HEALTHWATCH SHROPSHIRE formal questions to The Robert Jones and Agnes Hunt NHS Foundation Trust following contact from patients with the Independent Health Complaints Advocacy Service (IHCAS) provided by Healthwatch Shropshire and their Enter & View visit

Healthwatch Shropshire questions in bold followed by the Trust response received [date of their letter]:

1) In the past we [Healthwatch Shropshire] had a regular information sharing meeting with the Director of Nursing at RJAH, but these have not been restarted since the pandemic. 

We would be happy to discuss reinstating these meetings and how we can support the Trust to hear from patients about their experiences of services throughout their patient journey. We have recently had a change in leadership and have an interim Chief Nurse She has indicated that she would be keen to re-establish these meetings and work with you more closely going forward. She will ask her PA to reach out to you to get some dates in the diary. 

2) The experiences shared by two patients appear to show some shared experiences and challenges. Are any concerns and complaints received from individual patients and their families reviewed and discussed by the team working with the patient to identify improvements, learning and how needs could be addressed? If so, what is the process and how is learning shared and reported? 

Concerns and complaints are initially addressed locally, either by a Ward Sister or Ward Manager. As per our complaints process, these are usually completed via a process called “Local Resolution” where the senior nursing team on the ward aim to rectify any concerns without delay. 

All Local Resolutions processed via the Senior Nursing Team are shared with the Ward Managers and the Trust’s Clinical Governance team. The Trust’s Clinical Governance team log all Local Resolutions. Feedback from these are produced and shared at operational Clinical Governance meetings (which occur every four weeks) as well as the Senior Nurse Clinical Governance meetings (which also occur every four weeks).

 Any shared learning is fed back to the ward staff either via the ward’s daily safety huddle which occurs once per shift and/or via email. 

3) Due to the length of time people are patients on the wards, is the Patient Advice and Liaison Service (PALS) and/or complaints process designed to respond to concerns or complaints, and agreed actions or improvements implemented while they are still a patient? 

The Clinical Governance Team aims to provide a response to patient’s concerns raised via the PALS process within 10 working days. However, where complex concerns are raised, further time may be required to ensure they have been fully addressed. In the instance of a patient raising a formal complaint, a complaint response is provided by the Trust’s Chief Executive Officer (CEO), and a response is provided within 30 working days for a standard complaint and 45 working days for a complex complaint. 

Similarly to PALS concerns, there are occasions when due to the complexity of a complaint the Trust may be unable to provide a response within these timeframes, in which case the complainant is notified. 

The Trust process for patients raising concerns/complaints on MCSI is for the ward staff to undertake local resolution in the first instance. Where possible, the patient’s concern is addressed by the ward sisters, ward managers or consultants. However, if local resolution has not been successful (or exhausted), the patient is usually signposted to speak to the PALS team. 

The Specialist Unit Clinical Governance Manager (or her deputy) will arrange a visit to see the patient on the ward, usually on the same day (or within 3 working days of receiving a request). Occasionally, this time frame may be extended due to other scheduled commitments, but this is not usually the case. 

During the PALS visit, the patient’s concerns are noted, and feedback is sought from relevant members of staff who may be able to assist with resolving the patient’s concerns. Depending on the concern raised (and length of time until the patient is discharged), actions will usually be implemented whilst the patient remains an inpatient to improve their experience. 

Whilst we endeavour to address/implement actions in this time frame, it is not always possible to do so. For example, if the patient has requested a different wheelchair, it can take weeks for a custom wheelchair to arrive. 

4) Is advocacy available for patients who do not have family or visitors to support them to share their views or raise concerns? What are the arrangements for this? 

The Trust does not have a formal advocacy service within MCSI, however different members of the Multi-Disciplinary Team (MDT) will frequently act as advocates for patients when required. 

Within the MDT, psychology staff frequently advocate for patients who need support to share their views or raise concerns. The MCSI Assistant Psychologist meets all new patients and provides screening of their mood. If concerns are identified during screening, the psychology team will support by advocating for patients. In addition, all patients are allocated a keyworker from the MDT. 

The role of the keyworker is predominantly related to the Goal Planning System, but the keyworker role also involves a degree of advocacy, in that they will help the patient to communicate their needs, wishes and concerns to the MDT. 

If a patient lacks capacity to make decisions and does not have family or close friends to support them, a formal referral will be made to an Independent Mental Health Advocate (IMCA). 

If a patient has capacity to make decisions, it is much more difficult to get an independent advocate external to the MDT. MCSI have previously attempted to make referrals to various external advocacy agencies but have been informed that this service is only available for individuals who lack capacity.

5) Apart from the complaints process, what processes are in place to regularly gather patient and family views and experiences while they are on the unit so that issues can be identified and addressed in a timely way, avoiding the need for people to go through the formal complaint route?

In addition to the formal complaints process, MCSI has several processes in place to routinely gather patient and family views whilst they are on the ward. Given the long-stay nature of MCSI patients, staff develop strong, therapeutic relationships with patients and their families - supporting open and honest communication. 

The ward management team have an “open-door” policy with their office being situated on the ward to enhance visibility. Patients and relatives are encouraged to raise concerns, questions or suggestions at any time with the nursing staff, therapy team or medical team. 

Ward Sisters/Charge Nurses are usually present on the ward on every day shift, providing senior leadership. Ward Managers also work clinically, which increases their access to patients and families and allows them to directly observe care, engage in conversations and provide feedback in real time. 

Daily informal “check-ins” take place during nursing interactions, ward rounds, goal planning meetings and therapy sessions, allowing staff to actively seek feedback. 

Family members are also encouraged to share feedback during visits, phone calls and MDT meetings. These conversations are shared with the MDT during ward rounds and goal planning sessions. 

6) What support and training is offered to staff at ward level in handling concerns and complaints received about the care they are giving to avoid relationships between patients, families and staff deteriorating? 

Staff on the ward are supported through a combination of visible leadership, clear escalation processes and training to help them manage concerns effectively. Ward Sisters/Charge Nurses are usually visible on shifts, providing immediate support, guidance and reassurance to staff when concerns arise. 

All staff have been trained in de-escalation to enable intervention if required to do so. There is an open and honest culture on the ward, with clear expectations that staff escalate concerns to the Ward Sister/Charge Nurse or Matron for support. Staff are encouraged to seek advice, to ensure concerns are handled appropriately. 

Formal training is also provided, and Band 6 Nurses attend a dedicated study day delivered by management that covers the Trust’s complaints policy. This training equips senior nurses with confidence and skills to support junior staff and respond to concerns at ward level and manage complaints constructively.

 Ongoing learning is reinforced through team meetings and senior nurse huddles. 

7) Are concerns and complaints from all patients regularly reviewed by the Trust to identify common experiences and issues for all patients, including under PSIRF? How are patients and their families involved in this? 

All Patient concerns (PALS concerns), formal complaints and local resolutions are recorded in the Trust, and trends and themes of PALS concerns and formal complaints are shared at monthly Governance meetings. 

Governance Meetings are multi-disciplinary meetings attended by service managers, nursing teams, AHP’s, clinicians, and administrative staff. If a particular theme/trend has been identified, it would be discussed at this meeting, and actions would be assigned to the appropriate person. 

In addition to the Governance Meetings, a monthly Patient Experience Meeting takes place where complaints and PALS concerns are also discussed and trends and themes are identified. 

The Clinical Governance Team, Ward Managers and Matrons also attend a weekly meeting called the “Patient Safety Incident Review Group.” The purpose of this meeting is to review incidents graded as moderate harm or higher. If an incident is highlighted to require further investigation, a more in depth review (such as an After-Action Review (AAR) or Multi-Disciplinary Team Report (MDT)) is commissioned. 

These reviews all use PSIRF principles, and all leads for those reviews are PSIRF trained. In addition to this, a formal Patient Safety Incident Investigation may be undertaken should the national criteria be met. 

In the instance of any Patient Safety Review being undertaken utilising PSIRF principles, the patient and/or patient’s family are contacted to involve them in this process to provide them with an opportunity to ask questions which they wish to be addressed. With consent, a copy of the report will be shared with the patient and/or family. 

8) Does being bedbound and unable to participate in rehab or other activities for long periods influence the level of mental health, emotional or psychological support available to individual patients? 

Mental health and psychological support are available for all of the MCSI inpatients via the Mental Health Liaison Team and the inpatient Psychology Service. The needs of patients are assessed on an individual basis. 

Being bedbound would be considered as part of each assessment, alongside many different factors which will contribute to the level of support that is needed by each individual. 

The frequency that patients can be seen by the Psychology Service depends on the staffing resource available at any particular time, and the level of need of all patients within the service. 

Available resources are prioritised for those patients considered to have the greatest level of need at any given time. This is a clinical decision. We operate a ‘Matched Collaborative Psychological Care Pathway’ as defined in the 2023 SCI Standards for People with Psychological/Mental Health Needs. 

9) During our Enter & View visit on 25th November 2025 we heard from staff that patients on the unit increasingly have problems with substance misuse or significant mental health needs. What support is available to patients when the MCSI psychology team are not available, particularly at evenings and weekends? This could include signposting and access to online services and helplines. 

Staff have the ability to contact the Clinical Site Manager (CSM) and Senior Manager on Call (SMoC) during the weekend should they have any concerns for patients. There are also resources for out of hours mental health support which are signposted in the clinical area. This provision is concordant with the National picture. 

MCSI currently benefits from Psychology Provision for inpatients from Mon – Friday, 9-5. This does not mean that patients have open access to psychological support throughout the week, but that those needing a higher level of support may be offered a weekly/fortnightly session with a psychologist. 

The psychology team are also involved in team meetings and discussions, and as such provide specialist support to the MDT about how best to support the psychological needs of the patients. 

During 1:1 sessions there is opportunity to explore how each individual is coping throughout the week and to develop a plan of interventions that may support them, as well as identify potential triggers to determine how to manage these. If additional support is required between sessions, contact with Psychology can be made during the working week – Psychology also attend Daily Safety Meetings with MDT. 

The Trust also have access to the Mental Health Liaison Team who are available via telephone at all times (24-7) to provide advice to staff as needed. They can arrange to visit patients – and are usually present on the ward one day a week. 

MCSI also have close links with the Spinal Cord Injury (SCI) charities and have Peer Support Workers from four different charities available in person on Tuesdays, Wednesdays and Thursdays. They are available to all inpatients and their families. MCSI will also direct patients to other available support that is relevant for them. 

There is no specialist substance misuse support available to RJAH. Mental Health Liaison does not provide a substance misuse service, but the MCSI resettlement team would also sign post a patient to the substance abuse teams on discharge after liaising with mental health liaisons or our psychology team. This would be for support in the community post discharge. 

10) What are the referral processes for people to access mental health support when they are discharged from the wards, either home or to a step-down service? 

There is no ideal mental health service available to meet the needs of our highly complex client group when they are discharged from hospital. 

Patients are referred on for support in the community when this is indicated but there is no direct control over whether or not this will be provided. When patients have specific needs such as substance dependency, dementia, brain injury etc a direct referral will be made to the appropriate service for further input, or via the GP – if the most appropriate local service is unclear. 

For individuals with significant mental health needs, we can refer them to their local Community Mental Health Trust (CMHT) who will usually assess them on discharge. If they are not considered to have a ‘mental illness’ and their issues are related to adjustment to SCI, patients are unlikely to be supported by the local CMHT. 

The next level of support we can access for patients is Psychological Wellbeing Services – these are typically set up to support people to manage anxiety and depression and lower-level mental health needs – but are generally not set up in relation to thinking about the psychological impact of living with a life changing injury. 

The support that people receive varies significantly from area to area and patients have fed back to MCSI that this kind of support is not always appropriate or helpful. We encourage all of our patients to access support from the Spinal Injury Charities that we work closely with (SIA, Back Up, Peer and Aspire). These charities provide ongoing Peer Support, a helpline, access to information and guidance, further education and opportunities following discharge from hospital. 

We encourage patients to set up Peer Mentoring via Back Up and let them know about the availability of specialist SCI counselling that is available to them from SIA. 

11) What information and signposting is given to patients when they leave hospital, so they know what help and support is available to them and their families? 

Our psychology team will discuss support that may be available in the community and what would be most appropriate with each individual and their family. They would communicate with them regarding any specific referral that is made for them. 

The Trust also provides signposting to the community services that can be accessed following discharge – including NHS Mental Health Services, NHS Psychological Wellbeing Services, Charity Mental Health Support and the support from SCI charities. MCSI has an information sheet summarising all of this information that is given to patients prior to discharge. 

The same information is also available on the hospital website for future reference. As part of discharge planning, relatives are also signposted to available support in the community. 

All families are invited to attend a Relatives Day, where they are provided with the opportunity to meet different charities and learn about the support available. Relatives are also encouraged to access family support and mentoring from Back Up The MCSI resettlement team ensures that patients receive a discharge pack on discharge, highlighting all the internal MDT members’ contact details that have worked with them.

 They are told that they are an MCSI patient for life and whilst encouraged to deal with community services, they are informed that they can contact us if their issue is not resolved. Patients are also given contact details for the DWP and are advised to ring them immediately when they get home. 

Patients are also provided with contact details for their social workers and the CHC if they have gone through the CHC process. The resettlement team will always ensure that family will have been contacted by CHC prior to discharge. 

We would like to thank the Trust for providing this response. 

We have followed this up with a call to hear People’s Experiences of Spinal Injury Services across Shropshire. The campaign aims not only to gather feedback from people who have experienced spinal injury services - whether directly or as family members or carers - but also to raise awareness of the Spinal Injuries Association’s (SIA) Strategy 2030, which focuses on improving the lives of people with spinal cord injuries.