FT’s leaders unaware of staff’s ‘high-risk’ practices, warns regulator

The Care Quality Commission also cited “systemic” problems with staff training at Sheffield Health and Social Care Foundation Trust, in a warning notice which followed an inspection in January.

The formal notice, leaked to HSJ, warned trust leaders were not managing key risks faced by the provider.

High-risk practices of which they were said to be unaware included the use of mechanical restraint and allowing shared accommodation between young people and adults. In four incidents, the CQC found teenagers were admitted to the trust’s psychiatric intensive care unit overnight — one for a period of up to 47 hours — with adult patients.

Among concerns over staffing, the CQC said the trust was not ensuring it had appropriate levels of trained and experienced staff. For example, on its psychiatric intensive care unit, which treats some of the most complex patients, 60 per cent of nurses were newly qualified, some of whom were left to manage shifts.

The regulator also warned there was a “systemic” issue across the trust that staff were not receiving the training they needed. In all five of the trust’s core services, mandatory training completion rates fell below the required standards. In four out of five services, staff did not receive regular supervision.

Staff were also found not to be properly monitoring or managing the physical health of patients and, in particular, those on medication. Guidance from the National Institute for Health and Care Excellence was also not being followed in relation to rapid tranquillisation.

In one example, the physical health of one patient in seclusion, who had received high doses of rapid tranquillisation, was not monitored consistently. This patient was also given a dose of medication “outside the recommended limits”.

The trust, which has been rated “requires improvement” by the CQC since October 2018, has been given until 31 March to address staffing concerns and issues relating to the monitoring of patients’ physical health. It has until 29 May to address the other concerns.

A  Sheffield Health and Social Care FT spokeswoman said: “We take the concerns raised in the Section 29a notice from the CQC very seriously. We are already working on these issues and have put in place a rapid response action plan to address each of the areas of concern.

“We will continue to work with the Care Quality Commission to deliver high quality care for our service users.”