CQC publishes report on Sheffield Health and Social Care NHS Foundation Trust

The Care Quality Commission (CQC) has published a report following an inspection at Sheffield Health and Social Care NHS Foundation Trust.

Inspectors visited the trust in April and May to look at the Assessment and Treatment Service (ATS), also known as Firshill Rise, which has seven beds and provides assessment and support to people with a learning disability or autistic people who are experiencing mental health needs and difficulties with behaviour. This unannounced focused inspection took place following safeguarding concerns received from trust staff and other health and social care providers.

The ATS was last inspected in October 2018 and was rated good overall. However, CQC did issue requirement notices in relation to staff induction, training in managing aggression and violence and also, the review of incidents and sharing of lessons learnt. This inspection found that the service had not addressed all of these issues from the last inspection.

As a result of this inspection, CQC has now imposed conditions upon the trust which include preventing the trust from admitting people to the service without written agreement from CQC.

The trust’s overall rating didn’t change as a result of this inspection and remains as rated inadequate. The ATS which had previously been rated as good is now inadequate overall. It is rated inadequate in all five areas, for being caring, effective, responsive, safe and well-led.

Debbie Ivanova, CQC’s deputy chief inspector for people with a learning disability and autistic people, said:

“When we inspected the Assessment and Treatment Service (ATS) at Sheffield Health and Social Care NHS Foundation Trust, we were disappointed to find that a number of concerns raised at the previous inspection in October 2018 had not been addressed and the overall rating for the service has now dropped from good to inadequate.

“People were not being looked after in a way that was safe, effective, or caring. We saw staff ignoring a person for basic needs like food and drink, and staff were seen talking amongst themselves rather than engaging with people using this service.

“Some people had been living in the service for a long time which can lead to people becoming institutionalised. We met one person who had not been able to leave the service since January 2021 as they required rescue medication to prevent epilepsy seizures, but staff had not been trained in how to administer it.

“Before the inspection we were made aware of historical safeguarding incidents involving evidence of harm being caused to people. External organisations were investigating these along with the trust, but this investigation was significantly delayed as staff had not reported or escalated the incidents which caused harm.

“Despite these issues being historical, staff still did not understand how to protect people from abuse and the service did not work well with other organisations to do so, which meant people remained at risk of abuse and avoidable harm at the time of inspection.

“Staff and people using this service are being let down by senior leadership not addressing issues which are known problems.

“Due to our concerns, we have imposed conditions on the trust’s registration for this service, which prevent the trust from admitting people to the service without written agreement from CQC, and require the trust to submit regular updates detailing the improvements they have made.

“We are monitoring the service closely and will take further action to protect people if we are not assured that rapid improvements in the safety of care are being made.”

Inspectors found:

• The service was not safe as staff did not have the training and skills to care for people and respond to their needs.
• Medicines were not managed safely and there was no policy or protocol regarding people self-administering medicines or care plans for as needed medicines.
• Relatives were not involved in the development of people’s care or their discharge. This meant that people didn’t receive person centred care which prioritised their individual needs, and often stayed in the service for much longer lengths of time than they needed to.
• The service was not caring. Inspectors saw staff ignoring people’s request of basic needs of food and drink and staff talked amongst themselves rather than engaging with people using the service.
• People experienced harm because of a lack of protection, they experienced abusive incidents, restraint and seclusion. People had poor relationships with staff which were not therapeutic.
• The service was not well led. Governance processes had not ensured the delivery of safe and high-quality care. There was no ward manager in the service and the modern matron and general manager were new to their role.
• There was a lack of visible leadership, staff did not feel listened to, and management failed to act on known issues.
• The service could not show how they met the principles of ‘Right Support, Right Care, Right Culture’ CQC’s guidance on how all people with a learning disability or autistic people should expect to be treated when using services.

The report will be published on the website tomorrow (Thursday 15 July).

Notes to editor

Throughout the COVID-19 pandemic, the CQC’s regulatory role has not changed. CQC’s core purpose of keeping people safe is always driving decisions about when and where we inspect. As the risks from the pandemic change, we are evolving how we regulate services to reflect what we have learnt during this time. You can read more about our current approach on our website.

CQC is listening to what people are saying about services to help detect any changes in care. If there is evidence people are at immediate risk of harm, CQC can and will take action to ensure that people are being kept safe. People can give feedback about their care to CQC via the details below.

• Give feedback via the website

• Telephone - 03000 616161

CQC are currently carrying out a programme of work with a focus on improving the way it registers, monitors and inspect services, to make sure the quality of care in services for people with a learning disability and or autistic people is good. This work is being led by Debbie Ivanova, who was recently appointed as a Deputy Chief Inspector for people with a learning disability and autistic people. The programme is looking at all types of services — from hospital services to care homes and supported living.

The three key areas of the programme are:

1. Ensuring the right services are regulated and registered:The recently revised guidance ‘Right Support, Right Care, Right Culture’ will ensure people have the right model of care.
2. Responding to risks swiftly and taking appropriate action:With a reviewed approach to inspections of services for people with a learning disability and autistic people, people’s experience are at the heart of these inspections, so people won’t be expected to continue to live in a service that doesn’t meet their needs.
3. Pathways and healthcare: This workstream will look at access to services, and what happens to people as they move between health and care services.

To date, pilot inspections have been carried out in mental health settings, with others now taking place in care settings. These are being evaluated so that more can continue to take place. These pilots entail:

• Spending more time observing care.
• Spending more time engaging with people and the staff who support them and their families.
• Using new tools to better identify if services are meeting the needs, aspirations and skills development of people with a learning disability and/or autistic people.