding alerts; they could provide examples of the possible signs of abuse. Examples of referrals that had been made included instances when patients had been exploited financially by friends or family members. However, safeguarding training compliance was low for staff at the Mental Health Recovery Service North despite the training being mandatory; 64% of nursing staff had completed safeguarding children level 2 and only 22% of social workers had completed safeguarding adults level 2. Training compliance figures at the other services we inspected were between 90 and 100%.
The trust had policies and procedures in place in relation to equality and diversity to protect the people who used the service from discrimination and harassment. The trust also employed transcultural workers and spirituality leads to address issues around culture and religion. The Community Enhancing Recovery Team also held weekly firefighting meetings and case formulation meetings during which, staff discussed issues in relation to safeguarding and protecting individuals from discrimination and harassment.
Sheffield Health and Social Care NHS Foundation Trust submitted details of one external case review which was commenced or published in the last 12 months that relate to this core service. The trust has one on-going case relating to a young person. The services involved were the Early Intervention Service, Liaison Psychiatry, Home Treatment Team and Crisis House.
Staff access to essential information
Staff had access to all the information they needed to deliver safe patient care and treatment. The service used an electronic care records system, which staff could use effectively and arrangements were in place to enable all staff to share patient information both internally and externally with other health professionals.
1300 0 1300
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Medicines management
There were safe procedures in place for the transportation, recording, storage and disposal of medicines. The Community Enhancing Recovery Team only stored medication for patients who required support with self-administration. The room at the Community Enhancing Recovery Team used for storing medicines had been as high as 27 degrees Celsius for a few days prior to our inspection but staff had reported this to senior managers and plans were afoot to move the medicines to a cooler room.
The Mental Health Recovery Service North did sometimes hold controlled drugs at the service but this was rare. On the occasions controlled drugs were held, the team liaised with the accountable officer who worked in the trust’s pharmacy department to ensure the correct measures were in place. The service’s senior practitioner nurse was the lead with local medication management arrangements. Staff reviewed patients’ medication and the effects of medication on patients’ physical health during care programme approach meetings, multidisciplinary meetings, and other team meetings. These reviews were in line with guidance from the National Institute for Health and Care Excellence.
We reviewed 25 medication cards across the three services and found they were in order.
Track record on safety
Providers must report all serious incidents to the Strategic Executive Information System (STEIS) within two working days of an incident being identified.
Between 1 March 2017 and 28 February 2018 there were 14 STEIS incidents reported by this core service. Of the total number of incidents reported, the most common type of incident was Apparent/actual/suspected self-inflicted harm with 11 incidents.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with STEIS. There were 14 incidents in STEIS and the trust provided information on 15 serious incidents.
The number of serious incidents reported during this inspection was lower than the 18 reported at the last inspection.
Type of incident reported on STEIS
Number of incidents reported Apparent/actual/suspected
homicide meeting SI
criteria
Apparent/actual/suspected
self-inflicted harm meeting
SI criteria
Medication
incident
meeting SI
criteria
Total
Early Intervention Service 3 3
CMHT SW Access 2 2
CMHT SW Recovery 1 1 2
CMHT SE Home Treatment 1 1
North Home Treatment 1 1
CMHT North 1 1
CMHT SW Home Treatment 1 1
CMHT West 1 1
CMHT West Recovery 1 1
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Mental Health Recovery South 1 1
Total 1 11 2 14
Reporting incidents and learning from when things go wrong
The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths.
In the last two years, there have been no ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.
Staff at the services knew how to report incidents. Staff had access to the trust's electronic reporting system. Staff gave examples of the types of incidents that were reported which included assaults, verbal abuse, medication errors, high caseloads and low staffing levels. The trust’s patient safety team fed back any lessons learned from incidents to staff and managers fed back directly to staff members who had raised incidents. Manager debriefed and offered support to staff following serious incidents. The services also held reflective practice meetings during which staff were able to consider findings and learning points from incidents, which had been investigated. We also saw evidence in minutes of team meetings that incidents and associated issues were a standing agenda item. At the time of our inspection visit, an incident in which a member of staff had been threatened by a patient had recently occurred. Staff were debriefed and offered support afterwards. The trust was conducting a review of the incident to identify any lessons that could be learned for the future.
Staff understood the duty of candour. They described being open and transparent, offering patients and families a full explanation and apology when something went wrong, and keeping them regularly informed of any investigations.
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Is the service effective?
Assessment of needs and planning of care
We looked at 24 patient care records across the three services we inspected. Four out of the 24 records did not include details of a comprehensive mental health assessment of the patient. The records for the Community Enhancing Recovery Team and Home Treatment Team all contained evidence that patients had undergone a comprehensive mental health assessment.
Out of the 24 records we looked at, 23 contained evidence that staff had developed care plans in collaboration with the patient or their carers and all care plans were personalised, holistic, recovery based and included goals for each patient.
Best practice in treatment and care
Staff provided a range of care and treatment interventions, which were in line with guidance from the National Institute for Health and Care Excellence. For example, the services’ psychology teams offered interventions which included cognitive behaviour therapy, eye movement desensitisation and reprocessing and compassion focussed therapy. Staff also provided patients with support and advice around opportunities for education, employment, housing and benefits and living skills.
Staff ensured patients’ physical healthcare needs were met and encouraged patients to attend annual health checks and other appointments with GPs and other health professionals. Care records contained evidence that staff were monitoring patients’ physical healthcare and involving other healthcare professionals where appropriate. For example, one record showed that staff carried out monthly blood tests on the patient, conducted regular electrocardiogram tests to monitor the effects of their medication and referred the patient to their GP to review their medication. Another record contained evidence that staff were carrying dietetic assessments and providing advice to the patient about nutrition. Staff audited their own caseloads to ensure that physical health information was up to date and accurately reflected their patients’ current physical health status. Staff liaised with the multidisciplinary team and patients’ GPs if they had any concerns around a patient’s physical healthcare.
Staff encouraged patients to live healthier lifestyles by promoting exercise, eating healthily and smoking cessation. Posters and information about support, treatment and advice about cancer screening, diabetes and a range of other health related issues were also available in the waiting area.
The services used recognised ratings scales to rate patients’ severity and outcomes. These included Health of the Nation Outcome Scales, Recovering Quality of Life, and the clustering tool.
The services used online facilities to support patients effectively. This included online friends and families tests, which staff used to gain feedback and suggestions from the people who used the service and the purchase of tablets for mobile working. Staff also provided patients with details of the services’ and wider trust’s social media pages and website.
This core service participated in the following clinical audits as part of their clinical audit
programme in the 12 months leading up to the submission of the provider information return.
Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
National Audit
of Early
Intervention
Services
Early
Intervention in
Psychosis
Service
MH -
Community-
based mental
health
services for
adults of
working age.
Clinical
Data
collection
completed
January
2018.
Awaiting
publication
Awaiting publication of
results. Preliminary results
to be shared.
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Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
of report
Care Pathway
for Early Onset
Dementia
CMHT North
MH -
Community-
based mental
health
services for
adults of
working age.
Clinical Feb-17
Acknowledged need to
develop specific standards
for this referral pathway.
Physical Health
Monitoring in
the Early
Intervention
Service
Early
Intervention in
Psychosis
Service
MH -
Community-
based mental
health
services for
adults of
working age.
Clinical Apr-17
The results of this audit
were presented to the
members of the weekly
EIS Microsystems team.
The EIS team plan to
address the issues raised
in order to develop
changes in team practice
capable of driving the
necessary improvements.
Physical Health
Monitoring in
Patients on
Antipsychotics
South East
Home
Treatment Team
MH -
Community-
based mental
health
services for
adults of
working age.
Clinical Nov-17
Findings shared with the
South East Home
Treatment Team for local
improvements.
Clinical Audit to
review case
discussions of
newly allocated
service users
within MDT
meetings
West Recovery
team
MH -
Community-
based mental
health
services for
adults of
working age.
Clinical Oct-17
Detailed information and
discussion to be
documented on the
electronic care record
instead of MDT minutes.
Local audit of
completion of
Physical Health
Review forms
and appropriate
action taken
South West
Community
Mental Health
Team – Home
Treatment Team
MH -
Community-
based mental
health
services for
adults of
working age.
Clinical Oct-17
Shared with service for
local learning and
improvements.
Audit of
identification of
carers and
assessment of
their needs in a
community
mental health
team
North Recovery
team
MH -
Community-
based mental
health
services for
adults of
working age.
Clinical On-going Awaiting findings
Collaboration
with Primary
Care Clinicians
Service users
on CPA
Provider
wide
Clinical on-going Changes made following
previous audit round:
provide guidance to staff
on annual reviews of care.
Changes to care plan form.
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Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
Creation of a 'clinical
review for GP' IT system
solution.
Record keeping
audit 2016/2017
Trust wide Provider
wide
Clinical on-going From data collected so far:
Further clarity provided to
staff on use of
abbreviations - to be
incorporated into the
relevant policy.
Audit of risk
assessments
2016/2017
Trust wide Provider
wide
Clinical audit March 2017 Local action plans to
address identified issues.
Audit tool to be revised to
give clearer results.
Re-audit to be undertaken
in 2017/18.
Audit of risk
assessments
2017/2018
Trust wide Provider
wide
Clinical audit On-going Await findings
Audits of care
plans
Trust wide Provider
wide
Clinical audit January
2018
Agreed need for frequent
small scale audits.
Findings being shared with
teams.
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG43
Transition from
children’s to
adults’ services
for young
people using
health or social
care services
Trust wide Provider
wide
Clinical audit June 2017 Findings fed into
Commissioning for Quality
and Innovation and other
related joint work with child
and adolescent mental
health services to improve
transitions
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG13
Workplace
health:
management
practices
Trust wide Provider
wide
Clinical audit September
2017
Review practices against
guidance as necessary in
future
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG58
Coexisting
severe mental
illness and
substance
Trust wide Provider
wide
Clinical audit December
2017
Action plan under
development
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Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
misuse:
community
health and
social care
services
National audit of
psychosis
Adult acute
inpatient wards,
recovery team
and sort team
Multiple Clinical Data
collected
October
2017
Awaiting results
Cardio-
Metabolic
Assessment &
Treatments
Adult acute
inpatient wards,
recovery team
and sort team
Multiple Clinical Data
collected
February
2017
Agreed focus on physical
health reviews in
community settings.
The Community Enhancing Recovery Team was in the process of recruiting an assistant psychologist and researcher, part of whose role would involve looking into future audits at the service.
Skilled staff to deliver care
All services had a full range of specialists within the teams including psychiatrists, psychologists, nursing staff, recovery workers, support workers, occupational therapists, social workers, and other allied health professionals.
Staff were experienced, qualified and had the necessary skills to deliver effective care and treatment to meet the needs of their patients. In addition to mandatory training, staff could access specialist training for their individual role. Examples of specialist training undertaken by staff in the last 12 months included cognitive behaviour therapy, dialectical behaviour therapy, analytical therapy, substance misuse and psychosocial interventions. Staff were also able to attend lectures at local universities and colleges. Staff identified the training and development needs of staff during supervision and appraisal discussions and arranged for them to attend suitable training accordingly.
The service manager at the Mental Health Recovery Service North had been working at the service for three months at the time of our inspection visit. Prior to their establishment at the service, team meetings had not featured standard agenda items. The new service manager had introduced standing agenda items so the focus and structure of team meetings had greatly improved.
Managers provided new staff and agency staff with an appropriate induction. Staff were booked on training modules relevant to their role when they commenced their employment, shadowed experienced staff and completed mandatory training, which included health, and safety related modules. Managers monitored the new staff member’s progress in accordance with the trust’s probation procedures.
The trust had a performance management system in place, which included procedures for managers who needed to address poor staff performance.
There were no volunteers working at either of the services at the time of our inspection visit.
The trust’s target rate for appraisal compliance was 90%. As at February 2018, the overall appraisal rates for non-medical staff within this core service was 96%. At the time of the inspection, the appraisal rate for the Community Enhancing Recovery Team was 93%, Home Treatment Team 94% and the Mental Health Recovery Service North was 100%.
The rate of appraisal compliance for non-medical staff reported during this inspection was higher
than the 86% reported at the last inspection.
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Team name
Total number of
permanent non-medical
staff requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an appraisal
% appraisals
MH Recovery South 44 44 100%
North CMHT 2 2 100%
South East CMHT 4 4 100%
South West CMHT Admin 1 1 100%
West CMHT 1 1 100%
CERT 60 59 98%
Adult Home Treatment 36 34 94%
Early Intervention Service 34 32 94%
MH Recovery North 42 38 90%
South West CMHT 2 1 50%
Core service total 226 216 96%
Trust wide 1495 1440 96%
The trust’s target rate for appraisal compliance is 90%. As at February 2018, the overall appraisal
rates for medical staff within this core service was 91%.
The rate of appraisal compliance for medical staff reported during this inspection was higher than
the 90% reported at the last inspection.
Team name
Total number of
permanent medical staff
requiring an appraisal
Total number of
permanent medical
staff who have had
an appraisal
%
appraisals
Adult Home Treatment 1 1 100%
CERT 1 1 100%
Early Intervention Service 2 2 100%
MH Recovery North 2 2 100%
MH Recovery South 3 3 100%
South East CMHT Senior Medical 1 1 100%
North CMHT Senior Medical 1 0 0%
Core service total 11 10 91%
Trust wide 57 56 98%
We looked at the appraisal rates for all staff at both services during our inspection and both services' rates were high. The appraisal rate for the Community Enhancing Recovery Team was 93%, Home Treatment Team 94% and the Mental Health Recovery Service North was 100%.
The trust’s target for clinical supervision is 66% for non-medical staff.
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Between 1 March 2017 and 28 February 2018, the average rate across the two teams in this core service was 54%.
Caveat: there was no standard measure for clinical supervision and trusts collect the data in different ways, it is important to understand the data they provide.
The rate of clinical supervision reported during this inspection was lower than the 60% reported at
the last inspection.
The trust’s target for clinical supervision for medical staff is 66%
Between 1 March 2017 and 28 February 2018, the average rate across all teams in this core service was 100%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it is important to understand the data they provide.
The rate of clinical supervision reported during this inspection was higher than the 60% reported at the last inspection.
Team name Clinical supervision
sessions required
Clinical
supervision
delivered
Clinical
supervision rate
(%)
MH Recovery South
2 2 100%
Core service total 2 2 100%
Trust Total 91 250 275%
We looked at the compliance rates for the three services during our inspection. The compliance rates were low in all three services:
• 42% in the Home Treatment Team
• 48% in the Mental Health Recovery North Team
• 52% in the Community Enhancing Recovery Team
However, staff had access to additional supervision via ad-hoc one to one sessions with their managers and reflective practice sessions which were held three times a week. These additional supervisions were not formally recorded so we were unable to determine how many staff had taken advantage of them. The trust was only able to send limited supervision compliance data in relation to the Mental Health Recovery Service North as changes in the way the service recorded supervision had been recently implemented. For this reason, we have based the overall compliance rate for all three services for the January to April 2018 period to ensure each service has been treated equitably.
Multidisciplinary and interagency team work
Multidisciplinary team meetings at both services were held regularly. Other regular meetings included case formulations, handovers and reflective practice meetings.
Staff shared information about patients during handover sessions at each service. For example, at the Mental Health Recovery Service North, the senior practitioner nurse carried out handovers to staff taking over patient responsibility when their usual care worker was commencing leave. Managers allocated daily tasks in relation to patient care in staff calendars.
We observed multidisciplinary team meetings at the Home Treatment Team and Community Enhancing Recovery Team and a daily meeting at the Community Enhancing Recovery Team. They were well attended from a range of disciplines, including nurses, doctors and a psychologist.
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There was positive input from the whole team. Risk assessments and care plans were discussed and reviewed. There was strong evidence that the teams were providing an alternative service to those who would need a hospital stay and that disciplines had a good knowledge of their patients.
All services had effective links with external health organisations. Staff had been working with family care services and a local GP hub to increase awareness of each other’s needs and seek mutually beneficial ways of working together. Staff also reported that links with the police and adult social care organisations had improved over the last 12 months.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
As of 28 February 2018, 100% of the workforce had received training in the Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient and all community staff and renewed every three years.
There was a central team within the trust who staff could contact if they needed help and advice about the Mental Health Act. This team was also responsible for ensuring staff adhered to the Act and carried out audits of records to ensure staff followed best practice around the Act. The trust had a policy on the Mental Health Act, which reflected up to date guidance that staff could access via the trust intranet.
All services worked with detained patients who were due to be discharged to the community services or were on community treatment orders. The documentation relating to the Mental Health Act and use of community treatment orders was correct and up to date. Staff regularly reminded patients of their rights in ways they could understand and recorded this within patients’ care records. Patients had access to independent mental health advocacy services.
Care records referred to identified section 117 aftercare services where appropriate for patients who had been subject to section 3 or equivalent part 3 powers where appropriate. An example included reference to a patient who was receiving ongoing support from an occupational therapist following discharge.
Good practice in applying the Mental Capacity Act
As of 28 February 2018, 95% of the workforce had received training in the Mental Capacity Act Level 1 and 85% of the workforce had received training in Mental Capacity Act Level 2. The trust stated that this training was mandatory for all core services and renewed every three years.
However, staff at the Mental Health Recovery Service North were not up to date with their mandatory training in the Mental Capacity Act at the time of our inspection, as follows:
• 64% nursing staff had completed the Mental Capacity Act Level 1 training
• 76% nursing staff had completed the Mental Capacity Act Level 2 training
• 33% social workers had completed the Mental Capacity Act Level 2 training
The figures for all aspects of Mental Capacity Act training were high in relation to staff at the Community Enhancing Recovery Team and Home Treatment Team.
Despite some pockets of low compliance figures for the Mental Capacity Act training, staff at both services were adhering to the Act. Staff could give examples and explanations of different aspects the Act encompasses such as the use of capacity assessments, best interests decisions, Deprivation of Liberty Safeguards and the five statutory principles of the Act to demonstrate their knowledge and understanding. We saw evidence in care records that staff had undertaken capacity assessments, had involved professionals within and external to the team when appropriate, and had given patients help to make decisions on their own behalf. Patients had access to independent mental capacity advocacy services.
There was a central team within the trust who staff could contact if they needed help and advice about the Mental Capacity Act. This team was also responsible for ensuring staff adhered to the
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Act and they carried out audits of records to ensure staff followed best practice around the Act. The trust had a policy on the Mental Capacity Act which staff could access via the trust’s intranet.
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Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
We spoke with nine patients and three carers during our inspection who all stated that staff within the three services treated them with kindness, dignity, respect, and compassion. They said that staff understood their individual needs, were interested in their wellbeing and helped them to understand and manage their own condition, care, and treatment. Staff supported patients to attend their chosen place of worship in the community and there were posters in the service’s reception areas about the trust’s chaplaincy service. Staff directed patients to other services where appropriate. For example, one patient had told staff they wanted help to lose weight so staff provided advice on healthy food choices and arranged for them to see a dietician. Patients also confirmed that they were confident that staff always maintained their confidentiality.
We accompanied staff members for two visits to patients’ homes to observe how each patient was treated. Staff interacted with the patients in a calm, polite and friendly manner and as they explained what was happening, they clarified their understanding about their current care and treatment.
We received feedback from 11 people who used the service via comments cards. Nine of these people commented that staff were kind and caring and felt their care and treatment needs were being met.
Staff who spoke with us said the trust actively encouraged them to raise concerns about any inappropriate treatment of patients or carers and there was an open culture around the protection of people who used its services.
Staff received information governance training which included the requirement to always maintain patient confidentiality.
Involvement in care
Involvement of patients
Staff involved patients in care planning in relation to their care and treatment and offered patients copies of their care plans. We looked at 24 patient care records across the three services and all but one of these contained evidence that patients were involved in decisions about their care and treatment plans.
We saw evidence that staff communicated with patients clearly, so they understood their care and treatment needs during visits to patients’ homes. The services used pictures, cue cards, easy read information and sought advice and guidance from speech and language therapists to help patients with communication issues. Staff also used online translation services if patients needed written information in different languages.
Staff involved patients in decisions about the service they received. For example, patients were able to be part of recruitment panels when new staff were being recruited to the services. The trust also ran a community patient forum group called Sunrise, which enabled patients to make suggestions on how to improve the service they received. The services also used Friends and Family Tests as a way of gaining feedback on the care and treatment they provided. The Community Enhancing Recovery Team had offered patients the opportunity to buy equipment up to the value of £750 to help with their care and treatment.
Staff assisted patients who wanted to make advance decisions about their care and treatment choices when requested. Staff also made patients aware of advocacy services through information leaflets and posters. We saw posters that gave contact details for advocacy services in the reception areas at each of the services we inspected.
Two comments cards contained negative feedback about the service the persons concerned had received. One included negative comments about the reconfiguration exercise, which had led to the person having to travel further for appointments using public transport. The other person
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stated there was nothing good about the service they used but because the person did not provide their contact details or the name of the service they were using, we were unable to determine the reason for their being dissatisfied. Involvement of families and carers Staff involved families and carers appropriately in decisions about the care and treatment of the people they cared for and kept them informed. We saw evidence in patients’ care records that staff had consulted with families and carers about the care and treatment needs of the person they cared for and that carers assessments had taken place. Carers could ring the service during normal working hours or they could ring the first response team out of hours if they needed advice or support.
The services also used Friends and Family Tests as a way of gaining feedback on the care and treatment they provided.
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Is the service responsive?
Access and waiting times
We requested data from the trust in relation to the average waiting times for both services. The trust provided data for the average number of days from referrals to case allocation, which was two days and from when referrals were made to the services accepting them, which was eight days. The trust’s Single Point of Access team triaged referrals based on the individual needs and ensured the services dealt with urgent cases as a priority. An out of hours service was available if patients needed assistance during the night. The selection criteria for the Mental Health Recovery Service North was that patients were aged between 18 and 65, diagnosed with substantial and complex mental health needs, which primary care, secondary health care or social care services could not meet alone.
The criteria for the Community Enhancing Recovery Team was that patients were aged 18 or over at the time of referral, were living in Sheffield and under the responsibility of Sheffield care commissioning groups. The criteria for the Home Treatment Team was that adult patients were aged between 18 and 65, and patients aged between 16 and 17 years were experiencing their first episode of psychosis. It also cared for patients who were experiencing a relapse in their mental health, or were presenting with a first episode of acute mental health deterioration and needed treatment and/or additional intervention and who, without this, were likely to be admitted to hospital. The Mental Health Recovery Service North and Home Treatment Team receptionists took calls and care co-ordinators helped to identify how urgent calls were. The Community Enhancing Recovery Team’s telephone system was connected to an electronic call monitoring system so managers could monitor the number of calls received and identify any calls in queues, which staff needed to deal with. However, three people who completed comments cards stated they sometimes had difficulty getting through to the service they used by telephone. Any calls related to patients who were in crisis were referred to the trust’s Crisis Team. The services made attempts to engage with patients who were either reluctant to be involved with mental health care services or had been failing to attend their appointments. The multidisciplinary teams met to discuss and explore ways to encourage them to become engaged, for example other services that may be able to offer reassurance were contacted, agreements and increased flexibility with patients were negotiated in relation to their preferred times and locations for their appointments, and further discussions with the patient around their care planning and goals were held. The services rarely cancelled appointments and when it happened, staff gave patients a full explanation as to the reason why. The main reason for cancelling appointments was if a patient’s care worker was unexpectedly absent from work. If the patient needed a high level of support, an alternative care worker attended their appointment or the service contacted the trust’s enhanced support team. Appointments at the services usually ran on time. No patients we spoke with expressed any concerns about appointment times running behind and on the rare occasions they did, staff contacted them to explain why. The Community Enhancing Recovery Team contacted patients by phone or sent them text message reminders to alert them to any upcoming appointments. The Mental Health Recovery Service North previously had a similar arrangement in place but at the time of our inspection, the
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text message service was faulty and the service acknowledged it needed to be rectified. The service did, however, contact patients by phone to remind them their appointment was due. The Home Treatment Team had small caseloads so staff could make daily contact with patients and visited people on the inpatient wards to identify those ready for discharge. The services supported patients during transfers and referrals to other services. Care workers accompanied patients when they attended appointments with other services upon request, offered patients reassurance and worked with other health professionals when necessary. As part of the 2016/17 NHS England standard contract, care organisations are required to use consistent clinical content headings when sharing discharge summaries. The transfer of care initiative aims to improve patient care by promoting and encouraging the use of professional and technical document standards. The services we inspected complied with the transfer of care initiative as staff used template letters for the discharge of patients from the service, which contained standard clinical content headings.
The facilities promote comfort, dignity and privacy
The clinic rooms at the Home Treatment Team and Community Enhancing Recovery Teams were of a reasonable size. However, the clinic room at the Mental Health Recovery North Team was too small. Patients who required a depot-injection were required to stand up for staff to administer these injections. While administering these injections standing up is not unusual, some patients prefer to receive them in a seated position. However, other rooms were fit for purpose at all three sites and included spacious reception areas with sufficient numbers of chairs that complied with infection control procedure and interview rooms with adequate soundproofing. At the Mental Health Recovery Service North, a flask of water and plastic cups were available in the reception area so patients could have a drink while they waited.
Patients’ engagement with the wider community
Patients we spoke with told us that staff at the services supported them in accessing education and work opportunities. Staff had supported a patient in accessing a course around building better opportunities and the service had helped them with an application for accommodation through a housing association. Staff had helped another patient to access courses in hair and beauty and mental health awareness, both of which resulted in the patient gaining recognised qualifications.
Staff encouraged patients to maintain contact with their families, friends and carers. Staff utilised charitable community services to help patients to maintain relationships and had a list of all the mental health charities in the Sheffield locality.
Staff encouraged patients who could not drive to access public transport as a way of travelling to and from the homes of those people who mattered to them and, where appropriate, reduced ongoing contact with patients to help promote their independence.
Meeting the needs of all people who use the service
The services made adjustments for disabled patients and patients with specific communication needs. Each of the services had lifts, were wheelchair accessible with doors to the areas used by patients that opened automatically. The services used pictures and cue cards and sought advice and guidance from speech and language therapists to help communicate with patients with communication issues. Staff provided information in an easy read format for patients with a learning disability when required and had specific tools for communicating with patients on the autistic spectrum. Staff used online translation services if patients needed written information in different languages.
During our tour of the service buildings, we saw leaflets and posters, which included advice and
contact details in relation to:
• patients’ rights
• making complaints and giving feedback on the service
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• health checks
• forced marriage
• chaplaincy service
• smoking cessation
• mother and baby wellbeing sessions
• credit unions
• safeguarding
• service user focus groups
• the Care Quality Commission.
Staff also routinely reminded patients of their rights during appointments.
Patients had access to signers and translators when required and staff could usually organise for them to attend to the needs of a patient with hearing impairment or for whom English was a second language within 48 hours. The services were also able to use a telephone translation line to help patients if needed.
The trust and Sheffield City Council were identified to work with a group of individuals to offer choice and control over their care through the provision of a personal health budget. The trust tasked the Community Enhancing Recovery Team with implementing the project which aimed to offer patients choice and control in their care by supporting each person to identify items that would improve their health. A budget of up to £150 was allocated for each patient and they worked alongside the staff team to formulate person centred plans. Examples of items that were purchased included bicycles, gym memberships, dialectical behavioural therapy workbooks, televisions and walking attire.
Listening to and learning from concerns and complaints
Whilst we observed patient leaflets on making complaints and giving feedback on the service, three out of the nine patients told us that staff had not provided them with information about how to make a complaint.
If complaints against staff members were of a serious nature, the services allocated an alternative staff member to the patient to prevent any anxiety on their part and to avoid any investigation being compromised. This also helped to mitigate the risk of the patient being discriminated against, harassed or unfairly treated by the person under investigation.
Staff handled complaints appropriately, as they were aware that there was an electronic form that they needed to complete if people who used the service wanted to complain and they knew to refer complaints to the service manager and the trust’s corporate affairs team that managed complaints.
Staff received feedback on lessons learned from investigating complaints during team meetings, supervision and appraisals and these were used to improve practice within the service. We saw evidence in minutes of team meetings that complaints and associated issues were a standing agenda item.
This core service received 94 complaints between 1 March 2017 and 28 February 2018. Eleven of these were upheld, 30 were partially upheld, 38 were not upheld and 13 were currently under investigation. There was one complaint referred to the Ombudsman of which was not upheld. The number of either partially or fully upheld complaints reported during this was lower than the 56 reported at the last inspection.
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Team
name
Total
Complaints
Fully
upheld
Partially
upheld
Not
upheld
Referred to
Ombudsman
Upheld by
Ombudsman
Argyll
House 33 3 11 15 0 0
Wardsend
Road 13 3 7 3 1 0
East
Glade
Centre
11 0 2 7 0 0
Mental
Health
Recovery
Service
North
11 1 1 5 0 0
START 6 0 3 2 0 0
Limbrick
Centre 4 1 2 0 0 0
CERT 2 0 0 2 0 0
CRS 2 1 0 1 0 0
Firshill
Rise 2 0 0 1 0 0
Psychothe
rapy 2 1 0 1 0 0
SPA 2 1 0 0 0 0
CLDT 1 0 1 0 0 0
EDS 1 0 1 0 0 0
EWS 1 0 0 0 0 0
FDT 1 0 1 0 0 0
SORT 1 0 0 1 0 0
Street
Triage 1 0 1 0 0 0
This core service received 147 compliments during the last 12 months from 1 March 2017 and 28
February 2018, which accounted for 23% of all compliments received by the trust as a whole.
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Is the service well led?
Leadership
Leaders had the skills, knowledge and experience to perform their roles. Some managers within the services had undertaken training to develop them as leaders and enhance their skills including managing sickness, management and leadership associated training and courses. Junior staff also confirmed they could access development around management and leadership.
The trust ensured managers had the skills, knowledge, experience and integrity to perform their roles. The trust’s recruitment process was thorough and job adverts contained essential people criteria.
Staff told us that senior managers were visible and approachable.
Vision and strategy
The trust’s vision was to improve the mental, physical and social wellbeing of the people in our communities and its values were respect, compassion, partnership, accountability, fairness and ambition. Staff knew and understood these and applied them in their day-to-day work. The trust had communicated the vision and values effectively to frontline staff as they were displayed in posters around the service buildings and in documentation and information used routinely by staff.
Staff we spoke with confirmed they had been involved in discussions about the strategy of the service they worked in although staff at the Mental Health Recovery Service North perceived consultation around the reconfiguration exercise had simply been a ‘going through the motions’ exercise, and that decisions had already been made by senior managers prior to speaking to them.
Staff could explain how they were working to deliver high quality care within the budgets available. For example, the Community Enhancing Recovery Team service manager explained that part of their team’s role was to provide intensive care and treatment to patients who lived in their own accommodation, at an annual cost of £50,000 a year per patient. The service manager stated if this provision was not available, the alternative could be that patients may need to be admitted to an inpatient setting at an annual cost of £300,000 per patient, six times the cost to the NHS for each patient.
Culture
Staff felt respected, supported, valued, and proud to work within the services they worked. However, three staff members working at the Mental Health Recovery Service North did not feel respected or valued by the wider trust. This was mainly due to the fact that they perceived that senior managers had a lack of regard for staff welfare and had poorly handled the reconfiguration of the community mental health services for adults of working age. Staff felt able to raise concerns without fear of retribution although recent changes in senior leadership meant some staff were wary due to not being familiar with their new senior managers’ management approach.
Staff knew how to use the trust’s whistleblowing procedures and could access them via the trust’s website. Staff also knew whom the trust’s freedom to speak up guardian was and what their role entailed in respect of supporting staff to speak out and raise concerns. We spoke with the service leads who confirmed staff had approached the guardian about their concerns over the reconfiguration exercise.
The trust had a performance management system in place, which included procedures for managers who needed to address poor staff performance. Staff confirmed that managers supported them if there were ever difficulties within their team.
Staff confirmed that appraisals included discussions about career development and support available for helping them with their career prospects.
The trust promoted equality and diversity in its day-to-day work and in providing career progression. The trust had equality and diversity policies in place, which were available to all staff
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via the trust’s intranet. Discussions during staff supervision and appraisals focussed on issues around equality and diversity. Black, minority and ethnic staff within the services had raised concerns that patients and their carers had racially abused them. The trust had a zero-tolerance approach to racism and tried to work with people who used to service who had displayed racist behaviour to reduce the inappropriate behaviour. Staff devised interventions to tackle racism into patients’ care plans in a bid to address this issue but if attempts failed, the trust would allocate a different care worker to the patient. However, one staff member did state that the senior management team within the trust was not reflective of the diverse community as the majority of managers were white and British.
The sickness absence figures at the Mental Health Recovery Service North and Home Treatment Team were higher than the average for the provider. The trust average was eight per cent yet the average figure at the Mental Health Recovery Service North was 14% and the Home Treatment Team was 18%.
Staff had access to support for their own physical and emotional health needs. This included support from the trust’s workplace health and wellbeing group, smoking cessation support and an occupational health service.
The trust recognised staff success within the service. Staff had either received or been nominated for awards by their managers. Other teams within the trust had also praised the work undertaken by staff within the service.
During the reporting period, there were three cases where staff had been suspended, placed under supervision or moved to a different team.
Governance
There were inconsistencies with the effectiveness of the governance systems within the service. Some systems were effective, for example to monitor the progress of staff appraisals, the use of the Mental Health Act and Mental Capacity Act, to ensure lessons learned from complaints, incidents and safeguarding incidents were shared with staff and the services followed infection control prevention procedures. Other systems for monitoring staff supervision and mandatory training were ineffective as we identified low staff compliance in these areas across the three services we inspected. The governance of the medicines management arrangements at the Mental Health Recovery North Service had failed to address there being no system in place for the provision of emergency medication with the potential of placing people experiencing potentially life-threatening conditions such as anaphylaxis at serious risk. There were ineffective systems in place to ensure risk assessments were being regularly updated at the Mental Health Recovery North Service
Staff understood arrangements for working with other teams, both within the provider and externally, to meet the needs of the patients. Staff worked with colleagues within the trust’s inpatient services and shared information with external partners through electronic systems, face-to-face meetings and e-mail.
There was a clear framework of what staff should discuss at meetings. The service leads confirmed that the teams they were responsible for used standard agenda items for meetings so all essential information was cascaded from managers to frontline staff.
Staff within the service participated in clinical audits and acted in response to these audit findings.
We saw evidence from minutes of clinical services leadership meetings that managers had an oversight of teams they managed. The minutes evidenced that safeguarding alerts, incidents, sickness levels, staff compliance with the Mental Health Act, physical health reviews and a wide range of other issues were being monitored and addressed where necessary. For example, at the Mental Health Recovery North Team, the need to ensure that all patients were being reminded of their rights under the Mental Health Act had been identified and the service manager had asked the trust’s Mental Health Act Team to facilitate a workshop around the obligations for staff under the Act.
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We met with the service leads who had recently been appointed to their roles. They explained that the reconfiguration exercise had given them the opportunity to review governance structures. The key lines of enquiry used by the Care Quality Commission as part of its inspection process had been recently implemented to make the service’s governance structures more robust. The service leads were aware of high caseloads within the Mental Health Recovery North Team and confirmed that funding for an additional two care co-ordinators on a two-year fixed term contract had been secured.
Management of risk, issues and performance
Staff could discuss items for inclusion on their team’s risk register and that of the wider trust. Staff confirmed that their concerns were reflective of those contained within the risk registers.
The services we inspected had business continuity plans in place. These plans contained arrangements for emergencies such as adverse weather conditions, loss of information technology and premises, and outbreaks of flu.
The core service had recently undertaken a reconfiguration exercise to make efficiency savings and create a single point of access team where referrals were received and triaged. The single point of access team also worked with the trust’s acute and crisis services. The reconfiguration had also resulted in three different aspects of care being created; caseload management for stable patients who required less hands-on treatment, active care and intensive care for patients who required high levels of care or whose needs were particularly complex. Patients could step up and down from these three different levels of care when required.
Information management
The services collected data from other teams and directorates both within and outside the trust. Staff produced internal information from the trust’s electronic system. Staff confirmed the data was in a suitable format and not over-burdensome although one manager did indicate that because primary care services used totally different systems, there were occasionally issues with the quality of information received.
The services had access to sufficient information technology and equipment to do their work, which included mobile phones, tablets and laptop computers.
Information governance training was a mandatory requirement for staff within the trust. This training included the need to ensure that staff always maintained patient confidentiality.
The service managers used key performance indicators to monitor compliance in relation to mandatory training and other progress within their teams.
The services made notifications to external bodies as required. This included statutory notifications to the Care Quality Commission and safeguarding alerts to local safeguarding teams.
Engagement
Staff, patients and carers had access to up-to-date information about the services they used and wider trust through social media, emails, newsletters intranet and internet. Patients and staff were able to meet with members of the senior leadership team and governors to give their feedback and ideas for shaping the service.
The service enabled people to provide feedback in a variety of ways. People could complete questionnaires, attend feedback forums and participate in Friends and Families Tests. People could receive help in providing feedback to the services through local advocacy services.
The trust had engaged people who used the service and other stakeholders in the reconfiguration exercise during feedback sessions, presentations and drop in sessions.
Service leads confirmed that the trust had good relationships with patients, carers, commissioners, local authorities and other third-party organisations. At the time of our inspection, service leads were about to meet with a number of these stakeholders to discuss any ideas as to how the trust could help improve access to care.
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Learning, continuous improvement and innovation
Staff were given time to consider opportunities for improvements and innovation during team meetings, reflective practice sessions and during supervision and appraisal sessions.
Staff within the service had participated in national audits. These included audits relating to physical health, early interventions, medication, Prescribing Observatory for Mental Health and pharmacy.
The trust used the quality improvement methodology Microsystems which was developed by the Dartmouth Institute. This initiative enabled frontline staff to train as coaches and work with teams to help improve the quality and value of care they deliver to patients. They did this by understanding their systems and processes and redesigning care through testing small changes.
NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.
The trust confirmed that the Early Intervention in Psychosis Service had applied for accreditation from the Royal College of Psychiatrists and hoped to be accredited by September 2018.
The trust collaborated with the National Centre for Sports and Exercise Medicine in a project called move more for mental health to help people with mental illness to become more physically active in everyday life.
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Wards for older people with mental health problems
Facts and data about this service
Sheffield Health and Social Care NHS Foundation Trust provides wards for older people with
mental health problems over two sites. These were;
• G1 ward at Grenoside Grange Hospital – An 18 bedded mixed sex ward
• Dove dale ward at the Michael Carlisle Centre – An 18 bedded mixed sex ward
Location site name Ward name Number of beds Patient group (male,
female, mixed)
Grenoside Grange Hospital G1 Ward 16 Mixed
Michael Carlisle Centre Dovedale Ward 18 Mixed
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Is the service safe?
Safe and clean care environments
Safety of the ward layout
G1 was separated into two wards A and B three. Ward B had a garden in the centre and housed
male patients, as well as a self-contained flat, a seclusion room, lounges, along with staff training
rooms and the manager’s office. Ward A was connected to B via a staff only corridor, this ward
also had a garden at its centre and housed mainly female patients. The ward manager informed
us that if a bed was required for a patient they may be placed on a ward with patients of the
opposite sex due to bed numbers. In this case patients would be risk assessed to ensure this
placement was appropriate. Each ward had multiple lounges and dining areas as well as shower
and toilet facilities. The bedrooms at G1 were all en-suite and contained a sink and toilet. Some
en-suites also contained a shower. The ward was dementia friendly with furniture that contrasted
with the floor and there were dementia friendly signs on the doors. However, the handrails that
covered all of the ward did not markedly contrast with the colour of the walls. This could make it
difficult for patients to differentiate between the wall and the rail.
Dovedale ward consisted of one main corridor split into males at one end and females at the other.
The female corridor also housed a four-bedded female dormitory. The corridors were connected
by a central area which included the nurses’ hub and the clinic room. When you entered the ward,
it opened into the main lounge and dining area. There were separate lounges for male and female
patients. However; we found that the male lounge was over crowded with furniture and it would be
difficult for all male patients to congregate in the lounge at once.
Both services had a laundry room. Patients on Dovedale ward could use the laundry facilities to do
their own washing however; the area was small, untidy with paint peeling off the walls. We were
informed by the ward manager that the majority of relatives took patients’ clothes home to wash.
Both wards had outside areas available for patients to access. G1 had two central court yards
which were used by patients for growing vegetables and gardening. This area also contained a
shed where patients could sand and saw wood under staff supervision. There were also other
outdoor areas surrounding the site which were used by the service for outdoor events.
Dovedale ward had access to an outdoor area where patients could garden and grow vegetables
which were eaten on the ward. However, this area contained an old smoking shed which was
taped off for patients not to use as it was in disrepair. The path to the garden was slippy which
could be dangerous for patients.
Both wards had a variety of alarms to assist patients and staff. Both wards could provide call
bracelets to patient’s dependent upon their need. This was assessed individually. Both wards also
had access to bed and chair alarms for patients, which was also assessed on a patient by patient
basis. Nurse call alarms were available throughout Dovedale ward. G1 did have call buttons
however; we found that they were not easily visible and were located and varying heights on the
walls which meant they were not easily accessible to patients. We were informed this was
mitigated by patients having their own risk assessed alarms and staff observations, along with the
alarms having the ability to be detached and relocated if required.
Both ward areas were visibly clean and well maintained. Each ward was adequately furnished,
with the furniture of good standard and well maintained.
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Over the 12 month period from 1 March 2017 to 28 February 2018 there were two mixed sex accommodation breaches within this core service.
Both incidents were due to gender mix and location of the bathroom facilities at the time of the incident. These breaches occurred on Dovedale ward. Work has since been undertaken on the layout of the ward and we found it was now compliant with the guidance on same sex accommodation.
Staff informed us that patients would be individually assessed if a bed was required for a member of the opposite sex. Following the assessments, patients on the ward could be moved to alternative rooms to ensure dignity and respect was maintained. We found that G1 ward at the time of inspection had a male patient between two female patient rooms, the ward manager informed us that the male and female had been assessed in regards to risk and there were no concerns with this patient.
There were ligature risks on both wards within this core service. All wards had a ligature risk assessment in the last 12 months.
One of the wards presented a high level of ligature risk due to the acuity of patients and remaining anchor points which included: door handles, ensuite doors, door corners, grab rails/mobility aids, beds, window restrictors, taps and flush handles.
The trust had taken the following actions to mitigate ligature risks: individual risk assessments, observations levels and the removal of items that may be used as ligatures. Work was underway to further reduce anchor points via programme of works to include door handle replacement, ensuite door replacement and a ward redesign.
For the most recent patient-led assessments of the care environment (PLACE) assessment (2017)
the locations scored higher than similar trusts for all four of the four aspects overall.
Site name Core service(s)
provided
Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
Michael Carlisle Centre
MH - Wards for older
people with mental
health problems
MH - Acute wards for
adults of working age
and psychiatric
intensive care units
MH - Other Specialist
Services
98%
97.3%
88.7%
91.6%
Grenoside Grange
MH - Wards for older
people with mental
health problems
100%
98.2%
97.4%
100%
Trust overall 99% 97.8% 91.1% 91.8%
England average (Mental
health and learning
disabilities)
98% 95.2% 84.8% 86.3%
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We observed staff adhering to handwashing and infection control principles. Staff could describe
to us the infection control procedures in place for the various pieces of equipment that were used
by patients and staff.
Seclusion room
The seclusion room on G1 allowed for clear observation and two-way communication. The room
also had toilet facilities and a clock as well as windows to view natural daylight.
The windows were one way so the patient could look out but it was not possible to look into the
room from the exterior of the building, allowing for the patient’s privacy and dignity. There was no
way of observing the patients when in the bathroom so when not in use the bathroom was locked.
The bathroom was unlocked when patients required it. The Mental Health Act code of practice
states that seclusion rooms should have access to toilet and washing facilities, therefore the
seclusion room on G1 was in line with the code of practice.
Dovedale ward did not have a seclusion room however; they did have a newly refurbished
destimulation room which had the ability to adjust light colour and play music for patients. The
room was designed to be a quiet place to help calm patients. This room at the time of inspection
only had minimal furniture as the ward was looking to design the room in collaboration with
patients and staff. A patient who liked to frequent the room at the time of the inspection had
requested that there only be a mattress and pillow in the room.
Clinic room and equipment
We checked each clinic room at both sites; both were visibly clean and tidy. Room and fridge
temperatures on both wards were checked on a regular basis. The clinic room on Dovedale ward
had recently been refurbished this was due to the redesign of the ward to fit mixed-sex
accommodation guidelines. The ward manager informed the inspection team that the clinic room
was now larger and brighter and a better place to see patients. Resuscitation equipment on G1
ward was stored in the nurses office so it was accessible to staff. G1 ward had evidence that the
grab bag and emergency equipment was regularly checked. Dovedale did demonstrate regular
checks of the grab bag, emergency equipment, and machines. However, these records were
inconsistent, as we found gaps in recording.
Safe staffing
Nursing staff
Staffing levels were adequate to meet the needs of the patients on both wards. Staffing levels were established through the trust’s acuity system which took into account the number of patients and their individual risk needs. Each ward worked on a two shift basis with G1 having on average two qualified nurses and five support workers on the day shift and two qualified nurses and four support workers on the night shift. Dovedale’s staffing mix was slightly different with three qualified nurses and two support workers on the day shift and two qualified nurses and one support worker on the night shift. Managers were able to adjust staffing levels dependant on the acuity of the patients. When necessary, managers were able to use bank and agency staff to maintain safe staffing levels. Both wards aimed to
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use regular bank staff as they were accustomed to the ward and the patients. The ward managers on G1 did feel that getting bank and agency staff at short notice was a struggle. In this situation the ward managers and deputy ward managers would fill the vacancy for the shift. Bank staff on both wards had access to the online system for patient records and were given a handover. Agency staff on Dovedale ward were given agency logins if they did not work regularly work on the ward they were accompanied by a support worker on shift. We did not see any evidence of leave or activities being cancelled due to staffing levels.
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 January 2018 75.5 N/A
Total number of substantive staff leavers 1 February 2017 to 31 January 2018
7.2 N/A
Average WTE* leavers over 12 months (%) 1 February 2017 to 31 January 2018
9% 13%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31March 2018 2 N/A
Total vacancies overall (%) At 31March 2018 3% NA
Total permanent staff sickness overall (%) Most recent month (At 31 January 2018)
14% 5%
1 February 2017 to 31 January 2018
9% 5%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 March 2018 36 N/A
Establishment levels nursing assistants (WTE*) At 31 March 2018 26 N/A
Number of vacancies, qualified nurses (WTE*) At 31 March 2018 8 N/A
Number of vacancies nursing assistants (WTE*) At 31 March 2018 -5 N/A
Qualified nurse vacancy rate At 31 March 2018 22% N/A
Nursing assistant vacancy rate At 31 March 2018 -19% N/A
Bank and agency Use
Shifts bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 March 2017 and 28
February 2018 440 (8%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses)
1 March 2017 and 28
February 2018 33 (1%) N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses)
1 March 2017 and 28
February 2018 108 (2%) N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 3716 (40%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants)
1 March 2017 and 28
February 2018 899 (10%) N/A
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Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants)
1 March 2017 and 28
February 2018 270 (3%) N/A
*Whole-time Equivalent
This core service reported an overall vacancy rate of seven percent for registered nurses at 31
March 2018. We found that the vacancy levels during inspection were better than that recorded in the
provider information request ahead of the inspection; with the vacancy rate for qualified nurses for both
wards being 4.8 whole time equivalents.
This core service reported an overall vacancy rate of -19% for registered nursing assistants (minus numbers indicate an over establishment).
This core service reported a vacancy rate for all staff of three percent as of 31 March 2018.
Registered nurses Health care assistants Overall staff figures
Ward/Tea
m
Vacanc
ies
Establishme
nt
Vacan
cy rate
(%)
Vacanci
es
Establishme
nt
Vacan
cy rate
(%)
Vacanci
es
Establishme
nt
Vacan
cy rate
(%)
G1 Ward 3 16 19% -3 16 -19% -1 35 -3%
Dovedale 5 20 25% -2 10 -20% 3 43 7%
Core
service
total 8 36 22% -5 26 -19% 2 78 3%
Trust
total 32 433 7% 15 353 4% 68 1339 5%
NB: All figures displayed are whole-time equivalents
Between 1 March 2017 and 28 February 2018, bank staff filled eight percent of shifts to cover sickness, absence or vacancy for qualified nurses.
In the same period, agency staff covered one percent of shifts for qualified nurses. Two percent of shifts were unable to be filled by either bank or agency staff.
Ward/Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by
bank or agency staff
Dovedale
Ward 2666 46 (2%) 9 (<1%) 64 (2%)
G1 Ward 2700 394 (15%) 24 (1%) 44 (2%)
Core service
total 5366 440 (8%) 33 (1%) 108 (2%)
Trust Total 32,394 4977
(15%)
7252
(22%)
900
(3%)
*Percentage of total shifts
Between 1 March 2017 and 28 February 2018, 40% of shifts were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.
In the same time period, agency staff covered 10% of shifts for nursing assistants. Three percent of shifts were unable to be filled by either bank or agency staff.
Ward/Team Available shifts Shifts filled by bank
staff
Shifts filled by
agency staff
Shifts NOT filled by bank
or agency staff
20171116 900885 Post-inspection Evidence appendix template v3 Page 243
Dovedale
Ward 3222 629 (20%) 616 (19%) 125 (4%)
G1 Ward 6137 3087 (50%) 283 (5%) 145 (2%)
Core service
total 9359 3716 (40%) 899 (10%) 270 (3%)
Trust Total 59,514 21,770
(37%)
5623
(9%)
1760
(3%)
* Percentage of total shifts
This core service had 7.2 (9%) staff leavers between 1 March 2017 and 28 February 2018. This was lower than the 12.2% reported at the last inspection (November 2016).
Ward/Team Substantive staff
Substantive staff Leavers Average % staff leavers
G1 Ward 34.7 4.6 12%
Dovedale 40.8 2.6 6%
Core service total 75.5 7.2 9%
Trust Total 1351.6 129.6 8%
The sickness rate for this core service was nine percent between 1 February 2017 and 31 January 2018.
Ward/Team Total % staff sickness
(at latest month)
Ave % permanent staff sickness
(over the past year)
Dovedale 18% 10%
G1 Ward 9% 9%
Core service total 14% 9%
Trust Total 8% 7%
The below table covers staff fill rates for registered nurses and care staff between November 2017 and February 2018.
Dovedale ward had a fill rate of over 125% for care staff for all day and night shifts.
Key:
> 125% < 90%
N-nurses
C- care staff
Day Night Day Night Day Night Day Night
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Medical staff
There was adequate medical cover on both wards, with two consultants and a junior doctor
covering Dovedale ward. G1 ward had a consultant along with a clinical fellow. Out of hours cover
was provided by an on-call rota. In a medical emergency, the policy on each ward was to contact
the emergency services.
Mandatory training
The compliance for mandatory and statutory training courses at 28 February 2018 was 94%. Of the training courses listed one failed to achieve the trust target and just failed to score above 75% at 74%.
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service %
Trust target % Trustwide mandatory/ statutory training total %
Safeguarding Children (Level 3) 100% 80% 91%
Mental Capacity Act Level 2 100% 80% 85%
Deprivation of Liberty Safeguards
Level 1 100%
80% 87%
Equality and Diversity 99% 80% 95%
Health and Safety (Slips, Trips and
Falls) 99%
80% 97%
Fire Safety 2 years 98% 80% 96%
Mental Health Act 97% 80% 83%
Domestic Abuse Level 2 97% 80% 85%
Safeguarding Adults (Level 2) 97% 80% 87%
Mental Capacity Act Level 1 96% 80% 94%
Hand Hygiene 96% 80% 94%
Safeguarding Children (Level 2) 95% 80% 85%
Adult Basic Life Support 94% 80% 81%
Medicine management training 94% 80% 87%
Clinical Risk Assessment 92% 80% 91%
Rapid Tranquilisation 91% 80% 88%
Dementia Awareness (inc Privacy &
Dignity standards) 90%
80% 85%
Autism Awareness 89% 80% 88%
Immediate Life Support 88% 80% 88%
Information Governance 85% 80% 80%
Respect Level 3 85% 80% 83%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
N
%
C
%
November 2017 December 2017 January 2018 February 2018 Dovedal
e 94.6 162.
1
78.
3
226.
7
75.4 164 76.
1
206.
5
68 186.
6
72.
7
222,
6
69.
2
198 69.
6
261.
2
G1 106.
7
98.7 83.
7
108.
4
112.
4
95.
7
95.
3
121.
5
109.
9
102.
2
79.
3
133.
9
73.
2
103.
4
79.
9
114.
2
20171116 900885 Post-inspection Evidence appendix template v3 Page 245
Respect Level 2 80% 80% 80%
Deprivation of Liberty Safeguards
Level 0 74% 80% 80%
Core Service Total % 94% 88%
Overall; staff in this service had completed all modules of mandatory training set by the trust however; deprivation of liberty safeguards training was below the trust target at 74%. All staff we spoke to stated they were up to date with their mandatory training. Staff on Dovedale ward told us they had not had as much time for training recently due to recent building work on the ward.
Assessing and managing risk to patients and staff
Assessment of patient risk
All of the eight patient records reviewed had an up to date risk assessment for each patient. Upon
admission each patient had a detailed risk assessment and management plan, this is a recognised
risk assessment tool known as DRAM. Risk assessments were started in the community before
the patient was admitted to the ward and were completed in conjunction with patients and carers.
Falls risk assessments would be carried out if it was highlighted in the detailed risk assessment.
Risk assessments were updated regularly and were assessed at the twice weekly multidisciplinary
team meetings.
Management of patient risk
Staff were aware of patients’ individual risks. These could be accessed through the patient’s notes
and were discussed in handovers. Risk assessments were reviewed at the multidisciplinary team
meeting each week and updated where appropriate. We saw evidence of patients’ specific risks
being addressed, for example a patient susceptible to falls had been given hip protectors.
Staff informed us that if they thought a patient was at risk they would search the patient and room.
Both wards adhered to the trust search policy and had a list of banned items.
Staff were able to respond to the changing risks of patients, for example we saw evidence of a
patient’s risk of falls reducing while on the ward.
Staff adhered to best practice when implementing a smoke free policy where practicable. G1 was
a smoke free ward but due to the nature of the patients they cared for, some patients were
sometimes not able to remember they had given up smoking. In these cases; the staff would work
with the patient and carers to carry out interventions and if needed to facilitate smoking in a safe
way. Dovedale had a smoking shelter in the garden that was not in use.
Informal patients were able to leave the wards at will; notices were visible throughout the wards
informing patients if they wished to leave they should ask staff to open the doors for them.
Use of restrictive interventions
This core service had 46 incidents of restraint (on 32 different patients) and 22 incidents of
seclusion between 1 March 2017 and 28 February 2018.
Over the 12 months, there was an increase in the incidence of restraint in January 2018 where
there were 10.
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The below table focuses on the last 12 months’ worth of data: 1 March 2017 and 28 February
2018.
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
G1 ward 22 24 19 0 (0%) 0 (0%)
Dovedale
ward 0 22 13 0 (0%) 6 (27%)
Core service
total 22 46 32 0 (0%) 6 (13%)
Staff on Dovedale ward informed us that they used rapid tranquilisation as a last resort. Rapid tranquilisation was reported on the incident system by staff when it occurred and physical health monitoring took place following incidents of rapid tranquilisation. As per the trust policy, staff attempted de-escalation strategies which included the use of ‘as required’ medication, in line with National Institute for Health and Care Excellence guidelines. Patient medication charts included information on when ‘as required’ medication should be used, the minimum time between uses if the first dose of medication had not worked and information on the patients’ care plan.
There were six incidents of rapid tranquilisation which accounted for 13% of the restraint incidents.
There have been zero instances of mechanical restraint over the reporting period.
The number of restraint incidents reported during this inspection was lower than the 55 reported at the time of the last inspection.
Staff on both wards had received RESPECT training, this training provided staff with the skills to de-escalate situations without using methods of restraint.
Over the 12 months, the use of seclusion fluctuated. Instances of seclusion ranged from zero to six per month during this time.
The ward manager on G1 at the time of the inspection said the spikes in seclusion on August 2017 and January 2018 were related to one patient in August and two patients in January. Staff on G1
3
7
0
6
10
1
3
6
3
10
6
0 0 0 0 0 0 0 0 0 0 0 00
2
4
6
8
10
12
Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18
Total restraints over the 12 month period
Number of incidents of the use of restraints
Number of prone restraints
Number of mechnical restraints
Number of incidents resulting in the use of rapid tranquilisation
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ward explained that in many cases they would not use seclusion as they would sit and speak with patients in a quieter room which they found proved effective in calming them down.
There have been no instances of long term segregation over the 12 month reporting period.
Safeguarding
Staff received training in safeguarding. At the time of the inspection 95% of staff had attended safeguarding children level 2 and 95% safeguarding adults level 2. All staff on the wards had attended safeguarding children level 3. Staff we spoke to had a good understanding of what safeguarding was and were confident in raising safeguarding concerns. The wards had specific guidelines for children visiting the ward. For example; G1 stopped any children under the age of 12 visiting the wards due to a previous near miss incident. Relatives were informed that any child under the age of 12 would have to visit with their relative in the café area in front of the ward, if this was not deemed suitable for the patient the ward would request that the children did not attend visits.
A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional.
Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.
This core service made no safeguarding referrals between 1 February 2017 and 31 January 2018.
Sheffield Health and Social Care NHS Foundation Trust submitted no serious case reviews commenced or published in the last 12 months [1 March 2017 and 28 February 2018] that relate to this core service.
1
0 0 0
2
6
3
0
2
0
5
3
0
1
2
3
4
5
6
7
Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18
Total seclusions over the 12 month period
Number of incidents of the use of seclusion
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Staff access to essential information
All records were electronic including patient records and medication charts. All staff had access to
the online system including bank staff. Dovedale ward provided temporary system logins for
agency staff who attended the ward. G1 ward printed information for agency nurses as they did
not have separate logins. All 1:1 observations that were hand written were scanned into the
system.
Medicines management
We reviewed eight prescription charts and found no concerns. All medicines on the wards were managed through the electronic system. For agency staff not able to access this system, there were pictures of the patients with the medication so staff were able to identify the patients’ correct medication. Staff followed good practice in relation to the dispensing and administration of medication. We observed staff using the antipsychotic checklist for medication before and during the issuing of medication to patients. Patients’ physical health was monitored if they were prescribed an antipsychotic medication. G1 ward used the neuropsychiatric inventory tool, this is an assessment of psychopathology for patients with dementia.
Track record on safety
Providers must report all serious incidents to the strategic information executive system within two working days of an incident being identified.
Between 1 March 2017 and 28 February 2018 there were no incidents reported by this core service. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with the strategic information executive system.
The number of serious incidents reported during this inspection was the same as the number reported at the last inspection.
Reporting incidents and learning from when things go wrong
All staff knew how to record an incident and what should be recorded. Incidents were recorded through the trust electronic system and all incidents went to a ward manager to review. Once these incidents were reviewed by the ward manager they were sent to the senior operational managers for review further if required. All incidents were reviewed at the quarterly governance meeting. Learning from incidents was fed back to staff at team meetings and handovers. G1 ward had adjusted their policy around children visiting the ward due to a near miss incident with a young child. Staff were aware of duty of candour and were open and transparent when things went wrong. Staff on G1 ward provided examples of facilitating multiple meetings with a family due to the family wishing to be informed more frequently about the care their relative was receiving.
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Ward managers informed us that following a serious incident, staff would receive debrief along with patients and psychological support would be offered if required.
The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths.
In the last two years, there have been no ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.
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Is the service effective?
Assessment of needs and planning of care
We reviewed eight care records during our inspection. All records contained a care plan and risk assessment that was created following admission. Each patient had received a physical health check upon admission, however one patient had refused a physical check. This refusal was noted in the patient records each time a physical health assessment was attempted. Each patient received a comprehensive detailed risk assessment and management plan on admission; this was completed with involvement from the psychologist liaison and relatives and/or carers. The risk assessments were assessed each week at the multidisciplinary team meeting and were updated as necessary. Care plans were formulated with the involvement of the patients, relatives and /or careers and the nursing teams. All of the care plans we reviewed showed evidence of patient involvement, were personalised, holistic and focused on the patient’s recovery.
Best practice in treatment and care
The ward staff on G1 utilised therapy dolls for patients and found this very effective however; staff noted that family members could find this distressing, therefore they would explain the use of the therapy dolls and the effect it was having on their relative. G1 ward also had the use of Paro seals, Paro seals are therapeutic interactive robots baby seals that are used for patients with dementia and other cognitive disorders. Staff found the seals to be very effective as they brought back patients memories of having birds and various other pets. The ward also used numerous memorabilia items to help patients. They had used a world war two uniform along with other memorabilia from the era such as soap and toys. G1 ward had also used pet therapy on the ward; they used miniature horses for an Ascot themed day and also had visits from a local dog handler. Both wards ensured patients had access to physical health care, in many cases the wards facilitated patients going to their regular opticians and dentists where possible. Each ward had access to a dietician who assessed patients’ dietary needs. Patients on both wards were encouraged to live healthier lives with the meals they chose and smoking cessation was offered. Staff acknowledged that patients may not be aware that they had ceased smoking and would offer alternatives. G1 ward utilised the Neuropsychiatric Inventory tool for patients. The Neuropsychiatric Inventory tool is
a tool used to measure patient outcomes. The use of the tool had been reviewed by a junior doctor
who had presented their findings nationally.
This core service participated in the following clinical audits as part of their clinical audit
programme in the 12 months leading up to the submission of the provider information return.
Audit name Audit scope Core service Audit type Date
completed
Key actions following the
audit
QS86 Falls in
older people
Older-adult
inpatient
settings
MH - Wards
for older
people with
mental health
problems
Clinical Apr-17 Regular Falls audits to be
undertaken
Mental
wellbeing and
independence
for older people
(QS137)
Dovedale Ward
MH - Wards
for older
people with
mental health
problems
Clinical On-going Awaiting findings
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Collaboration
with Primary
Care Clinicians
Service users
on CPA
Provider
wide
Clinical on-going Changes made following
previous audit round:
provide guidance to staff
on annual reviews of care.
Changes to care plan form.
Creation of a 'clinical
review for GP' IT system
solution.
Record keeping
audit 2016/2017
Trust wide Provider
wide
Clinical on-going From data collected so far:
Further clarity provided to
staff on use of
abbreviations - to be
incorporated into the
relevant policy.
Audit of risk
assessments
2016/2017
Trust wide Provider
wide
Clinical audit March 2017 Local action plans to
address identified issues.
Audit tool to be revised to
give clearer results.
Re-audit to be undertaken
in 2017/18.
Audit of risk
assessments
2017/2018
Trust wide Provider
wide
Clinical audit On-going Await findings
Audits of care
plans
Trust wide Provider
wide
Clinical audit January
2018
Agreed need for frequent
small scale audits.
Findings being shared with
teams.
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG43
Transition from
children’s to
adults’ services
for young
people using
health or social
care services
Trust wide Provider
wide
Clinical audit June 2017 Findings fed into
Commissioning for Quality
and Innovation and other
related joint work with child
and adolescent mental
health services to improve
transitions
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG13
Workplace
health:
management
practices
Trust wide Provider
wide
Clinical audit September
2017
Review practices against
guidance as necessary in
future
Assessment of
National
Institute for
Health and Care
Excellence
Guidance: NG58
Coexisting
Trust wide Provider
wide
Clinical audit December
2017
Action plan under
development
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severe mental
illness and
substance
misuse:
community
health and
social care
services
Skilled staff to deliver care
Both wards had access to consultants, junior doctors, occupational therapists, speech and language therapists, psychologists, psychiatrists, dieticians and pharmacists. Staff were able to refer to the local authority for the assistance of social workers. All off the staff who worked on the wards were knowledgeable and skilled in their field of work.
Volunteers were recruited and trained centrally by the trust; if the wards wished to have a volunteer they could request this centrally.
The trust’s target rate for appraisal compliance was 90%. As at February 2018, the overall
appraisal rates for non-medical staff within this core service was 99%.
The rate of appraisal compliance for non-medical staff reported during this inspection was higher
than the 81% reported at the last inspection.
Ward name
Total number of
permanent non-medical
staff requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an appraisal
% appraisals
G1 40 40 100%
Dovedale 43 44 98%
Core service total 83 84 99%
Trust wide 1495 1440 96%
The trust’s target rate for appraisal compliance was 90%. As at February 2018, the overall
appraisal rates for medical staff within this core service was 100%.
The rate of appraisal compliance for medical staff reported during this inspection was the same as
the 100% reported at the last inspection.
Ward name
Total number of
permanent medical staff
requiring an appraisal
Total number of
permanent medical
staff who have had
an appraisal
%
appraisals
Dovedale 2 2 100%
G1 1 1 100%
Core service total 3 3 100%
Trust wide 57 56 98%
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The trust’s target for clinical supervision was 66%.
Between 1 March 2017 and 28 February 2018 the rate across both teams in this core service was 50%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide.
Ward name Clinical supervision
sessions required
Clinical
supervision
sessions delivered
Clinical
supervision rate
(%)
Dovedale 196 100 51%
G1 Ward 167 80 48%
Core service total 363 180 50%
Trust Total 3420 2183 64%
Both ward managers acknowledged that supervision was low on the wards. Each staff member should receive two supervisions per quarter. Staff had received at least one supervision in each quarter. We were informed by ward managers and senior operational managers that the low level of supervision was due to demands on staff on the ward. The senior operational managers and ward managers felt that there were activities they did with staff that could be counted toward supervision but did not fit in with the model. This included discussions in meeting around changes in guidance and discussions around specific areas of patient’s needs. Senior operational managers for the ward acknowledged the low levels of supervision and had started to place extra staff on the wards so supervision could be accomplished. The trust was in the process of changing the way supervision was recorded to include electronic recording to ensure it could be more effectively monitored. Staff we spoke to felt that there were receiving a good level of supervision and felt supported by the management team.
Multi-disciplinary and interagency team work
Multidisciplinary team meetings were held twice a week on both wards. These meetings included consultants, psychiatrist, ward manager, discharge co-ordinator, senior occupational therapist and a nurse. Other parties were invited to the meeting depending on the needs of the patient. We observed a multidisciplinary team meeting while during our inspection. We found that the meeting explored the clinical, social, emotional and psychological needs of the patient and was very patient focused. The patient’s relative attended the meeting and the team clearly explained the patients care to relatives and discussed their ideas and concerns raised. Ward handovers included information on the patients currently being treated on the wards. We observed a handover where the staff discussed patients’ risk assessments, the activities that would take place during the shift along with an update from the multidisciplinary team meeting. Both wards had effective working relationships with the discharge teams and social services.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
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As of 28 February 2018, 97% of the workforce in this core service had received training in the Mental Health Act. The trust stated that this training was mandatory for all core services for inpatient and all community staff and renewed every three years.
The training compliance reported during this inspection was higher than the 67% reported at the last inspection.
Staff we spoke to had a good understanding of the Mental Health Act and its guiding principles. Support workers informed us that they were regularly informed about each patients’ section 17 leave. A Mental Health Act administrator was available to staff if they required support. The trust policies and procedures for the Mental Health Act were available on the electronic system for all staff. Both wards undertook a weekly audit of the Mental Health Act to ensure that all patient records were up to date. Patients who were detained under the Mental Health Act had access to an independent mental health advocate, staff knew how to refer patients to this service and information was displayed around each ward. Patients’ rights were read to them in a way that they understood. Ward managers noted that if a patient had not understood their rights, this was documented on the patient’s care record and further attempts to communicate the patient’s rights would be made. Each ward had displayed information for informal patients informing them they could leave the ward at any time, as both wards were locked patients could request that staff opened the doors for them if they wished to leave.
Good practice in applying the Mental Capacity Act
Staff we spoke to had a good understanding of the Mental Capacity Act, including the deprivation of liberty safeguards. Staff were aware of the policy and informed us that it could be found on the electronic system for them to access. We saw evidence of patient’s mental capacity being assessed in their medical records. Patients files were audited in relation to Mental Capacity Act each week to ensure compliance with the Act.
As of 28 February 2018, 96% of the workforce in this core service had received training in the Mental Capacity Act. The trust stated that this training was mandatory for all core services for inpatient and all community staff and renewed every three years.
The training compliance reported during this inspection was higher than reported at the last inspection. G1 ward reported training compliance of 95% at the last inspection and Dovedale reported 25%
The trust told us that two deprivation of liberty safeguard applications were made to the local authority for this core service between 1 March 2017 and 28 February 2018. CQC received no direct notifications from the trust between 1 March 2017 and 28 February 2018. The trust policy for deprivation of liberty safeguards stated that wards managers were responsible for notifying CQC once the outcome of the application has been received. Upon reviewing the evidence we can see that a notification was submitted to CQC regarding a deprivation of liberty safeguard application. The number of deprivation of liberty safeguards applications made during this inspection was lower than the nine reported at the last inspection.
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Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
We observed staff interacting with patients while on the ward, these interactions were respectful and responsive. Whilst observing meal times on the ward, we saw staff treating patients with dignity and respect. Patients were supported to eat meals when required. Staff on G1 ward shared the meal times with patients and engaged with the patients while they ate. On Dovedale ward we observed that interactions with patients and staff were limited, for example staff did not ask patients if they were enjoying their meal or if there was enough food. Both wards actively encouraged patient involvement in their care. This was evidenced in the risk assessment and care plans for each patient which reflected their individual needs. All patients and carers we spoke to had positive things to say about the care they or their relative was receiving. Carers we spoke to on G1 ward felt that they had learnt more about dementia while their relative was on the ward which allowed them to understand the condition and the treatment their relative was receiving. Staff understood the individual needs of patients including their personal, cultural, social and religious needs. G1 had a patient whose relative loved to cook for the ward and they would regularly bring in food related to their cultural heritage. The ward welcomed and celebrated this by having an Indian themed day. Patients got involved by building a Taj Mahal with the occupational therapist and enjoying Indian food. G1 hosted multiple themed events, during the inspection they had a pub themed day with a bar and live piano music with pie and peas for lunch.
The 2016 Patient-led assessments of the care environment score for privacy, dignity and wellbeing at both core service locations scored higher than similar organisations.
Site name Core service(s) provided Privacy, dignity
and wellbeing
Michael Carlisle Centre
MH - Acute wards for adults of working age and
psychiatric intensive care units.
MH - Other Specialist Services
MH - Wards for older people with mental health
problems.
94.3%
Grenoside MH - Wards for older people with mental health
problems 100%
Trust overall 96.6%
England average (mental health
and learning disabilities) 90.6%
Involvement in care
Involvement of patients
On admission to the ward, patients were shown round and given a welcome pack with information about the ward. Patients’ family and/or carers could be invited to join the induction to the ward. All patients, where possible, were included in their risk assessment and care plan and we found evidence of this in the care records we reviewed. Staff told us that they also invited families and/or
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carers to be involved in developing patients care plans and risk assessments. Families were able to provide information such as the patients likes, dislikes, preferences and their routine. Support workers on the ward supported the patient and their family to fill out the ‘this is me’ booklet to get to know the patient. G1 ward had adapted its outdoor space to fit the likes of the patients on the ward for example: they had added a shed as some patients had feedback that they were used to being occupied with woodwork. This shed allowed patients to sand, saw and paint bits of wood. Access to the shed was available to all patients with supervision required. Patients also had access to the garden to grow fruit and vegetables which were then used in the ward food. Staff told us that this brought a sense of achievement to many of the patients. Patients were actively encouraged to give feedback on the care they received. Staff supported patients to complete comment cards if they wished to make a comment. Patients had access to independent mental health advocates; information about this was available for patients on the ward.
Involvement of families and carers
Staff encouraged the involvement of families and carers where they could, this included getting them involved in the care plan and risk assessments. The wards also provided psychological support to families and careers if they required it which was provided by the onsite psychologist. G1 ward had a carers meeting available for family and carers to attend, the sessions included activities and provided a place to talk to other carers. The ward also conducted themed meetings depending on the needs of the carers. Dovedale did have a carers meeting but they stated that it was not well attended. Ward staff at G1 also encouraged friends and relatives to join them for activities and themed days, this included events such an Ascot day where miniature ponies visited the ward. Families and carers were actively invited to give feedback on the service their families were receiving through comment cards and directly to staff.
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Is the service responsive?
Access and discharge
Bed management
The trust provided information regarding average bed occupancies for four wards in this core service between 1 March 2017 and 28 February 2018.
Ward name Average bed occupancy range (1 March 2017 and 28
February 2018) (current inspection)
Dovedale 96.95 – 107.22
G1 Ward 65.4 – 101.25
The trust provided information for average length of stay for the period 1 March 2017 and 28 February 2018.
We are unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the time period that was covered.
Ward name Average length of stay range (1 March 2017 and 28
February 2018) (current inspection)
Dovedale 42.33 – 188.57
G1 Ward 67 - 147
This core service reported no out area placements between 1 March 2017 and 28 February 2018.
This core service reported no readmissions within 28 days between 1 March 2017 and 28 February 2018.
Discharge and transfers of care
Between 1 March 2017 and 28 February 2018 there were 115 discharges within this core service. This amounts to 14% of the total discharges from the trust overall (804).
There were 91 delayed discharges between 1 March 2017 and 28 February 2018, all of which were on G1 ward.
The ward manager at G1 explained that at the time of the inspection, five patients’ discharges were delayed due to funding not being agreed. They also informed us that patients could be delayed as relatives had not been able to find somewhere suitable for the patient. In the past the ward had gone with relatives to help them pick a new residency for their family member.
The patients discharge journey from both wards commenced at the time of admission. Patients potential discharge dates and recovery were discussed in the multidisciplinary team meetings. Both wards worked closely with the discharge teams and social services to ensure that patients were discharged smoothly. Referral to assessment and treatment times was not provided for this service.
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Facilities that promote comfort, dignity and privacy
Both wards provided patients with their own private rooms, except for Dovedale ward which had one female dormitory for up to four patients. Patients were able to personalise their rooms if they wished however; this was done on a case by case basis depending on the patients’ risks. All patients had access to lockable safes in their rooms to secure their possessions. Patients on each ward were able to have a key to their own room however; this was individually risk assessed in regard to whether they could use the key and if they wanted a key to their room. Staff and patients had access to therapy rooms, a clinic room, dining room and multiple lounges throughout the services. Dovedale ward had access to an indoor gym on site for patients to use. Patients were able to meet visitors on the ward in the lounge areas and in a separate coffee area on G1 ward. Patients were able to make personal calls in private and G1 ward had facilitated skype calls for patient who had relatives in other countries. Both wards enabled patients to access outdoor space and each ward had gardening facilities where patients would grow their own fruit and vegetables. G1 had multiple outdoor spaces which were used for gardening, they also had a shed where patients could sand and chop wood if they wished.
The 2016 Patient-led assessments of the care environment score for ward food at the Michael Carlisle centre scored higher than similar trusts. Grenoside scored lower when compared to other similar trusts for ward food.
Site name Core service(s) provided Ward food
Michael Carlisle MH - Acute wards for adults of working age and
psychiatric intensive care units.
MH - Other Specialist Services
MH - Wards for older people with mental health
problems.
97.5%
Grenoside MH - Wards for older people with mental health
problems.
88.9%
Trust overall 96.4%
England average (mental health and learning disabilities) 91.5%
Patients’ engagement with the wider community
Patients were supported to maintain contract with their families and careers. We were informed that one patient was unable to remember when a family member had visited and would get upset that they were not seeing family. The ward decided to film the visits and show the patient when they became upset.
Meeting the needs of all people who use the service
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Both wards were enabled externally for disabled access. Each ward layout lent itself to disabled access and had disabled toilet facilities. Each ward also had a hearing loop system. Staff were able to provide documentation in other languages and easy read format for patients if they required it, this was available through the trust intranet system. Staff had access to an interpreter system and could request signing assistance if required. There was a variety of food choices available to meet specific dietary requirements. All food at G1 ward was cooked on site. The ward had a relationship with a local pub that served vegan meals which allowed them to cater to these specific needs if required. Dovedale wards food was not cooked on the ward, however there was a range of food to choose from that took into account patients dietary and religious needs. Both wards had access to spiritual support with various chaplins of different denominations. Dovedale ward had links with local churches to allow patients to attend their own church if they desired. The Chaplin on G1 ward visited regularly and joined in with activities on the ward.
Listening to and learning from concerns and complaints
Patients and carers received a brochure about the ward at admission. This included key information about the ward including how to complain or raise concerns. The patient and carers we spoke to were aware of how to make a complaint. This core service received no complaints between 1 March 2017 and 28 February 2018.
This core service received 221 compliments during the last 12 months from 1 March 2017 to 28
February 2018 which accounted for 34% of all compliments received by the trust as a whole.
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Is the service well led?
Leadership
Each ward had an experienced ward manager who was registered professional nurses, each had
been with the trust for a number of years.
Ward managers had a passion for the service they were delivering and could clearly explain how
their teams were working to provide high quality care.
Development and leadership opportunities were widely available to the ward managers and staff.
We saw examples of domestic staff on the ward having RESPECT training and leading on
infection prevention control audits. Ward managers were actively involved in projects outside of
the ward. The ward manager on Dovedale was working with the trust to help design and develop
the new ward that was in development. They actively encouraged all staff to attend the feedback
meetings and give their opinion. The ward manager on G1 regularly attended and spoke at
national conferences and due to this the ward had been able to procure samples of new
technology to assist in their patient’s recovery.
Vision and strategy
Most staff we spoke to could tell us the trust values. These values were incorporated into each wards vison and values which had been put together with collaboration from staff and patients. Ward values were in line with the trust’s vision and values. Staff involvement in discussions about changes to the service was actively encouraged. This was seen with the development of the new site for Dovedale ward, the ward manager and all staff members had been encouraged to attend meetings and feedback sessions on the design of the new ward. Staff had also had the chance to look at the blue prints for the new design and give feedback. Staff informed us of the variety of different work they were involved in to help deliver high quality care. G1 ward had applied for a local grant to help develop the outside space for patients and staff also participated in the local art show every year that were displayed around the city. Both ward managers reported they received a good level of support from their senior operation managers in relation to maintaining high-quality care.
Culture
All staff we spoke to across each ward felt respected, supported and valued by their team and
managers. Staff told us that they enjoyed coming to work and felt very supported by the ward. We
observed positive staff interactions with managers while touring the wards. The culture across
both wards was a very positive one with staff feeling like they could raise concerns and contribute
to the ward.
Staff were aware of the whistle-blowing policy but informed us that they have never had to use it.
Many staff told us that if they had concerns they felt comfortable raising them with the
management team directly.
Psychological support was offered to staff for a variety of reasons, a staff member reported they
had been strained due to the acuity of patients and psychological support was offered. A staff
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member with personal difficulties had also been offered psychological support. This was offered
through occupational health but also on the ward by the team members.
Staff sickness rates for this service were higher than the overall trust average, especially on Dovedale ward. The ward manger advised that a large amount of this sickness was due to long term sickness of staff such as bereavement and physical health issues. Staff files demonstrated staff being supported back into work following sickness.
During the reporting period, there were no cases where staff had been either suspended, placed under supervision or were moved to a different ward.
Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these should be noted.
Governance
Mandatory training was above the trust target of 80% except for the training on deprivation of liberty safeguarding which as was 74%. Managers on each ward monitored the staff training compliance through an electronic system. We also found that ward managers kept their own working spreadsheet to highlight which modules were due for renewal. Managers could monitor staff appraisal and supervision compliance, both ward managers and senior operations managers were aware of the low levels of supervision and had plans in place to help improve the level of compliance. These included the use of a central electronic recording system of supervisions and bringing in extra staff so the supervisions could be completed. Staff would receive supervision once a quarter and were happy with the supervision received. Quarterly governance meetings were held across both wards which all staff could attend if they wished. The meeting discussed incidents, and the risk register. Ward managers across each ward had regular contact to discuss the individual wards and support each other. Wards held team meetings where key learning from incidents would be fed back. Staff had a good understanding of the Mental Health Act and Mental Capacity Act. A central Mental Health Act administrator helped monitor staff compliance and provided advice and guidance to staff when required. Staff undertook and participated in local audits on the wards, certain staff were leads for specific audits, for example the head housekeeper was the lead for the infection prevention control audits. Audits were cross checked by ward managers from other areas to ensure compliance.
Staff had a clear understanding of the arrangements for working with other teams, both within the provider and externally to meet the needs of the patients.
Management of risk, issues and performance
The ward manager had access to the ward risk register and was able to update the risks when appropriate. The risk register was reviewed at the quarterly governance meeting and with other ward managers across the service. Feedback from the risk register was also addressed within team meetings. Risks were escalated through this process.
Information management
Staff had access to the equipment and information required to do their job. All care records were stored electronically for staff to access. There were adequate devices on site for staff to access
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information electronically. Staff on Dovedale ward recorded all observations on the ward thorough tablet devices. Ward managers at both sites had access to the central system which allowed them to access information pertinent to their role. This included patient data, staff performance data as well as information on discharges and other key performance indicators. Each ward also had spreadsheets for collating and keeping up to date with staff training and supervision.
Engagement
Staff were kept up to date with information from the trust through the intranet and bulletins as well as
team meetings and handovers.
Staff on both wards actively encouraged feedback from patients and carers. This was done by collating
exit questionnaires and encouraging patients and carers to fill out comment cards on the wards.
Patients feedback that they had felt uncomfortable as visitors had been on the ward while they were
getting ready for bed. Due to these comments G1 ward had adjusted visiting hours on the ward to
prevent this.
The trust had a public facing website which could be accessed by the public which provided
information on the trust including details on the services provided and news from the trust.
Learning, continuous improvement and innovation
NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.
The wards did not participate in any national accreditation schemes.
Staff were given the time to speak at conferences and other organisations to relay best practice, this included the occupational therapist and the ward manager on G1 ward. There was evidence that the service was working with external organisations to help provide innovative care. The service used Paro seals as well as other distraction techniques. The ward manager for G1 had secured virtual reality devices to use with patients through external work. G1 ward had recently been assessed by positive practice in relation to their dementia environment. At the time of the inspection the results of this assessment was not known. Representatives from the trust presented at the international dementia congress in November 2017 on the subject of dementia and antipsychotic medication. G1 ward held an arts exhibition for patients to display and enjoy art.