The Care Quality Commission
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Sheffield Children's NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings

All Inspections

14 and 15 July 2022

During an inspection of Specialist community mental health services for children and young people

Sheffield Children’s Hospital NHS Foundation trust provides specialist mental health services for children and young people across Sheffield and the wider region.

The community child and adolescent mental health service (CAMHS) is made up of nine teams. These include mainstream CAMHS, the specialist eating disorders and treatment team (SEDATT), learning disabilities and mental health, healthy minds, primary mental health, forensic CAMHS and multi-agency psychological support for looked after children. The teams work across different geographical locations. These include Beighton, Centenary House, Albion House, Gibson House, Star House, Amber Lodge and the Acute Hospital site.

The teams provide assessment and treatment for children and young people up to 18 years old with mental health conditions, learning disabilities, autism and/or emotional and behavioural difficulties. The service operates between Monday and Friday 9am until 5pm. Staff work with patients and their carers at a range of locations including schools, homes and in clinic.

The trust also provides a day unit and outreach service for children and young people at the Becton Centre. Amber Lodge is a regional unit and accepts referrals from child and adolescent mental health services throughout South Yorkshire. It provides services for children and young people aged between five and 11 years old who have severe and complex mental health problems.

The trust established the Supportive Treatment and Recovery (STAR) team in 2015. The team operates between 8.30am and 9.30pm seven days per week. This team provides assessment and brief intervention sessions to children and young people who present to the accident and emergency department with concerns for their mental health. The team also provide community intensive treatment. This is commissioned for typically three sessions per week for up to eight weeks.

The trust also established a health based place of safety for young people aged 16 to 17 in 2015. A health based place of safety is a place at a hospital where people are taken by the police or ambulance service for mental health assessment when they have been found by the police to appear to be suffering from a mental disorder and in need of immediate care or control. This must be necessary in the interests of the person or for the protection of others. The health based place of safety is situated at the Becton Centre alongside the child and adolescent mental health wards.

As part of this inspection we visited the following locations;

• Centenary House

• Beighton community centre

• Sheffield Treatment and Recovery (STAR) team at Sheffield Children’s Accident and Emergency

  • Becton Centre health-based place of safety.

Our rating for this service stayed the same. We rated the service as requires improvement. The reasons for this rating are set out below;

  • Children and young people waited a long time to access the service, clinicians had high caseloads which had an impact on their ability to provide safe care.
  • The service did not always ensure that children and young people received a physical health check at their initial appointment.
  • Staff did not always complete mandatory training.
  • The trust did not always ensure that staff were safe in their role because policies, procedures and training in; management of violence and aggression lone working, and incident response were unclear.
  • There was not a clear process in place to support young people who were leaving the service and not making a transition to adult services.
  • Where there were gaps in delivery the service did not maintain adequate communication with young people, their carers or other agencies.
  • Appointments that were cancelled by the service were not always re-appointed.
  • Parents told us that they were concerned about the lack of urgent out of hours provision where their option was limited to attending the accident and emergency department.
  • There were some areas of good governance which were not entirely effective.

However;

  • Staff were described as patient and insightful.
  • Parents were grateful for flexibility given in appointment arrangements and the variety of settings in which these could take place.
  • The STAR team had expanded their remit to include all mental health presentations which improved access to mental health services for the wider community.
  • The risk assessments carried out were comprehensive and also included crisis plans which were shared with all those involved in the care of the child or young person.
  • The trust had made a number of improvements to the service and were taking an innovative approach based on continuous improvement.

14 and 15 July 2022

During an inspection of Child and adolescent mental health wards

We carried out this unannounced inspection because we had concerns about the quality of services.

We inspected three wards for Children and Young People.

  • Sapphire Lodge – a mental health ward for young people aged between 13 and 18 years old with mental health problems. The ward was commissioned for 12 beds, there were 10 beds open at the time of our inspection.
  • Emerald Lodge – a nine bed mental health ward for Children and Young People aged between 8 and 13 years old with mental health problems
  • Ruby Lodge – a seven bed mental health ward for Children and Young People aged between 8 and 18 years old with mental health problems and learning disabilities.

Our rating for the service remained the same. We rated the service as good. However, we did rate the safe key question requires improvement, the reasons for this are set out below;

Despite a national staffing crisis and some vacancies within the service, staffing was managed well. Daily safety huddles looked at staffing across the unit and deployed staff to where they were needed most. Lodges were clean. Staff followed infection control policies including those related to Covid-19.

Since our last inspection, the nasogastric room had been relocated to an empty bedroom. This gave Children and Young People needing to be fed via a nasogastric tube more privacy and dignity. Despite this, the room was not soundproofed, this meant that other patients did at times become distressed due to the noise and anticipation of this procedure.

Risk assessments were kept up to date and contained key information to manage risk safely. Staff had completed and kept up to date with mandatory training. The environment was in keeping with the needs of young people and was decorated and furnished to suit their needs.

Feedback from Children and Young People and their carers was mostly positive. Children and Young People felt that staff cared for them and made them feel safe on the lodges. Carers told us that staff involved them in their loved one's care and kept them up to date. Some carers felt that communication could be improved.

Leaders within teams had a background in child and adolescent mental health services. Staff felt proud to work as part of the service and told us they were a supportive team who cared for each other as well as the Children and Young People in their care. Staff were supported to improve their knowledge and skills via specialist training and were encouraged to progress their careers.

However,

We found that some blanket restrictions remained in place. This included locking of most doors to communal areas on Emerald and Sapphire Lodges. On Emerald Lodge we found that key rooms such as the female lounge and quiet rooms were locked. Although staff were happy to unlock the doors when Children and Young People wanted to go in, Children and Young People did not have free access to these spaces. In comparison, Ruby Lodge had all rooms unlocked with the garden open for Children and Young People to access.

The most up to date version of the ligature risk assessment for Sapphire Lodge was not available on the lodge when we requested it. We were given a risk assessment from 2019 which did not include new rooms that had been added since then. However, we did later receive a copy of the 2022 risk assessment. This was available electronically for staff. There had not been a permanent Consultant Psychiatrist in post on Ruby Lodge for over one year. There had been locum cover during this time, but these had sometimes been for short periods which meant a lack of stability for Children and Young People in relation to their care. The Locum consultant at the time of our inspection had been in post for a longer period.

Agency staff did not always have access to the electronic records system. This meant that they did not always have access to all relevant information about Children and Young People when they were on shift.

The electronic supervision recording tool did not accurately reflect the level of supervision and support staff told us they received. Although figures appeared low, it was acknowledged this was due to the recording system rather than a lack of support for staff. All staff we spoke to felt well supported and accessed supervision both formally and informally on a regular basis.

26-27 July 2021

During an inspection of Child and adolescent mental health wards

We carried out this unannounced focused inspection because we had concerns about the quality of services.

We inspected three wards for children and young people. We inspected:

Sapphire Lodge – a 10 bed mental health ward for young people aged between 13 and 18 years old with mental health problems

Emerald Lodge – a nine bed mental health ward for children and young people aged between 8 and 13 years old with mental health problems

Ruby Lodge – a seven bed mental health ward for children and young people aged between 8 and 18 years old with mental health problems and learning disabilities.

At this inspection we reviewed some key lines of enquiry within the safe, effective, caring and well-led domains.

We did not re-rate this service at this inspection.

  • The service did not always have enough nursing staff to meet patients’ needs. The service had vacancies and staffing pressures which were exacerbated by the impact of the Covid-19 pandemic. Staff did not always have capacity to complete one to one sessions with children and young people or to engage in therapeutic activity.
  • Facilities were not always fit for purpose. On Sapphire Lodge the clinic room was also being used as the nasogastric feeding facility. The clinic room was an inappropriate environment for this purpose and did not provide an appropriate level of dignity and privacy.
  • The service used high levels of restraint. Restraint was primarily used to support nasogastric feeding. Following feedback at the end of our inspection the service brought in a specialist team to review the use of restraint within the service.
  • Risk assessments for children and young peoples’ leave from the lodges were not robust.
  • There had been a recent serious incident involving children and young people on leave.
  • Feedback from children and young people and their families was mixed. Children and young people on Sapphire Lodge provided mainly negative feedback and expressed concerns about staffing levels and attitudes. Children and young people on Emerald Lodge were positive about the service and staff.
  • Shifts did not always run with sufficiently experienced staff. There were a high number of preceptorship nurses in post. Managers were qualified nurses and allied health professionals, however they did not all have backgrounds in child adolescent mental health services.
  • Staff morale was low, especially on Sapphire Lodge. Staff told us they did not always feel respected, supported or valued. Staff morale was impacted by staffing pressures and the Covid-19 pandemic.
  • The trust’s processes for the management of risk and performance had identified concerns in relation to this service prior to our inspection, but timely action had not been taken.

However:

  • Lodges were clean. Staff followed infection control policies including those related to Covid-19.
  • Staff completed risk assessments for each patient on admission and reviewed this regularly, including after any incident.
  • Staff had completed and kept up to date with mandatory training. The mandatory training programme was comprehensive.
  • Lodge managers were registered mental health or learning disability nurses, the trust’s head of nursing was a children’s nurse and one senior leader was a qualified social worker with a background in child and adolescent mental health services.

How we carried out the inspection

During the inspection we visited Sapphire and Emerald lodges and observed how staff were caring for children and young people. We spoke with 17 staff, seven children and young people and 11 family members and carers. We reviewed six care records. We visited Ruby Lodge and completed an environmental review.

We spoke with senior leaders at the trust. We looked at a range of policies, procedures and other documents relating to the running of the service. We attended three meetings

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

What people who use the service say

We spoke to seven children and young people and 11 family members and carers. Feedback was mixed. Children and young people on Sapphire Lodge provided negative feedback on care and treatment, staff and staffing levels. Children and young people on Emerald Lodge provided positive feedback on care, treatment and staff. Parents and carers also provided mixed feedback. We received negative feedback from some parents and carers of children and young people on Sapphire Lodge. However, we also received positive feedback regarding Sapphire Lodge and in relation to Emerald Lodge.

26 Mar to 04 Apr 2019

During a routine inspection

  • We rated effective, caring, responsive and well-led as good and safe as requires improvement.
  • Sheffield Children’s Hospital was rated as good overall. Safe, effective, caring, responsive and well-led were all rated as good. All ratings were the same as the previous inspection with the exception of safe, which had improved one rating.
  • At this inspection, we rated five out of the six services we inspected as good overall and one as requires improvement. In rating this trust, we took into account the current ratings of the five services not inspected this time.
  • Since our previous inspection in 2016, transition services and child and adolescent mental health wards had undertaken some significant work and improved one rating from requires improvement to good overall.
  • Our full inspection report summarising what we found and the supporting Evidence Appendix containing detailed evidence and data about the trust is available on our website .

26 Mar to 04 Apr 2019

During an inspection of Specialist community mental health services for children and young people

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

  • Patient risk assessments and care plans were not completed for all patients and were not regularly reviewed. Description of risks were brief, and only basic risk management plans were in place. Crisis plans had not been considered for all patients and implemented where required in line with best practice guidance. Care plans were brief and did not evidence involvement of patients or carers or of regular goal setting and review. Information was not readily available in accessible forms and staff were unsure how to access these if required.
  • The Sheffield Treatment and Recovery (STAR) team were unable to take referrals for community intensive treatment due to low staffing levels, and staff within a variety of teams told us that in some cases high caseloads prevented them from seeing patients as often as they would like.
  • Waiting lists for assessment and treatment continued to be long, and mandatory training compliance continued to be low in a number of courses, including Mental Health Act and Mental Capacity Act. This was despite some action plans in place to drive improvement in these areas.
  • Staff did not regularly receive feedback from complaints, audits and incidents, and patients and carers did not consistently receive feedback when making suggestions for the service.

  • Governance systems and processes in place to assess, monitor and improve quality and practice within the service at the time of inspection were not effective. Some staff members were being managed and supervised by staff external to the service rather than internal managers. Policies were not consistently reviewed and updated in line with set timescales.

However:

  • Staff reported incidents and made safeguarding alerts where appropriate. Staff understood the duty of candour and were open and transparent with patients. Staff knew how to contact the trust Freedom to Speak Up Guardian and could access the trust whistleblowing policy.
  • Staff attitudes when interacting with patients were respectful and responsive and most patients and carers were positive about their interactions with staff.
  • Staff provided a range of care and treatment interventions and the staff team included a full range of specialists required to meet the needs of patients. Staff used recognised rating scales to assess and monitor outcomes of care and treatment.

26 Mar to 04 Apr 2019

During an inspection of Child and adolescent mental health wards

  • The service had undertaken significant work to improve since our last inspection. They had reduced the amount of fixed ligature anchor points, improved staff knowledge and practice on safeguarding, ensured that medicines were managed safely and properly and increased the reporting of incidents and feedback to staff following incidents. Remaining improvements were in progress and managed through the service’s action plan and risk register. This included the installation of the nurse call alarm system.
  • Leaders were visible and approachable and engaged with staff. Staff who raised concerns reported positive experiences of the support they received and the action taken to address their concerns. The trust was engaging with staff for their views in the development of the new child and adolescent mental health services vision and strategy. Staff could be involved in developing and delivering the strategy through quality improvement methods in use.
  • The service managed the beds available well and the wards were discharge focussed. The only patients placed out of area required specialist services to meet their needs, staff planed discharge from admission and there was only one delayed discharge in a 12-month period.
  • The teams comprised of a range of multi-disciplinary professionals that provided a range of therapies and worked together and with external agencies to review patients’ progress through care and treatment and to plan discharge.
  • Staff understood and carried out their responsibilities in relation to Mental Health Act and its code of practice, Mental Capacity Act and the five statutory principles and Gillick competency.
  • Staff knew patients and their needs well. They involved patients as partners in their care and valued parents and carers’ involvement. They demonstrated supportive and non-judgemental approaches.
  • The care environments and facilities promoted recovery, comfort privacy and dignity. The Patient Led Assessment of Care Environments for ward food and disabilities were higher than the trust and England Averages.
  • The wards received nominations in the recent trust staff awards and a member of staff from Sapphire Lodge won the award for direct patient care.

However:

  • The services implemented restrictions that included a blanket restriction on Emerald Lodge for mobile phones and electronic devices and areas of the wards were locked and only accessible with staff supervision including outdoor space and kitchenettes. The environmental risk assessments for outdoor space contained conflicting information about the level of supervision required.
  • The health-based place of safety had been used on two occasions both of which were not in line with the trust policy and not in relation to risk of the patients who were cared for there.
  • There were some lapses in record keeping. When staff added incidents to patient risk assessments, it was not clear whether they had reviewed these, on Sapphire Lodge, three patients’ expired section 17 leave forms had not been cancelled or removed and the template for patient observation recording was pre-populated with times.
  • Not all staff were up to date with all the mandatory training requirements.
  • Although patients were involved in their care and treatment, staff had not always ensured that care plans reflected patient views and the patients voice. We also identified issues with one patient’s care and treatment records which had not always reflected their wishes about their identity. Although easy read information was available, this was not used for relevant patients.
  • Activities mostly took place between Monday and Friday during the day times.

14 to 15 August 2018

During an inspection of Specialist community mental health services for children and young people

We found that:

  • There continued to be issues with the waiting list for the community child and adolescent mental health team for both initial assessment and following this an internal waiting list for treatment. The key performance indicators reported that the trust was achieving an assessment to treatment target which was not an accurate reflection of the performance. The services’ risk register, which contained an item on internal waiting list for treatment, and the services’ business continuity plans had not been reviewed regularly. The team did not actively monitor the waiting list for initial assessment to review changes in patients’ risks and needs.
  • There were lapses in the assessment of risk and implementation of management and mitigation in relation to fire and ligature risks. Ligature cutters were not quickly accessible. Patient risk assessments completed by the community child and adolescent mental health team were brief and basic. Only one patient record reviewed contained a crisis plan.
  • Staff working at Centenary House did not have sufficient procedures in place to raise an alert for assistance quickly when required.

However:

  • Staff reported that leaders were visible and approachable and observations showed staff displayed the trust values.
  • The trust had made some improvements to the services through the introduction of the STAR team and health based place of safety. The services had implemented an electronic incident reporting system and addressed the issues identified at our last inspection that related to management of clinic rooms and emergency equipment.
  • The services had new initiatives including a daily clinical assessment team to screen referrals, pathway tracking reports and meetings to monitor waiting lists and had created job plans for staff.

14-15 August 2018

During an inspection of Child and adolescent mental health wards

We found the following issues that the trust needs to improve:

  • The trust was not consistently delivering care and treatment safely and in a way, that protected patients from avoidable harm and abuse. Staff were not managing and mitigating ligature risks. Patient risk assessments were reviewed but not consistently updated during reviews. Staff did not respond to an allegation of abuse in line with safeguarding procedures. Medication records were not maintained consistently and appropriately. Staff had implemented blanket restrictions and there was limited evidence of systems in place to identify and review restrictive practices on the lodges. Nurse call alarms were not available in patients’ bedrooms and communal areas and staff told us that there were issues with having enough personal alarms for each staff member on shift. Mandatory training compliance was below the trust’s target.
  • The trust was not consistently delivering care and treatment in a way that was well-led. Systems were not operating effectively to identify areas of concern in relation to the safety of the lodges. The trust had implemented guidance which undermined the systems in place to monitor the use of restrictive interventions on the lodges. There were issues with culture and staff morale which had impacted on high sickness and turnover levels. Managers had not ensured that staff undertook mandatory training, supervision and appraisal. There was mixed feedback on senior leader visibility. We found that breaches of regulation identified in the 2016 inspection had continued in this inspection.

However:

  • The trust had identified areas of concern in the service and had implemented an action plan to address them. This included concerns in the service in relation to leadership, workforce, clinical pathways, clinical risk, service review and improving the lodge environment. The action plan was in-progress at the time of the inspection.

14 to 17 and 30 June 2016

During an inspection looking at part of the service

Sheffield Children’s NHS Foundation Trust is one of four dedicated children’s hospital trusts in the UK. It provides integrated healthcare for children and young people from the local population in Sheffield and South Yorkshire, as well as specialised services to children and young people nationally.

We inspected the trust between 14 and 17 June 2016. We undertook an unannounced inspection at the Emergency department on 30 June. We previously inspected the Sheffield Children’s Hospital in May 2014 and rated it as good overall. The mental health services and community services were not inspected at that time. We have not inspected the Embrace service.

This inspection was to inspect the mental health and community services. We also undertook a focused inspection in areas within Sheffield Children’s Hospital that were identified as requiring improvement at the previous inspection. These were areas of emergency and urgent services, neonatal services, surgical services, medicine and critical care.

In the inspection in May 2014, we identified that the trust must ensure the hospital cover out of hours was sufficiently staffed by competent staff with the right skill mix, particularly in the Emergency department. We also identified the trust must ensure consultant cover in critical care was sufficient and that existing consultant staff were supported while there were vacancies in the department and that the process for ongoing patient review for general paediatric patients, following their initial consultant review, must be reviewed to ensure there were robust processes for ongoing consultant input into their care. We found that at this inspection, all these specific areas had been addressed.

At this inspection, we rated services that had not previously been rated and also the specific areas we inspected. However, we did not review the overall rating for the trust as the inspection was focused on specific areas only.

We rated children’s, young people and families services within the community services as good. Child and adolescent mental health wards, child and adolescent mental community services and transition services required improvement.

Our key findings were as follows:

  • The trust had taken action to address areas identified at the inspection in May 2014. However, the trust had made insufficient progress in developing transition services since our last inspection. The trust directors recognised there was further work to do.
  • There was an open culture within the organisation. Challenge was encouraged by executives and non-executive directors. However, the trust was not fully compliant with the Duty of Candour regulation.
  • There were some staff shortages; the Board had approved additional posts in principle and recruitment was underway.
  • Incidents were reported and investigated and lessons learned, although there were some concerns about the reporting of restraint in mental health services. The trust was planning to introduce an electronic incident reporting system which would improve capability to analyse themes.
  • Infection prevention and control policies were effective. There had been no cases of MRSA reported since 2008. All reported cases of Clostridium difficile between April 2015 and March 2016 were unavoidable.
  • Feedback from people who used the services we inspected and those who are close to them was mostly positive about the way staff treated people.
  • There was evidence of public engagement, however it was recognised by the trust, that there needed to be a more systematic approach; there was no patient and public involvement strategy in place.
  • There were no mortality outliers at the trust.
  • There was a lack of robust monitoring and governance in some areas, for example use of the Mental Health Act and equality and diversity.
  • Staff did not always take a proactive approach to safeguarding, particularly in the emergency department and within mental health services.
  • Within mental health services, staff used restrictive practices, some of which met the definition of seclusion. However, these were not recognised as such and were not dealt with in accordance with trust policy.
  • The trust was in the process of building work to provide new accommodation for some of the wards and outpatients. The aim was to provide an environment to better meet the needs of children, young people and their families.

We saw several areas of outstanding practice including:

  • The CAMHS service had been successful in securing NHS England and local clinical commissioning group funding for a child and adolescent mental health service schools link pilot scheme. The aim of this was to improve joint working between child and adolescent mental health service and schools. The project arose from the ‘Future in Mind’ Department of Health document and the transformation plan to improve early access to mental health support for young people. The scheme consisted of a number of tier three child and adolescent mental health professionals working within 10 schools. The project had been positively received by the funders and organisations involved.
  • The trust had established paediatric palliative care simulation training.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure compliance with the Duty of Candour (regulation 20).

Child and adolescent mental health wards

  • The trust must ensure that practices used by staff to manage behaviour such as time out and seclusion are used and recognised correctly. Staff should follow applicable procedures for the use of these practices with clear rationale and evidence documented.
  • The trust must ensure that informal patients are aware of their rights, and any restrictions, and understand these when they consent to their admission and treatment. Staff should not use the threat of detention in order to prevent patients from leaving where this is not a justifiable and required intervention.
  • Staff must ensure that incidents involving abuse between patients are referred as safeguarding concerns where necessary. Evidence of safeguarding considerations must be documented accordingly.
  • The trust must ensure that there is consistency between staff about what incidents are reported and what the threshold is for reporting physical interventions.
  • The trust must ensure there are appropriate systems in place at service level in order to effectively assess and monitor the service and how it operates. This should include the ability to identify and monitor staff training requirements and that staff supervisions are undertaken in accordance with policy.
  • The trust must ensure there are effective systems and processes in place to monitor medicines management and infection control practices. These should be able to identify and highlight shortfalls in practice which must be addressed as necessary.
  • The trust must ensure that policies in place in relation to the Mental Health Act appropriately reflect current practice and legislation.
  • The trust must ensure that relevant staff receive appropriate training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
  • The trust must ensure that there is appropriate oversight of the application of the Mental Health Act and any breaches of this within the service.

Specialist community mental health services for children and young people

  • The trust must ensure that environments are assessed in order to identify and mitigate risks that may be present to people using the service.
  • The trust must ensure that lone working procedures are risk assessed as necessary and lone working processes are suitably robust to maintain safety.
  • The trust must ensure there are appropriate systems in place at service level in order to effectively assess and monitor the service and how it operates. This should include the ability to identify and monitor staff training requirements and that staff supervisions are undertaken in accordance with policy.
  • The trust must ensure that clinic room equipment is safe and suitable for use. There must be effective systems and processes to monitor infection control practices. These should be able to identify and highlight shortfalls in practice.
  • The trust must ensure staffing levels are sufficient to enable young people to access treatment within timescales set out in trust and NHS national targets.

Transition care

  • The trust must ensure that there are effective governance systems in place to capture, respond, and learn from transition related complaints and incidents.
  • The trust must ensure that sufficient numbers of staff have appropriate training in the Mental Capacity Act 2005.
  • The trust must ensure that there is an effective clinical audit system in place to monitor transitional care provision.

Urgent and emergency care

  • The trust must ensure all children are appropriately assessed for safeguarding risks.

Medical care

  • The trust must ensure that staff undertake and document appropriate risk assessments to promote safe care.
  • The trust must ensure all staff disciplines have safeguarding training.

Community health services for children, young people and families

  • The trust must ensure that electronic record systems enable staff to identify and assess risks to the health, safety and welfare of people who use the service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

14 - 17 June 2016

During an inspection of Child and adolescent mental health wards

We rated child and adolescent mental health wards as requires improvement because:

  • Staff used restrictive practices to manage patient’s behaviour. Some of these practices were not recognised correctly and were not handled in accordance with trust policy or the Mental Health Act code of practice.
  • There was inconsistency and differing thresholds between staff about what incidents were reported as restraints. There were omissions in incident data and the system for reporting incidents did not allow for detailed incident analysis to be undertaken.
  • Informal patients were not all aware of their rights as patients and aware they could leave. There was no evidence to demonstrate they were aware of and had consented to any restrictions with regards to leaving the service.
  • There was no evidence of how staff had assessed patients as being competent to make their own decisions and give consent in relation to their care and treatment.
  • Medicines were not always managed in a safe way and staff did not complete any audits to identify and address shortfalls and medication errors.
  • Mental Capacity Act training was not mandatory for staff and there was no set plan about what training all staff required in order to be suitably equipped for their roles.
  • Patients and parents said they were involved in their care plans but this was not reflected within care plans.
  • There was no oversight of staff training and supervisions at service level in order to ensure staff received necessary training and support.
  • There was a lack of audits that took place in order to monitor the effectiveness of the service.
  • Some policies in relation to the Mental Health Act were still awaiting ratification and referred to out of date information.
  • Some staff felt there was a disconnect between the service and the acute trust.

However:

  • Staffing levels were reported to be good amongst most lodges although Amber lodge staff reported there were not enough staff.
  • The service had a dedicated safeguarding nurse in post.
  • Patients received an assessment upon admission to the service and support for their ongoing health. There was a wide ranging multidisciplinary team made up of a variety of professional disciplines.
  • Staff said they received regular supervision and appraisal and were encouraged to undertake additional training. They felt supported within their teams and by their managers.
  • Some patients said staff were caring and supportive. Parents of young people using the service said staff were caring, professional and respectful.
  • Patients had access to advocacy services, said they were involved in their care plans and care reviews and had their own ‘mini team’ to support them
  • The facilities and environments were designed in a way to meet the needs of the patients and individualised to the different patient groups.

14 -17 June 2016

During an inspection of Community health services for children, young people and families

We rated effective, caring, responsive and well led as good. Safe was rated as requires improvement. We rated this service as good overall because:

  • Staff were aware of their responsibility to report incidents, they knew how to report incidents, near misses and accidents and were encouraged to do so. Learning from incidents was shared between teams. However, it was hard for service leads to identify trends with regards to incidents as reporting was paper based.
  • Safeguarding processes were in place and there was a dedicated safeguarding team in place. Practitioners received safeguarding training. However, we were not assured that the computer system kept children safe but relied on practitioner’s knowledge of the system.
  • Care and treatment was evidence based with policies, procedures and pathways available to staff. There was good evidence of multi-disciplinary working. Staff were aware of their responsibilities with regards to obtaining consent.
  • We observed staff treating people with compassion, kindness, dignity and respect. Feedback from children, young people and their families was positive.
  • Services were planned to meet people’s needs and the needs of different people were taken in to account. Practitioners were aware of the needs of the local population.
  • Leaders were approachable, supportive and encouraged staff engagement. However, some staff felt that there was not enough information given to them at an unsettling time, due to service redesign.
  • Staff knew the trust vision and values. Governance systems were in place to ensure delivery of good quality care.

However:

  • Health visitor caseloads exceeded recommendations and not all areas were offering a face to face antenatal contact to all mothers as part of the core offer.
  • There was no consistency across the trust with regards to records. There was a risk that practitioners did not have access to information in a timely manner.

14 - 17 June 2016

During an inspection of Specialist community mental health services for children and young people

We rated specialist community mental health services for children and young people as requires improvement because:

  • Environmental risks within the service had not been assessed and therefore there were no plans as to how such risks were to be mitigated. No risk assessments were completed in relation to lone working practices.
  • We found out of date items in clinic rooms and equipment that had not been calibrated to ensure it was accurate to use. There were no regular checks of clinical areas and infection control practice which meant these issues had gone unnoticed.
  • Some young people in the generic services had to wait significant amounts of time for treatment. These timescales exceeded the trust’s own target and NHS referral to treatment time scales.
  • There was no oversight of staff training and supervisions at service level in order to ensure staff received necessary training and support. There was a lack of audits that took place in order to monitor the effectiveness of the service.
  • There was no evidence of how staff had assessed young people as being competent to make their own decisions. Staff were not required to have training in the Mental Capacity Act 2005 as this was not mandatory training.
  • The system for reporting incidents did not allow for detailed incident analysis to be undertaken. Some staff felt they did not always receive meaningful feedback from incidents.
  • Although the service was able to offer some flexibility of appointments, including out of hours, some carers said that a lack of flexibility in their cases impacted upon their routine and that of their child.
  • The service did not use agency staff and tried to maintain continuity of care for young people. However, there were instances where staff absences had not been effectively covered or communicated to carers and young people.

However:

  • Staff used recognised clinical outcome rating scales to assess and monitor young people’s progress. There were a variety of professionals at the service who were able to offer different treatments to suit young people’s need.
  • Staff regularly reviewed waiting lists and there was a consultation line for carers and young people to contact if their circumstances deteriorated. The service could offer rapid response appointments where these were deemed as being required.
  • The service had introduced initiatives to try to combat high demand and reduce waiting times. The service was participating in a schools project to address early intervention for mental health problems in children.
  • Young people and carers spoke positively about staff who they described as caring, supportive and professional. Our observations of how staff engaged with young people and carers supported this.
  • Staff felt confident about their safeguarding responsibilities and had resources to support them with this.

7-9 & 22 May 2014

During a routine inspection

Sheffield Children’s NHS Foundation Trust is one of four dedicated children’s hospital trusts in the UK. It provides integrated healthcare for children and young people from the local population in Sheffield and South Yorkshire, as well as specialised services to children and young people nationally.

Sheffield Children’s Hospital has been a foundation trust since 1 August 2006. They employ around 3,000 staff. They treat around 30,000 children and young people admitted to hospital as inpatients or day cases and more than 164,000 attending outpatient clinics or being treated in emergency department.

The trust has three locations registered with the Care Quality Commission. These include Sheffield Children's Hospital, Becton Centre for Children and Young People, and Ryegate Children's Centre. The trust also runs the EMBRACE retrieval service for the region.

The trust was in the process of a new hospital build, due to be complete in 2016. This aims to improve privacy and dignity of patient with increased number of single rooms and larger bed space areas. It also aims to increase the recreational and support facilities for children and young people and their families.

We carried out this comprehensive inspection as part of the pilot phase for the methodology adapted for dedicated children’s hospitals. Sheffield Children’s Hospital NHS Foundation Trust was rated as medium risk in the CQC’s intelligent monitoring system. The inspection took place between 7 and 9 May 2014 and an unannounced inspection took place on 22 May 2014. We did not inspect the Children’s and Adolescent Mental Health Services (CAMHS) provided by Sheffield Children’s Hospital.

Overall, this trust was rated as good. We rated it good for being caring, effective and responsive to patients’ needs and being well led, but improvement was required in providing safe care.

Our key findings were as follows:

  • All staff working at the hospital were extremely proud to work for the hospital and dedicated to their work.
  • The culture was found to be open and transparent with an evident commitment to continually improve the quality of care provided.
  • The executive team were well known throughout the hospital and some members of the team did regular walkabout, and the medical director still worked clinically in the A&E department.
  • The care provided throughout the Hospital was consistently found to be compassionate and demonstrated dignity and respect with good examples of providing emotional support to children, young people and their families or carers.
  • Staffing out of hours (OOH), particularly within the A&E department was not always sufficient. The trust was in the process of presenting a paper on OOH cover to increase the number of consultants available and strengthen the OOH cover at the hospital.
  • The nurse staffing tool used by the hospital was developed specifically by the Chief Nurse to take into account national standards and other factors specific to the needs of each ward and agreed levels for each shift were agreed with the ward manager as a basis for recruitment and ongoing staffing.
  • The end of life care service demonstrated a clear commitment to always meet the preferences of patients on an end of life care pathway.
  • The accuracy of statutory and mandatory training data was not consistent between the central database and those records held locally at the wards. Staff reported this was due to them reluctance to rely on the central database at it was often inaccurate.
  • The hospital was clean and infection prevention and control measures were found to be good in the majority of areas, although a few staff were found to not comply with being bare below the elbows.
  • The flow throughout the hospital was in the majority good and they had a high rate of day case activity to prevent children and young people having to stay in hospital. They were also starting to work with other providers to develop pathways to keep care closer to home.

We saw several areas of good and outstanding practice including:

  • Outstanding practice was found to be evident in end of life care, in particular their leadership and responsiveness to patients wishes and preferences on an end of life care pathway.
  • The commitment and dedication of all staff and the transparent and open culture.
  • The tool used for nurse staffing was developed by the chief nurse and agreed staffing levels were decided in a collaborative manner with ward managers to ensure all aspects of specialism and acuity were taken into account.
  • The care and commitment provided in the A&E department was found to be excellent and the trust had consistently met the A&E 4 hour target for the previous twelve months.
  • There was a drive to deliver care closer to home and reduce unnecessary admissions.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure the hospital cover out of hours is sufficiently staffed by competent staff with the right skill mix, particularly in A&E.
  • Ensure consultant cover in critical care is sufficient and that existing consultant staff are supported while there are vacancies in the department.
  • Review the process for ongoing patient review for general paediatric patients following their initial consultant review to ensure there are robust processes for ongoing consultant input into their care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.