We are taking the issues raised by the Care Quality Commission (CQC) very seriously and have given our work to respond to the issues the highest priority possible. 

On 22 October 2020 the CQC published their focused inspection results which were based on unannounced follow-up inspections they carried out in August to check on the progress we've made since our original inspection between January and February 2020. 

We were told that they had seen enough evidence to lift their warning notice on us.

On this page you'll see examples of the different work we've done to address concerns raised by the CQC, as well as things we already knew we wanted to improve, as part of our our journey to get Back to Good.

What progress have we made?

Every month our Back to Good Board meet to check in on the progress we're making. 

During these meetings we review actions that have recently been completed and give the work the scrutiny it needs to ensure the changes that have been made are robust, sustainable and making the necessary changes.

Removing dormitories and moving to single gender wards

We have removed our dormitories on our inpatient wards so all our service users now have their own room with privacy and dignity in mind. We are working towards single sex wards.

We hope that by creating single gender wards, sexual safety will improve and service users will have more modern environments to be cared for in.

Therapeutic inpatient areas

We are making our inpatient setting more therapeutic. For example on our new Dovedale 2 ‘decant’ ward we are creating a garden space that service users can access all year round and a lounge with comfy seating, French windows to allow access to the garden, a TV and computer game consoles. We’ve got great new artwork for the walls planned too.

Clinical and social care strategy development

We have been co-producing our new Clinical and Social Care Strategy with our teams and services across the organisation. All of our plans are driven by what we have heard from the people we serve.

We’ve also been working with our partners in the health system and our local partners such as Sheffield Flourish and Sheffield Healthwatch. We’ve also involved voluntary, community and social enterprise organisations such as ADIRA, Share Psychotherapy, Sheffield Mind and Sheffield City Council.

At the heart of our strategy is our ambition to give care that:

  • Is based on the needs of the person we are caring for, seeing the whole of a person, their history and what is most important to them
  • Uses evidence and we will use this to influence how we care for people
  • Gives a person who has experienced trauma a feeling of safety where they can develop trust
  • Allows people to work with our services to reach an outcome that draws on their strengths.

Improving our staff networks

We now have more staff network groups than ever before having expanded our groups over the past 12 months.

Our staff network groups are:

  • Rainbow staff network 
  • BAME staff network group
  • Disabled staff network group
  • Lived experience staff network group
  • Staff carers staff network group
  • COVID-19 staff support forum

These groups have connected staff from across Team SHSC on common issues and have played a key role in influencing policies. They have supported, championed and lifted each other to get their voices heard by our leaders.

In 2020 the BAME staff network group hosted its fifth Working Together Conference online. The Rainbow staff network group led the launch of the national Rainbow Badge scheme across the organisation by training colleagues on LGBTQ+ awareness. Our Disabled Staff Network also introduced a new workplace Adjustment and Wellbeing Passport.

Supporting detoxification

We are training staff in how to manage and support service users who are going through detoxification.

We are proud to say our teams are receiving training in safe detoxification from drugs and alcohol, to make sure people who use our services are safe during this crucial part of their recovery.

Reducing restrictive practice

We are reducing restrictive practice, working on ‘safe wards’ and refreshing our focus on human rights.

The 'safe wards' model is evidence based and clinically proven and introduces interventions at a team level. It supports improvement in patient and staff experiences and aims to reduce conflict.

We know that when patients experience less conflict and containment, they have a better experience in our services. We are appointing a new Human Rights Officer to ensure both staff and patients have access to understanding how human rights can help them make decisions.

Nursing leadership

We now have enough nursing leaders in our acute mental health wards for working age adults and Psychiatric Intensive Care Unit.

Mandatory training

We have improved how we manage and govern mandatory training - ward and senior managers are monitoring mandatory training at ward level and alert staff when they need to update their training.

Regular supervisions

We are doing more clinical supervisions and we have made it easier to record and report on these sessions.

Last July 44% of our staff were having regular supervisions, now 86% of us are having them.

We have launched a new Supervision Network to help staff too – it’s an online support system for enquires, including the supervision forms, or simply someone to seek advice from.

Quality Improvement Week

From Monday 19 October to Friday 23 October we held our annual Quality Improvement Week.

Quality Improvement Week is a chance for staff, service users and carers to come together and find out more about the range of improvement projects we're running at the moment, to contribute thoughts, share ideas and give feedback to the changes we're making.

The underlying theme throughout the week was our journey to get Back to Good.

To find out more about the week click here

NEWS2 rolled out

In our most recent Care Quality Commission (CQC) inspection, inspectors told us that we needed to do more work to address the physical health needs of our service users and during our Back to Good work staff have also told us they need more support in this area.

To address these issues we're delighted to be rolling out a new tool that will give us an early warning on any deterioration in our service users' physical health. 

The National Early Warning Score, also referred to as NEWS2, is replacing our current Early Warning Score and will help standardise the physical health observations staff carry out. The tool is one that has been used across the NHS in acute hospital trusts, and is a proven method to help us provide the highest quality care to our service users. 

You can read more on NEWS2 here

Mental Health Act training

Staff in our North and South Recovery Teams have received training on the Mental Health Act, with positive feedback received from staff in both teams. With increased understanding of the Mental Health Act, and the associated Code of Practice, this will enable staff to ensure their practice is in line with the legal requirements and support our service users to better understand their rights. 

Changes to supervisions

Having regular supervisions is essential to support our staff to learn and develop in their role. Following feedback we received during Rapid Improvement Week we have proposed increasing the number of supervision sessions staff receive a year, from four to eight. 

We have committed to ensuring managers are trained to deliver supervisions in flexible ways, that everyone understands the importance of supervisions and how supervisions can be included as part of busy clinical schedules in advance throughout the year. 

Fastrack Forms

Our Fastrack Forms are a way for service users, family, carers and staff to raise a concern, and for that concern to be responded to within 10 working days. We know that the forms aren't working as well as they could be, and this was something we've received lots of feedback on. 

We have now stopped using Fastrack Forms and have streamlined our complaints process to ensure that all complaints are treated consistently. 


We’ve gone smoke free. This means we are giving free access to Nicotine Replacement Therapy (NRT) or vaping products (e-cigarettes) to our service users to help them manage tobacco dependence.

We are also offering service users other therapeutic activities to replace smoking and stop smoking support for service users and staff who would like to quit permanently.

It’s great news that now fewer people leave our acute wards as smokers than arrived as smokers. We’ve still got work to do to support this life changing initiative.

Rapid Improvement Week

On 29 June we held our first Rapid Improvement Week which was designed to help us identify issues, look at what changes we need to make and commit to practical things that we can improve on quickly. 

Throughout the week we held workshops with staff to look at a variety of issues, including:

You can hear feedback from these workshops from our clinicians by clicking on each topic. 

Collaborative care plans

We have been working hard to improve the quality of service users’ Collaborative Care Plans. We want all plans to be relevant, up-to-date and produced with the person who is receiving care. A pilot is currently underway using a colour coding system to help identify care plans that are within date, approaching review and those that overdue for review.

We are also working with our South Recovery Team to make sure plans are of consistently good quality and help to jointly manage expectations with our service users. We are using a goals template, supportive prompt sheet and guidance to support the writing of collaborative goals.

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