All inspections: Nottinghamshire Healthcare NHS Foundation Trust

We carried out this unannounced focused inspection because we received information that gave us concerns about the safety and quality of the services.

We have rated safe and well led following this inspection. The rating at the previous inspection of March 2022 was requires improvement, this inspection shows that the rating has gone down.

We inspected the Acute wards for adults of working age and psychiatric intensive care units as part of this inspection. The trust has 9 wards across 2 locations, Highbury Hospital and Sherwood Oaks. We visited the following wards:

Highbury Hospital- Redwood 1: acute wards for adults of working age (male) 16 beds.
Highbury Hospital - Redwood 2: acute wards for working are (female) 16 beds.
Sherwood Oaks hospital - Elm ward: acute ward for adults of working age (male) 18 beds.
Sherwood Oaks hospital - Cedar ward: acute ward for adults of working age (male) 18 beds.

Following this inspection, we told the trust they must make improvement to mitigate urgent risks. The trust responded with an action plan to mitigate the risks and we were assured by their response.

Our rating of acute wards for adults of working age and psychiatric intensive care units went down. We rated them as inadequate because:

There was an inconsistent approach to recording patients details when they accessed their leave from wards.
There was an inconsistent approach on which documentation to use when recording seclusion observations.
Observation records completed by staff had been falsified.
We found incidents of assaults on patients by staff members.
There were ligature risks which had not been identified but not acted on to reduce the risk of harm to patients.
There was a high use of agency staff due to staff vacancies.
Staff did not always share key information to keep patients safe when handing over their care to others.
Staff did not always raise concerns and report incidents and near misses in line with trust policy.
The service did not always learn from incidents.
Management processes did not operate effectively at team level.

However:

We found all wards were clean well equipped, well furnished.
Staff made sure cleaning records were up-to-date and the premises were clean.
Staff completed and kept up to date with their mandatory training.
Patient notes were comprehensive, and all staff could access them easily.

How we carried out the inspection

During the inspection we:

spoke with 14 patients
interviewed 15 staff members
reviewed 7 patient care plans
reviewed 5 incidents on CCTV
reviewed 4 seclusion records
visited 4 wards
reviewed handover documents
reviewed section 17 leave documentation on all wards
looked at environmental risk assessments.

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

People told us that they felt unsafe at night due to the use of agency staff not knowing how to support them.

People told us that they struggled to get answers from staff when they ask questions or wanted something.

People told us that they liked the food.

A patient told us that they felt the night staff was shocking.

People told us that they feel that their observations are not completed properly.

A patient told us that staff do not wear names badges and sometimes they do not tell patients their name.

People told us that they felt their beds were comfortable.

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services.

We have rated safe, effective and well led following this inspection. The rating at the previous inspection of March 2022 was requires improvement, this inspection shows that the rating has gone down.

We inspected the Wards for older people with mental health problems as part of this inspection. The trust has 5 wards across 2 locations, Highbury Hospital in Nottingham and Millbrook Hospital in Mansfield. We visited the following wards:

Highbury Hospital - Silverbirch ward for older people with mental health problems. This ward was for patients living with dementia. 18 beds (male and female)
Highbury Hospital - Cherry ward for older people with mental health problems. 16 beds (male and female)
Millbrook Hospital – Kingsley ward for older people with mental health problems. 20 beds (male and female)
Millbrook Hospital – Orchid ward for older people with mental health problems. 11 beds (female)

Our rating of services went down. We rated them as inadequate because:

We found missing signatures on the administration of patient's medicines.
We found examples where a patient's sedative medication had been administered against the prescribed dose and against medical advice.
We observed examples of moving and handling that put patients at risk of harm.
The ward for patients living with dementia did not follow national guidance in its environment.
We were not assured that falls risks were routinely identified effectively, and mitigation or plans how to manage the risk.
There was an inconsistent approach on which documentation to use when recording patients risks.
There was an inconsistent approach in the completion of charts that were being completed by staff.
We found inconsistencies on the provisions of informing informal patients of their rights under the Mental Health Act.
There were still wards in the service that did not have single ensuite rooms and dormitories were still in place on 3 out of the 4 wards visited.
There were documents for staff to complete on each ward we visited. We were not assured that data collection was used for specific reasons, such as stool charts or self-care charts when patients did not present risks in these areas.
We were not assured that dietary intake of patients was being effectively completed by staff.
We were not assured that management had timely oversight over data collected by staff regarding patient risk.

However:

We found activities taking place on 2 out of 4 wards visited.
Staff were receiving supervisions from there managers and felt supported
Clinic rooms were stocked, organised and clean.

How we carried out the inspection

During the inspection we:

spoke with 12 patients
interviewed 11 staff members
reviewed 18 patient care plans
Looked at 4 clinic rooms
Reviewed 48 patient medical cards
visited 4 wards
reviewed handover documents
Reviewed patient records on food and fluid and self-care
Observed staff interacting with patients
reviewed section 17 leave documentation on all wards
looked at environmental risk assessments.

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

A patient told us that they don’t like sharing a room.

People told us that the ward is noisy with the building work, and they didn’t know what was being built.

People told us they were confused which room they could sit in.

People told us that sometimes they don’t have their own clothes and have someone else’s.

People told us that staff were kind and caring.

People told us that there are some activities.

We carried out this unannounced focused inspection of Rampton High Secure Hospital because at our last inspection in September 2022, we rated the hospital overall as requires improvement. Due to our findings, we served the trust with a Section 29A warning notice, informing the trust they were required to make significant improvements. This inspection was carried out to check if changes and improvements had been made.

Following this inspection, we have issued further enforcement action for the trust to make significant improvement in the areas not complied with since we issued the warning notice at our last inspection in September 2022. We have imposed conditions onto their registration and issued these in September 2023.

The provider took actions following the inspection to improve and address the concerns we raised.

We have rated safe, effective and well led following this inspection.

We found:

Managers had not ensured that wards had enough nurses to keep patients safe and wards had high vacancy rates. Activity and therapy staff were regularly redeployed to wards to support nursing staff, which impacted on patients’ ability to access recreational and therapeutic activities. Staff did not always minimise the use of restrictive practices. Staff regularly confined patients to their bedrooms during the day to maintain safety on the wards. This was not carried out in line with trust policy, which only permitted confinement at nighttime. Staffing levels was highlighted as a concern at our last inspection.
Managers did not always ensure that staff received regular formal supervision.
The hospital did not ensure that effective systems and processes were in place to correctly authorise medicines in line with the Mental Health Act.
Staff had not ensured accurate titration (adjusting the balance) of some medicines over a specific timeframe had been calculated. This meant that patients were exposed to the risk of having higher doses of medicine than required.
Staff did not always observe patients fully when in seclusion.
De-escalation techniques were not always used by staff as a first resort to manage patients who became distressed. We found episodes of seclusion that were not proportionate to the risk posed by patients.
Managers did not ensure that there were effective systems and processes in place to monitor quality of care when staff were supporting patients in distress.
Staff used restrictive practices such as early confinement and late unlocking routinely and this had become usual routine practice authorised by managers to manage risk. Managers had not taken timely steps to prevent this becoming a normal culture within the hospital.
The hospital did not have enough staff trained in British Sign Language to meet the needs of deaf patients. Staff on the ward for deaf people, communicated with each other verbally, and did not use BSL. This meant, deaf patients could not be included in the everyday sounds and noises of the ward and were excluded from social communication that takes place between people in communal areas of the ward. This also excluded deaf patients from joining conversations with staff, meant they were not able to understand what was happening around them and what was happening on the ward.

However:

Staff had improved how they had managed patients’ access to risk items on the wards.
Staff had improved how they identified and recorded patients’ physical healthcare needs on the wards.
Seclusion care plans for patients were completed in line with the trust’s restrictive practice policy since our previous inspection.
Staff improved how they monitored patients’ physical health after rapid tranquilisation was used.
The hospital had improved mail and telephone monitoring arrangements, in line with the Mental Health Act.

How we carried out the inspection

During the inspection we:

spoke with 23 patients
interviewed 24 staff members
reviewed 18 patient care plans
reviewed 34 patient medical records
reviewed 7 telephone and mail recording reviews
reviewed 3 incidents on CCTV
reviewed 2 seclusion records
reviewed 2 long term seclusion records
visited 10 wards.

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 hospital say

We spoke with people in the learning disabilities services who told us they sometimes get locked in their room from dinner time until the next morning. They told us that they don’t like being locked in their rooms. People told us that there were enough staff when in seclusion but not enough when they come out. People told us that the Southwell Centre is closed so there were no activities because staffing from the Centre were needed on the wards. Patients would like to do more activities. People told us that when in early confinement they can’t make phone calls with family or have contact with other patients. People told us that when in confinement the rooms can be really hot and uncomfortable.

We spoke with patients in the women’s service who told us they were offered activities, but it depended on staffing levels. People told us the hospital was short staffed and sometimes felt unsafe. People told us staff were kind.

We spoke with patients in the deaf services who told us they wanted to do more but there were not enough staff. People told us that there were staff trained in British Sign Language (BSL), but it was basic. This meant deaf patients had to adjust how they spoke with staff so they were understood. People told us that there just wasn’t enough staff.

We spoke with patients on the mental health wards who told us staff can’t form relationships with patients because they don’t stay at Rampton long enough. A patient told us that they had more freedom in prison due to the confinements in place at Rampton. People told us that they are not able to do much on these wards due to lack of staff

We carried out this announced inspection of Rampton Hospital as part of our continual checks on the safety and quality of healthcare services and to check if improvements had been made since our last inspection in November 2019.

Our rating of the hospital improved. We rated it as requires improvement because:

We rated safe as inadequate and rated effective, caring, responsive and well-led as requires improvement.
Managers had not ensured that wards had enough nurses since our previous inspection and wards had high vacancy rates. Activity and therapy staff were regularly redeployed to wards, which impacted on patients’ ability to access recreational and therapeutic activities.
The hospital did not have enough staff trained in British Sign Language to meet the needs of deaf patients.
Staff did not effectively manage patients’ access to risk items on Newmarket ward.
Staff did not effectively identify or record a patient’s physical healthcare needs on Canterbury ward. They did not seek timely medical attention for this patient when it was required.
Staff did not complete seclusion care plans for patients in line with the trust’s restrictive practice policy.
Staff did not always minimise the use of restrictive practices. Staff regularly confined patients to their bedrooms during the day to maintain safety on the wards. This was not carried out in line with trust policy, which only permitted confinement at night time.
Staff did not always follow good practice with respect to safeguarding. This is what we found at our previous inspection. At this inspection, they did not always report patient- on-patient assaults as safeguarding incidents.
Staff did not always monitor clinic room and fridge temperatures to ensure that refrigerated medicines were stored safely.
Staff did not consistently monitor patients’ physical health after rapid tranquilisation was used. This is what we found at our previous inspection.
Managers did not always ensure that these staff received regular supervision and kept up to date with their mandatory training.
The trust had not ensured that ward teams had access to the full range of specialists required to meet the needs of patients on the wards since our previous inspection. There were no occupational therapists in the women’s’ service at the time of our inspection.
Whilst most staff treated patients with compassion and kindness, we reviewed CCTV footage of an incident where a patient appeared to be pushed by one staff member. This incident was not reported by a second staff member who appeared to witness this.
We observed one occasion where staff did not respect a patient’s privacy and dignity whilst using a communal bathroom on Emerald ward.
The hospital did not ensure that effective systems and processes were in place to correctly authorise medicines, or to review mail and telephone monitoring arrangements, in line with the Mental Health Act.
We observed blind spots in the seclusion rooms on Coral and Grampian ward. There was a notice in place to inform staff of the blind spot on Coral ward but not on Grampian ward.

However:

Most ward environments were clean.
Staff stored and managed most medicines safely.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
The service was well led and governance processes had improved since our last inspection. Managers had worked to improve the culture of the hospital by completing cultural reviews on several wards.
Staff understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
The culture of the hospital had improved. Newly appointed quality matrons had started to review culture and equality diversity and inclusion. Staff felt valued and supported.

We carried out this unannounced inspection of Nottinghamshire Healthcare NHS Foundation Trust of the mental health and community health services provided by this trust the services hadn’t been inspected since for over three years and they had an overall rating of requires improvement.

At this inspection, we visited the three mental health services which had been rated as good in 2014 and four community health services, one of which had been rated as requires improvement in 2018. This inspection was carried out as part of our programme of ongoing checks on the safety and quality of healthcare services.

We also inspected the well-led key question for the trust overall.

At this inspection, the overall rating for the three mental health services we inspected went down to requires improvement. The ratings of the four community health services we inspected remained the same as good for three services and rated one as requires improvement.

At this inspection the overall ratings for mental health services stayed the same in safe and responsive, which we rated as requires improvement. Caring stayed the same, rated as good. The ratings for effective and responsive went down. We rated these as requires improvement.

The rating for well-led in mental health services, remained the same as requires improvement.

At this inspection the overall well-led provider rating improved stayed the same as requires improvement.

We inspected two mental health inpatient services, and one community based mental health service. The two mental health inpatient service inspections were unannounced. The community based mental health service was announced 24 hours before the inspection began.

Long stay rehabilitation mental health wards for working age adults.
Wards for Older People with Mental Health problems.
Community-based mental health services for older people.

We inspected all key lines of enquiry in all domains (safe, effective, caring, responsive and well-led) in these services.

We inspected four community health services. The community health inpatient service was inspected because of the ratings from the previous inspection. The other three community health services were inspected as they hadn’t been inspected since 2014. The community health inpatient services inspection was unannounced and the remaining three community health based services were announced 24 hours before the inspection began.

Community Health – Inpatients.
Community Health – End of Life Care.
Community health services – children, young people and families.
Community Health – Adults.

We inspected all key lines of enquiry in all domains (safe, effective, caring, responsive and well-led) in these services.

We also assessed if the organisation is well-led and looked at areas of governance, culture, leadership capability and improvement. Our inspection approach allows us to make a judgement on how the trust’s senior leadership leads the organisation and the provider level well-led rating is separate from the ratings of the services we inspected.

Prior to this well led review of Nottinghamshire Healthcare NHS Foundation Trust we also carried out two focussed inspections of forensic inpatient or secure wards and acute wards for adults of working age that had been rated as inadequate in 2019. To check if these services now met legal requirements. These inspections were unannounced.

We did not inspect the following core services previously rated as requires improvement:

high secure hospital.

We did not inspect the following core services previously rated as good:

child and adolescent mental health wards
wards for people with a learning disability or autism
community based metal health services for adults of working age
mental health crisis services and health-based places of safety
specialist community mental health services for children and young people.
community based mental health services for people with a learning disability or autism.

We are monitoring the progress of improvements to these services and will re-inspect them as appropriate.

In rating the trust overall, we took into account the current ratings of the seven services we did not inspect this time and the two focussed inspections.

Our overall rating of this trust stayed the same. We rated them as requires improvement because:

The trust had not responded in a timely way to eliminate shared sleeping arrangements (dormitories). At the last inspection in 2019 we told the trust that they should have an action plan to eradicate dormitories at Bassetlaw and Millbrook Mental Health Unit. We were pleased to see that this plan was in place with set deadlines for this work to be completed. However, we were concerned that the timelines within the plan had slipped due to the significant additional remedial works and refurbishment of a newly purchased hospital site. The impact of these delays meant that a total of 80 patients, on nine wards across the trust were required to share sleeping accommodation. Whilst the bed areas were separated by curtains the bedroom areas did not promote privacy or dignity of the service users admitted into these areas.
Whilst the trust had a robust appointment process for all board directors, they did not ensure that that the senior leaders personal files met General Data Protection Regulations (GDPR) and the fit and proper persons checks had not been reviewed as they should have been.
We found that the trust equality impact assessments required improvement and had not fully delivered on reducing inequalities that they were designed to deliver. The trust agreed with this. Although, we were assured that the equality impact assessments were always completed and approved by the board.
In two of the community health core services and one mental health core service inspected we found that were issues with medicines management. This included, the ineffective audit system processes, omissions in recording when a patient had self-administered critical medication, incorrect storage, and ineffective monitoring, use, and correct disposal of prescription pads.
Patients at Thorneywood Mount did not have up to date crisis or contingency plans. The absence of these plans meant that if a patient’s mental health deteriorated either on the units or when in the community, their carers, or staff would not know what action should be taken to ensure their safety. Whilst the provider addressed this issue within two weeks of our inspection, we did not feel the processes for updating these plans had sufficient time to become embedded into practice.
In two mental health core services and one community health core services staff were not up to date with mandatory training. The compliance rates fell below the expected 75% compliance rate for specific training. It was acknowledged that the pandemic and COVID-19 outbreaks on wards and community teams had impacted on staff training.
Governance systems and processes, and the strategy of the organisation had been extensively reviewed since our last inspection but was not fully embedded into services. It was not clear how the divisional teams used governance processes and measures to make positive, sustainable changes. Many of the leaders within mental health and community health core services did not use the trust governance process and reports effectively within their roles.
Not all governance processes operated effectively at team level. Some of the mental health and community heath core services were still waiting for the roll out of the governance dashboards. It was planned within the next 10 months they would all be in place. Governance processes including clinical and pharmacist audits and recording of meeting decisions were not embedded into practice and therefore the service might not be aware of findings that would improve practice. In addition, governance structures were not robust, and this meant that there were gaps in training and supervision.
The trust had a digital strategy in place. The use of digital technology was evident in some areas throughout the trust. However, divisions across the trust did not have designated digital leads. In addition, we were not clear how the board were using information and communication technology (ICT) as a key enabler to service change and transformation. We found there were delays with some digital produces such as Electronic Prescribing and Medicines Administration (EPMA).
Whilst managers ensured staff had access to regular, constructive clinical supervision of their work, clinical supervision compliance rates in four of the inspected core services did not meet the trusts target rate of 80%. We could not ascertain if this was because staff had not accessed supervision or recorded that supervision had taken place.
There were not always additional alarms for staff working in the wards for older people if staffing numbers increased. This meant staff could not get help quickly if there was an emergency.
Within two mental health core services and one community health core services inspected we found that staffing numbers did not always provide enough suitably qualified staff on duty to meet patient needs.
In long stay rehabilitation mental health wards for working age adults, the environment had not been well maintained and maintenance teams had not undertaken repairs in a timely way. At Thorneywood Mount showers had not worked properly for nearly two years; managers had reported the showers for repair on at least six occasions. On all occasions a temporary fix was made but the issue remained.

However:

The executive board members were proactive, accomplished, open and responsive to feedback and passionate about improving the organisation. The trust demonstrated succession planning at board level. Since the last well led review there had been changes to the executive team; this had been strategically planned to ensure that the changes were implemented effectively with minimal impact on the running of the trust.
Non-executive and executive directors were clear about their areas of responsibility. The trust used the organisational risk register and its board assurance framework to support good governance. Individual directorates were held to account by the board on financial, performance and quality.
The board recognised that they needed more work to ensure the diversity of the board reflected the diversity of the communities it served.
The trust had a Quality Mental Health legislation committee which chaired by a non-executive and lead by an executive. They provided leadership and held mental health operational groups, across the three divisions within the trust. The trust had reviewed their responsibilities and requirements under the Mental Health Act. This led to an organisational change in the structure of the mental health act teams.
The trust had a clear vision and a set of values with quality and sustainability as the top priority. The trust worked inclusively when developing its strategy for 2022-2026. The strategy was launched in April 2022 and was the culmination of 18 months of engagement with a wide range of stakeholders. The strategy clearly demonstrated the trusts ambition over the next five years. It detailed the way in which they planned to improve the delivery and quality of care, support the workforce and embed a culture of continuous improvement across the organisation.
The strategy was aligned with the local health economy and took into account the needs of the developing Integrated Care System (ICS). It outlined the need for collaboration and building strong clinical and non-clinical alliances between the health and care services to reduce barriers and improve patient care. The trust had responded proactively to the Integrated Care Board (ICB) development, and specifically the development of provider collaboratives.
The trust had identified that they needed to further develop the culture to allow people to perform at their best and where everyone was able to be themselves, with a zero tolerance for inequality, harassment, discrimination and bullying. The trust promoted inclusivity and celebrating diversity in daily work and provided opportunities for staff development and career progression.
The Black and minority ethnic network was one of the longest and best established staff groups in the trust with 285 members. We heard from some of the staff in this network. The network reported that their ideas and suggestions for change had been listened and heard by the trust, but they had not been followed through to bring about change.
The trust continued to provide an extensive range of health and wellbeing offers to staff. Leaders of the trust viewed staff wellbeing as a high priority. The trust worked closely with their staff health and wellbeing leads to ensure that they supported colleagues in line with the staff feedback from the staff survey. The trust had a strong emphasis on safety and wellbeing of all staff and promoted a culture of having the right support in place for all staff.
The trust was committed to patient involvement and experience and working with volunteers. The trust had an active volunteer network within excess of 185 volunteers.
The trust had a people and culture committee which coordinated and supported implementation and development of the trust equality and diversity action plan with associated equality and diversity initiatives. At an executive level the trust had a good understanding of the equality, diversity and inclusion challenges and how the trust was meeting these challenges.
Since the last inspection the trust corporate governance structure had been reviewed, redeveloped and improved. The structure was effective at board level with clear process and systems of accountability to support the delivery of the trusts strategy.
The board recognised that that risk management was an essential and integral part of good management practice. The trust had a risk process in place to manage current and future performance. The trusts risk register report was comprehensive and identified risk to the organisation. The Board had developed a well-documented Board Assurance Framework and Risk Register. Most actions for assurance were clearly set out and were specific, measurable, achievable, and timely.
During our inspection it was evident that clinical staff took part in clinical audits, benchmarking and quality improvement initiatives. Senior leaders supported improvement and innovation work and there was a strong programme of staff training.
Quality improvement was high on the agenda of the trust. We were pleased to hear and see how quality improvement was in action. The trust had a quality improvement lead and has participated in Quality, Service Improvement and Redesign programme since 2020.

How we carried out the inspection

During the inspection, our inspection teams carried out the following activities across 10 wards and 11 community mental health teams, 4 community health services inpatient services and two community health teams:

reviewed 97 care records
reviewed 60 medication records
interviewed 153 staff and 20 managers
held 13 focus groups
interviewed 43 patients
spoke with 35 family members or carers of patients
observed 20 episodes of care, multidisciplinary meetings.

During our well-led inspection, we spoke with 33 senior leaders of the organisation and looked at a range of policies, procedures and other governance documents relating to the running of the trust.

You can find further information about how we carry out our inspections on our website: 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 with nine patients receiving care from the Community-based mental health services for older people. Their feedback was continually positive about the way staff treated them. Patients told us there was a strong focus on person centred care. One patient said the service had sign posted them to a Parkinson nurse to support them. Another patient said the doctor had visited her at home about mobility problems and provided options and advice. A third patient told us they had knowledge about their medicines as staff always provided full explanations which gave them a better understanding of their condition. A fourth patient told us staff had spent time explaining their diagnosis and answering their questions.

Other patient feedback received, “The service had transformed our lives. “Staff were very patient and took time to explain, you never felt rushed” “All matters were discussed openly.” Patients told us the service was wonderful, staff were kind, will go out of their way to help and support you, the service had been a lifesaver, enjoyed visits from the team. Patients consistently told us staff were motivated went over and above their duties.

We spoke with six patients and five carers on Wards for Older People with Mental Health problems. Feedback was generally positive. They said staff were compassionate and caring and that staff always made time for them. Patients also said they saw their consultant regularly.

Some patients in multiple occupancy dormitories said they would prefer to have their own bedroom.

Patients spoke positively about the food including the range of options, although one patient said they wanted more healthy choices including fruit and vegetables.

Patients said they were encouraged to take part in activities and to exercise.

Carers described the challenges of COVID-19 and not being able to go on to the ward but said that they had been able to visit patients outside of the ward.

Carers mostly said staff kept them informed of care and treatment decisions, including explaining the purpose and side effects of medication to them. One carer said they had not received a call back from the consultant in a timely manner.

We spoke with five people using the service and four carers within Long stay rehabilitation mental health wards for working age adults. Patients we spoke with were all positive about how the service was helping them to move on and treated them as responsible adults. They all agreed that the staff were great and even when busy they could make time to listen to patients.

Patients felt that lock down had been a difficult time particularly as many of them had only recently started to get more freedom to access community activities and home visits but the lock down rules had prevented them from doing these things. Patients told us that during lock down staff had gone out of their way to ensure they still did meaningful activities and explained how those activities would support their mental health recovery.

However, all patients we spoke with commented that the showers at both 106 and 145 Thorneywood Mount were awful and had not worked for a long time. Two patients said they did not like the bedrooms as they did not have their own shower and toilet and the building (145) was very old fashioned. Though another patient described the same building as homely. Patients from 106 told us there was very little space on that ward and no therapy space and they had to come to 145 for group therapy and craft type activities.

Carers we spoke with said communication with the wards was good and all four carers knew who their relatives named nurse was and knew they could ring them if they had queries. Three carers said they had copies of their relative’s care plans but only after permission had been gained another carer said their relative did not want them to have a copy of the care plan.

Two carers commented on how good the doctors were and how they had time to explain things to them clearly and without rushing.

All carers said they could see improvement in their relative’s mental health and wellbeing. One carer said staff try to create a community on the ward, give patients responsibility for themselves as much as possible and help people to become friends. Another carer said, “her son was much happier since moving to this service, he got into a lot less trouble with other patients and for the first time in many years said he felt safe on the ward”.

We spoke with 13 patients across the Community Health – Adults service, and three carers. Every patient and carer we spoke with told us how caring and respectful the staff were. Every patient and carer we spoke with talked highly of the service and of the staff.

All patients and carers said that staff used gloves, aprons and masks which made them feel safe with COVID-19. Patients and carers were aware that visiting staff had been regularly tested for the virus.

All patients and carers had a contact number so that they could contact the service if needed. Most patients had used this.

One patient explained that they were awaiting some new dressings from her GP. A visiting nurse had managed to locate a few while they were awaiting the delivery.

One patient described the nursing service as “very efficient” and said that they “help me emotionally”.

One patient confirmed that the nurses had got to them very quickly when they experienced a blocked catheter.

Two patients said that they had experienced a cancelled visit but had been visited the following day. Staff had called them individually and had explained to them why and offered an apology.

We spoke to 12 family members and three patients within the Community Health – Inpatients service. All three patients spoke positively about their experiences on the ward. One family member was not positive about the care of her family member or the way staff had communicated with them and three other families told us that they thought communication from staff on the ward could be improved. Not all families knew how to make a complaint, but they did say that they would ask staff if they wanted to raise a concern and some families said they would like to know more about activities on the ward.

However overall families reported that patients were well cared for on the ward and that patients were well-nourished and hydrated. They told us staff were kind and caring and that the ward environments were very clean. They did not report any issues in respect of patient safety and said that medication was well managed, including pain relief. Three families referred to the wards being short of staff some of the time.

We reviewed 23 complements across the Community health services – children, young people and families service that recognised the team’s individual clinicians, including health visitors, school nurses, orthotics, speech and language therapists, and nurse family practitioners. The following are examples of the comments we reviewed; “we could not express more gratitude to the Home Talk scheme,” “so dedicated and passionate and truly enabled my daughter to feel proud of the progress and “the nurse helped with sorting out problems with GP.”

We spoke with nine parents; they were overwhelmingly positive about both the care and the staff. Three parents said that the staff were outstanding and had gone the extra mile to ensure children and young people’s voices were heard and their needs considered.

They said staff were caring, respectful and supportive and they felt very valued and involved in their child's care and treatment.

This report relates to Nottinghamshire Healthcare NHS Foundation Trust Acute wards for working age adults and psychiatric intensive care units.

This service was last inspected on 12 February 2020. We found the following actions the provider needed to improve:

The trust must review the governance structures to ensure adequate oversight of key performance areas across the organisation including clinical / staff engagement, the shared learning and lessons across all staff groups and cost improvement programmes.
The trust must ensure there are enough suitable and qualified staff on the ward to ensure patients have access to leave and one to one sessions with their named nurse.
The trust must ensure that staff carry out physical health observations after rapid tranquilisation in line with trust policy and national guidance.
The trust must ensure that staff carry out checks of resuscitation equipment on all wards to ensure it is safe to use and ensure adrenaline is fit for use and stored in a place where there is immediacy of access.
The trust must ensure that it reviews blanket restrictions on B2 wards so that patients are individually risk assessed for restrictions relating to accessing sleeping areas and bedrooms.
The trust must ensure that staff follow physical health care planning and complete physical health observations for patients when required throughout admission.
The trust must ensure that staff ensure the privacy of patients on the ward when observations are carried out.
The trust must ensure that it has effective governance structures to ensure that team meetings take place and that learning from incidents and complaints are recorded.
The trust must ensure risk assessments are in place and that they contain all relevant risk information.
The trust must ensure that they take action to ensure emergency medical bags are sealed.
The trust must ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure patients are kept safe.
The trust must ensure that observations of patients are carried out in line with trust policy and recorded fully.
The trust must ensure that all incidents are fully recorded in patient notes and on the electronic reporting system.
The trust must ensure that the senior managers have a clear framework of what must be discussed at a ward level to ensure that essential information, such as learning from incidents was shared and discussed.
The trust must ensure that managers have access to information in an accessible format, that is accurate and identifies areas for improvement to support their management role.

We carried out this unannounced focused inspection on 1 and 2 March 2022 to see if the provider had made improvements identified in the 2020 inspection. We covered all the key lines of enquiry, during our inspection we found the above actions had been met.

However, our rating of this core service stayed the same. We rated them as requires improvement because:

The service did not comply with national guidance regarding shared sleeping arrangements as there were dormitories on wards for up to 35 patients. The dormitories contained lockable storage facilities for patients to store personal possessions. Staff and patients used privacy curtains to ensure patients privacy and dignity when in their bedroom space. There were plans in place to eradicate dormitories. The trust was relocating the acute wards to a newly purchased hospital site when the renovations had been completed and provided a phased plan that would eradicate all dormitories style accommodation by 2025/26. The plan has been slow and no alternative arrangements to improve the experience of service users has been taken whilst they remained in dormitory accommodation.

Clinical supervision and appraisal rates were variable across the wards. We found that managers had rescheduled supervision and appraisal meetings or cancelled them as staffing levels dropped due to the pandemic. We found two wards had compliance rates below 75% for both supervision and appraisal.

Mandatory training for Safeguarding, Mental Health Act and Mental Capacity was below 75% on some wards. We found training rates for Mental Capacity Act on Redwood 1 was 64% and safeguarding adults training was 62%. We also found Mental Capacity Act training rates on Rowan 2 was 69%.

Managers did not have sufficient oversight of mandatory training, supervision and appraisal.

We looked at 31 care and treatment plans all of which reflected patients’ assessed needs and were holistic and recovery oriented. However; 10 care plans did not record if the patient had been offered a copy of their plan, eight of these were on Lucy Wade ward.

However:

The management of emergency equipment had improved since the last inspection. When we inspected the service in 2019, we found staff were not completing checks of resuscitation equipment and adrenaline was not stored appropriately.

We inspected six clinic rooms, including Lucy Wade ward, all of which were tidy, fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked, stored and recorded appropriately. We found that staff had ensured that emergency medical bags were sealed. The clinic rooms on each of the wards had a “green zone”. This was an easily recognised area where emergency equipment such as ligature knives and defibrillators were kept.

We saw staff involved patients in decisions about the service, when appropriate for example suggestions on the décor, menu choice and therapeutic activities. Staff and patients attended weekly ward community meetings where items on the agenda included the environment, meals, patient involvement opportunities and staying connected with family and friends. We were told that following feedback from patients that small refrigerators had been purchased for patients to store drinks in their rooms. Patients also gave feedback on the service and their treatment; a questionnaire was sent to every patient on discharge asking for their experiences whilst on the ward.

Our inspection team was led by an inspection manager.

The team included two CQC inspectors, two specialist advisors and two experts by experience.

To get to the heart of people who use services’ experience of care, we always ask the following five questions of every service and provider:

Is it safe? 

Is it effective? 

Is it caring? 

Is it responsive to people’s needs? 

Is it well-led? 

Before the inspection visit, we reviewed information we held about the location.

During the inspection visit, the inspection team:  

visited four wards at the Highbury hospital, one ward at Bassetlaw hospital and one ward at Millbrook hospital. We looked at the quality of the ward environments and observed how staff were caring for patients 

spoke with 27 patients and 18 carers both face to over the phone

spoke with four ward managers and one senior manager  

spoke with 20 other staff members including doctors, nurses, occupational therapist, psychologist, peer support worker, practice development nurse, physical health lead nurse and healthcare support workers

attended and observed one multi-disciplinary meeting and three group therapeutic activity sessions

looked at 31 care and treatment records of patients 

carried out a specific check of the medication management and prescribing practice on three wards looking at 41 charts in detail

looked at a range of policies, procedures and other documents relating to the running of the service.

You can find 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 with 27 patients and 18 carers both face to face and over the phone.

Three patients told us healthier lifestyles were promoted and encouraged, wards were clean and warm, and they could open the windows for fresh air. Eight patients said they could get into their room whenever they wanted, and staff always knocked before coming in and were polite and very caring.

One patient said staff were great, that they had a care plan which is still being developed with their involvement. Six patients said there was not a lot to do during the day and they were often bored, and five patients told us there was not enough therapy.

We spoke with 18 carers, 10 told us staff were great and caring.

Five carers told us there are occasions especially at weekends when there is a shortage of staff and there is a high use of bank and agency staff.

This report relates to Nottinghamshire Healthcare NHS Trusts’ Forensic and secure inpatient service. People in these services have often been in contact with the criminal justice system. These services may be low, medium or high secure, reflecting the different levels of risk that people may present. This service has 268 beds, on 17 male or female wards, across three hospital locations known as Wathwood Hospital Rotherham, Arnold Lodge Leicester, and Wells Road Nottingham.

We carried out this unannounced focused inspection between 08 and 18 February 2022. At this inspection we looked at the specific issues raised in the requirement and warning notices and sampled evidence across 13 of the possible 17 wards. We covered all the key lines of enquiry.

We wanted to see how the trust had met the requirement notices from our comprehensive inspection in May 2019 and the warning notices from our focussed inspection in February 2021.

After our comprehensive inspection in May 2019, we rated this core service as requires improvement overall. In response to concerns raised in late 2020 early 2021 we carried out a further responsive focussed inspection in February 2021. We re-rated this core service as Inadequate overall and issued warning notices.

To get a representative sample of evidence across the service we visited the Assessment and ICU ward, Continuing care ward, Rehabilitation ward and the Lodges at Wathwood Hospital; Ridgeway, Cannock, Foxton, Coniston and Thornton wards at Arnold Lodge; Porchester, Lister, Thurland and Seacole wards at Wells Road. We reviewed a range of data, reports, policies and procedures sent to us by the trust covering all wards in the service.

Our rating of this core service improved. We rated them as good because:

Managers addressed all warning notices from 2021 at Wells Road. We reviewed their action plans, and it was evident they had addressed all the previous concerns. The action plan clearly demonstrated what was complete and work that was still in progress. It was evident on the wards we visited that there had been significant and positive changes in practice. We were assured that the trust had complied with the warning notice.
We were pleased to see that managers across the service had addressed the requirement notices issued in May 2019.
We were assured that managers had learnt lessons from the Warning Notices served at Wells Road. Managers used what they learnt to review service delivery and quality at Wathwood Hospital and Arnold Lodge. This resulted in changes to some of the practices and procedures at Wathwood Hospital and Arnold Lodge as well as Wells Road, as detailed below.
The service had enough nursing and medical staff, who knew the patients and received basic training to keep people safe from avoidable harm.
Staff assessed and managed risks to patients and themselves well. They achieved the right balance between maintaining safety and providing the least restrictive environment possible to support patients’ recovery.
Staff provided a range of treatment and care for patients based on national guidance and best practice. They ensured that patients had good access to physical healthcare and supported them to live healthier lives.
There was strong and visible leadership in the service, staff morale was good and robust governance systems and processes enabled managers to ensure that they delivered a safe and good quality service for patients.

However:

On Thornton ward there were 20 male bedrooms each with en suite toilets but shared shower rooms or bathrooms. There were three shower rooms and one bathroom to service the 20 bedrooms, but one shower room had been out of action for over two months. This was not adequate provision for 20 patients. who told us they often waited a long time to use the bathroom. This was a different issue to those raised at previous inspections.
At Wathwood Hospital across all wards, we found brown staining below the water line in some toilets. This was due to stained limescale build up rather than lack of cleaning. While risk of infection from this was low the limescale staining could harbour germs. We advised the manager of this issue. After the inspection we were advised that the facilities department were going to change their limescale remover for a more effective product. This was a different issue to those found at our previous inspections.
At Wathwood Hospital closed-circuit television had not yet been installed in courtyard areas of the wards. Managers told us that following the Mental Health Act Review visit the absence of closed-circuit television in the courtyard was escalated to the trust’s blanket restrictions review meeting for ongoing review. In mitigation we saw that the trust was now considering this as part of their site improvement plans, and as soon as funds become available closed-circuit television will be installed in the courtyards. Individual risk assessments were in place for patients. The issue was discussed with patients in community meetings.
We found opened, unlabelled food items in patient fridges on Thurland and Lister wards at Wells Road. This included an opened packet of ham on Thurland ward and opened jars of chutneys. This could prove to be hazardous to health.
At Arnold Lodge there was not always enough staff to monitor the twin seclusion rooms. On four occasions they only had one staff member to monitor both rooms. While on Porchester ward at Wells Road, there was poor line of sight into the seclusion rooms, though the installation of closed-circuit television in these rooms would eliminate the issue.

How we carried out the inspection

During our inspection visit we:

visited 13 wards and 10 clinic rooms across the service and looked at the accommodation and communal areas of the wards, we looked at the quality of the environment and saw how staff were caring for people
spoke with 35 people who were using the service
spoke with 10 relatives, who had family members using the service
spoke with 10 senior managers
spoke with 10 ward managers
spoke with 38 other staff members including doctors, nurses, therapists, and healthcare support workers
observed four multidisciplinary team care and treatment and handover meetings
observed seven staff and patients’ interactions
reviewed 24 care and treatment records of people using the service
reviewed 42 prescription charts of people using the service
reviewed prescribing practice and medicines management across the service
looked at a range of policies, procedures, records and other documents relating to the running of the service.

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

Patients told us they were “not worried about violence or anything, it is friendly”. “They feel safe during the day and at night”.

A patient told us “I have met the advocate face to face, and she is friendly and understanding. I can have 1:1 session whenever you want”. Another patient told us “I know my named nurse and am happy with the care I receive. I attend psychologist appointments on a weekly basis. I work in the coffee bar once a week and do shop management work on a computer twice a week”.

Another patient told us he was following a fish diet; he said, “kitchen staff are particularly good and try and give you what you want to eat. I have a different meal for lunch and dinner. The pudding is okay and there is a choice of different foods for other patients”.

Patients were positive about the activities available on the ward saying, “there is a pool table and a games console”. “We have ward timetables showing what activities we can join such as cooking, going to the gym, visiting the coffee bar, television and video players. The timetables are updated on a weekly basis”. “Each of us has an individual timetable to help us get well again”. Another patient confirmed “we can have televisions and gaming in our rooms if our risk allows this”.

At Wathwood Hospital patients told us “We have access to gardening at the allotment, farm visits, and escorted leave to Christmas markets and restaurants”. Other patients said, they had “access to education courses through the onsite recovery college, voluntary dog walking at a nearby animal sanctuary and a new wellbeing therapy group had started on the ward one evening a week”.

Carers said they were mostly happy with the care and treatment provided by the service. Staff seemed very approachable and listened to any concerns. They tried to sort out problems before they become an issue.

Six out of ten carers said they knew about the carers forums and how to give feedback to the service.

However:

Patients told us that occasionally short staffing meant they “have to wait longer for things, for example, if you want to go into the kitchen or hospital shop”.

Other patients said that COVID-19 had made family visits difficult particularly when there was COVID-19 on the ward. While a carer said they were not allowed to see their relative for six weeks during a COVID-19 outbreak and because their relative did not like using the telephone or video calls they felt very cut off.

This focused inspection was completed because we received information giving us concerns about the safety and quality of the care within Seacole ward at Wells Road Hospital. At our last inspection we rated the trust overall as requires improvement.

We inspected Seacole ward following an anonymous whistleblowing which identified several concerns in relation to patient care. Seacole ward is a 15 bedded low secure woman’s ward. People in secure services have often been in contact with the criminal justice system. These services may be low, medium or high secure, reflecting the different levels of risk that people may present.

We did not inspect other forensic or secure wards as the whistleblowing did not refer to other wards. However, we are monitoring the progress of improvements to services and will re-inspect them as appropriate.

This was a focused inspection. Because of its limited scope, we did not rate each key question at this inspection. You can view previous ratings and reports on our website at www.cqc.org.uk. However, as a result of this inspection the rating for this core service will move to Inadequate overall.

We found:

Staff did not always treat patients with compassion and kindness, respect their privacy and dignity. Patient’s told us staff were sometimes rude and were not patient with them. Staff did not regularly involve families and carers in the support and care of their relative. Patients did not have regular one to one session with their named nurse. Patient’s physical health was not adequality monitored in line with the trusts policy.
Governance processes were not robust. Leaders failed to drive adequate improvement from previous internal investigations. Complaints were not logged accurately on the ward’s complaint tracker.
Not all staff felt valued and respected in their role. Staff told us they felt disconnected from the managers from the service and did not feel valued as a team. Staff were not adequately supervised, and the ward did not hold regular team meetings. Staff did not raise concerns as they did not feel listened too.

However

Staff had access to personal alarms which were tested regularly to keep themselves safe. Patients had access to nurse calls alarms in their bedrooms. The ward environment was clean and well maintained. Leaders had established the number and grade of staff required to safely staff the ward.
Nursing and health care assistant vacancies were recruited too. Service managers had good oversight of the staffing requirements for the hospital. The ward had implemented a restrictive interventions governance group to review all blanket restrictions to ensure they were minimised.
Staff developed recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.Patients had access to a structured ward-based activity timetable and the occupational therapy team supported patients to develop a personalised activity timetable that was meaningful to them.

How we carried out the inspection

This was a focused inspection we inspected against the following Key Lines of Enquiry:

Is it safe?
Is it effective
Is it caring?
Is it responsive?
Is it well-led?

During the inspection visit, the inspection team:

inspected one ward, looked at the quality of the ward environment and observed how staff were caring for patients
reviewed four physical healthcare records
spoke with four patients who were using the service and three carers
spoke with the one ward manager and one general manager for the service.
spoke with 11 other staff members; including doctors, nurses, occupational therapist, assistant occupational therapist, the advocacy manager, health care assistant and the housekeeper.
looked at four care and treatment records of patients
looked at a range of policies, procedures and other documents relating to the running of the service.

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 with four patients during the inspection. Three patients told us that staff were not always discreet, respectful or responsive to their needs. One patient told us staff speak about personal information of other patients Infront of them and did not always follow confidentiality principles when discussing patient information.
Patients told us staff did not always treat them with dignity and respect and did not always behave appropriately towards them. Patients told us staff were sometimes rude and were not patient with them.
However, one patient told us the staff team were like a family, they get stressed, but it is a hard job and they are short staffed.

The service provided safe care. The ward environments were safe and clean. The wards had enough staff to meet the needs of the patient group. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
Staff developed recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance and best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Leaders of the service had the skills to ensure wards were managed safely. Leaders were visible and approachable on the wards. Staff told us they were proud to work for the trust and there was a positive culture within their teams.

However:

Staff had not ensured that patients had care plans in place for patients prescribed high dose antipsychotics Although, we found clear evidence high dose anti-psychotic monitoring was taking place.
We were not assured that ward managers followed clear systems or processes to monitor staffing fill rates.
Staff had opened emergency Epi Pen stored in the clinical fridge, this rendered them unusable. This was raised with staff who took immediate action to rectify this. In addition, two of the wards have insulin pens in use stored in the medication trolley that were not labelled. We were concerned that this medication could be administered to another patient other than the one it was prescribed for. We raised this at the time of inspection and the trust took robust action to share the learning across inpatient wards.

Security was a key priority on the wards. Staff spoken with knew the security procedures well. We saw each ward had an allocated security lead daily who was responsible for the environmental security checks.
The trust had established the staffing levels required to meet the needs of the patients. Ward managers had the autonomy to increase staffing levels if required. Staff training was all above 75% compliant. There was suitable medical cover and on call cover throughout the week.
Staff held regular and effective multidisciplinary meetings. Clinical staff completed a comprehensive review of patient needs and reviewed progress made. Staff understood their roles and responsibilities under the Mental Health Act and the Mental Health Act Code of Practice.
Patients knew the complaints process and had access to an independent mental health advocate if requested. Staff were aware of the trust’s whistle blowing policy and knew their responsibilities in relation to safeguarding. Staff told us they felt confident to raise concerns to senior managers without repercussions.
The manager had oversight of the hospital. Ward performance was monitored by completing regular audits and the outcomes were recorded and monitored over time to ensure the ward continuously improved. Leaders were visible in the service and supported staff to develop their skills, take on more senior roles, and responsibilities.
Patient feedback was positive. Most patients told us they felt safe on the ward. Patients spoken with told us that staff were kind and friendly. Patients told us they enjoy the activities on offer at the hospital and that they really liked playing on the computers or going for walks around the grounds.

The Lucy Wade Unit is a 16 bedded mental health acute inpatient unit for women. The ward offers care, assessment, treatment and support to women who are unable to be safely supported in the community.

We had serious concerns about safety and quality care provided and therefore served a Notice of Decision which required the trust to stop all admissions to the ward until further notice and provide us with an action plan that described how they would make the required improvements in a timely manner. We also required that we were provided with weekly update to enable us to monitor this.
Whilst we saw that staffing levels for each shift met the required ‘safe staffing numbers’ for the number of patients on the ward, this did not take in to account the number of patients requiring enhanced observations to keep them safe or the skills, experience and knowledge of the staff. We were not assured that enough staff, with the right skills, knowledge and experience were deployed to meet the needs of the patients safely. Senior managers had not ensured that band 5 preceptorship nurses (newly registered nurses) were supported by suitably experienced staff when on duty.
Staff failed to follow policies and procedures when observing patients. We found numerous records in which staff had failed to record whether they had carried out observations. In addition, we saw records that highlighted the incorrect amount of staff completing the observations, for example, we saw patients that should have been observed by two members of staff and were only being observed by one.
We were concerned that managers had not ensured that staff had implemented recommendations from reviews of deaths or incidents that had previously happened in the ward. Staff failed to accurately record all incidents in line with trust policy. Patients clinical notes highlighted that incidents had taken place but we found no incident reports within the electronic reporting system
Not all managers had the skills, knowledge and experience to perform their roles. Whilst leaders were visible in the service staff reported that not all them were approachable. Although staff felt positive and proud about working for the provider and their team the majority of the staff we spoke with reported they didn’t feel respected, supported or valued by all managers.
Team managers had access to information but it did not support them with their management role as the information was not in an accessible format, was not timely, accurate or identified areas for improvement. We were not assured that there was a clear framework of what must be used, shared and discussed at a ward, team or directorate level to ensure that essential information, such as learning from incidents was used to inform care and improvements in care and practice. Staff we spoke with told us they did not always receive feedback from investigation of incidents, both internal and external to the service.

Staff attitudes and behaviours when interacting with patients were not always respectful, discreet and did not always provide patients with help, emotional support at the time they needed it.

We were not assured that all staff, including agency and bank staff, were aware of the potential ligature points or the mitigation in pace to manage these risks appropriately. In addition, we were not assured that staff would be able to easily access ligature cutters in an emergency situation because they were kept in a locked cupboard with a key pad code which was changed regularly and staff weren’t always aware of the change.

Staff had not ensured that emergency medical bags had been sealed with a temper proof seal.

Managers did not offer debriefings for all ward staff after serious incidents .

However:

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. They worked with other agencies, sharing information across agencies and devised coordinated action plans to keep the patient safe.

We undertook this inspection to see if the trust had made improvements since our comprehensive inspection in July 2019. This was a focused inspection, we did not inspect all key lines of enquiry and did not rerate. The ratings from the comprehensive inspection in July remain.

The service continued to not have enough nursing and medical staff. To maintain safety, staff were moved between wards, sent as escorts off the ward, worked additional hours and went without breaks. This impacted on relational security, the quality of patient and staff experience, access to patient activities and access to fresh air. Relational security is the knowledge and understanding staff have of patients and the environment, and the translation of that information into appropriate responses and care. Caseloads of social workers, psychologists and occupational therapists were high in comparison to other high secure hospitals. This prevented them carrying out all aspects of their role.
Instances of lone working at night continued, which posed a risk should an emergency occur in a bedroom as three staff were required to go in.
Not all staff were aware of what and where ligature assessments for the ward they were working on were kept or whether accurate records were kept of the maintenance of ligature cutters.
Staff did not always respond to alarm calls promptly when incidents occurred. Staff continued to say they did not always report incidents or have time to write them up in detail.
Staff continued to be inconsistent in following the observational policy when recording observations. Staff continued to report they did not always receive breaks from continuous observations.
We found issues with the storage of medication such as a lack of stock rotation for supplementary medications. Staff did not consistently sign to record patients had received medication or follow National Institute for Health and Care Excellence guidance in reviewing the effects of medication when using intramuscular injection medication.
Staff did not receive effective handovers that included information about patient risks when they moved wards.
Staff did not consistently accurately record long term segregation on the electronic patient record.
Ward staff did not have adequate physical health care training and reported that the quality of clinical supervision was poor.
Patients continued to raise issues of inappropriate language, racist attitudes by staff and that their privacy and dignity was not respected and confidentially was not maintained by staff.
The hospital culture required improvement. Staff continued to report that they did not feel able to speak up about concerns without fear of retribution and morale was poor in some areas.
Governance systems did not operate effectively enough to manage or monitor the impact of staff shortages. In addition to this, there was a lack of consistent, effective recording of shortages or loans to other wards.

However:

The Rampton hospital implementation board had developed an action plan and we saw evidence that actions were being implemented.
Management changes across the trust and at Rampton hospital had started to occur and were welcomed by staff and medical consultants, although it was too soon to evaluate the impact.
All wards were safe, clean, and fit for purpose. Staff followed the infection control policy including hand hygiene.
Staff assessed the physical and mental health of all patients on admission. Staff completed risk assessments on admission and updated these regularly. They developed personalised individual care plans. They included specific safety and security arrangements and a positive behavioural support plan. Staff used recognised rating scales to assess and record severity and outcomes.
The ward staff participated in the provider’s restrictive interventions reduction programme. Mechanical restraint was used with a clear rationale and with individualised care plans.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
The service had access to a full range of specialists to meet the needs of the patients on the wards.

Our rating of this service went down. We rated Rampton Hospital as inadequate because:

Our ratings of safe and well-led went down to inadequate, our ratings of effective and caring went down to requires improvement, and our rating of responsive stayed the same at requires improvement.
The hospital had not dealt fully with issues raised at our last inspection and made the subject of requirement notices. Following the inspection we told the provider about our concerns. The provider gave us some assurance about these concerns and we will follow up their action plan through inspections and monitoring activity.
The service did not provide safe care. There were not enough staff to provide safe and effective care and treatment for patients. This had a direct impact on patient care and treatment through cancellations of patient activity, the use of restrictive practices and low patient and staff morale.
Medicines were not always managed safely. We issued the trust with a requirement notice on this at our last inspection and it had not been fully dealt with.
Not all the ward environments were clean. We issued the trust with a requirement notice on this issue at our last inspection and it had not been fully dealt with.
Although patients had access to the full range of specialists required to meet their needs, this was compromised by high caseloads of some specialists such as psychologists, occupational therapists and speech and language therapists. Some specialists worked as ward staff to support short staffing. Staff did not always report incidents of activities being cancelled or staffing shortages due to time constraints.
Staff still did not always ensure patients had good access to physical healthcare in a timely manner. They did not always accurately monitor patients’ physical health or implement physical healthcare plans. We raised concerns about the implementation of physical healthcare plans at our last inspection and issued the trust with a requirement notice to make improvements.
Staff still did not always review patients in seclusion in accordance with the Mental Health Act Code of Practice. Following our last inspection, we issued the trust with a requirement notice that they must make improvements in this area.
Staff across the hospital did not demonstrate a competent understanding of when a patient required a mental capacity assessment for issues other than consent to treatment.
Some staff and patients raised concerns about staff attitudes and staff using or condoning the use of racist and other inappropriate language towards and around patients.
The service was not consistently responsive to the needs of the patient group for whom they provided care and treatment. Although the service were trying to ensure there were enough staff trained to level 3 British Sign Language, patients who were deaf reported that staff were limited in their interactions with them and said this impacted on their ability to communicate with staff effectively.
Staff did not trust or feel listened to by the senior leadership team. Staff morale was low and staff did not feel valued or supported. They did not feel able to raise concerns without fear of retribution.
There was lack of engagement and involvement in decision making between medical consultants and management. We raised this at our previous inspection and improvements were still required in this area. There were tensions between hospital security managers and clinical leaders.

However:

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment.
Staff engaged in clinical audit to evaluate their work.
Most staff, patients and carers told us that staff treated patients and their carers with dignity and respect. We observed positive interactions between patients and staff. Overall, staff involved patients in their care planning and care plans were personalised and holistic.
The hospital was introducing innovative practice using information technology to provide patients with access programmes to complement their therapy treatment and to carry out observations.

Our rating of this service went down. We rated it as requires improvement because:

The service did not consistently provide safe care across the three hospital sites. Not all of the ward environments were safe or clean and staff did not always know how to use emergency equipment. The wards did not have enough qualified nursing staff to support patient care and treatment. The service did not effectively minimise the use of restrictive practice or follow good practice with regards to medicines management.
Staff did not use clinical audit and complaints effectively to evaluate and improve on the quality of care they provided.
Staff did not follow the trust’s policy around the use of observation and did not follow national guidance to monitor deterioration in patients’ physical health.
The governance processes did not ensure that wards were safe or that staff used every opportunity to improve on their practice.
The service did not consistently protect and promote patients’ privacy and dignity.
Vacancies in the psychology department at The Wells Road Centre had resulted in some patients having poor access to psychological therapies.

However:

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
Managers ensured that staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

Our rating of this service went down. We rated it as inadequate because:

We found that there was inconsistency and lapses in governance across wards. Risk and safety were not always well managed including staffing and clinical activity that kept patients safe. There were issues with bed management and availability of beds. Supervision did not always take place and neither did team meetings, therefore there was inconsistent evidence of learning from complaints and incidents.
Staff did not always monitor patients’ physical health adequately and had sometimes not completed National Early Warning Scores when indicated. Staff did not always undertake physical observations after giving patients rapid tranquilisation
Staff did not always carry out checks to see if emergency resuscitation equipment worked properly.
Staff did not always manage risks well. We reviewed 36 care records. Five of these contained no record of a risk assessment and, in a further seven, the risk assessments were not fully developed or did not contain all the risk information required.
On Lucy Wade Unit, some staff did not know how to open all the anti-barricade doors. There were three doors that had a different opening system. However, the trust was replacing these doors.
Wards had restrictions in place. All patients had restricted access to outside space and there were various restrictions in relation to the use of crockery and cutlery that were not always individually risk assessed. On B2 ward, staff restricted female patients’ access to bathrooms, toilets and bed space and male patients’ access to bathrooms.
There were not always sufficient staff numbers on the wards and the wards relied on bank staff. There were 23% of shifts where staff fill rates fell below 90% between July and September 2018. Staff told us they felt under pressure and that there were not always two nurses on the ward. This meant it was not always possible for a nurse to be available in communal ward areas and made it difficult for staff to offer patients one to one sessions. At the time of inspection staff vacancies had reduced but staffing continued to be reported as an ongoing issue.
There were some omissions in medication management. We observed that patients did not have care plans for medication that doctors had prescribed patients to take as required. Also, staff did not always record the date that they opened patients’ medication that became short dated when opened.
Care plans were personalised but did not always demonstrate a holistic approach. In 15 of the 33 care plans we saw this was not the case.
Patients had limited access to psychological therapies and activities. However, the trust had already taken steps to improve this and new staff started work following our inspection to provide this.
Staff did not always ensure the privacy of patients. On some occasions, staff left the privacy blind on patients’ bedroom doors open. We observed a male member of staff carrying out observations without telling female patients he was looking through the blinds. Also, on one ward we could clearly see patient information displayed on the patient information board, staff had not covered this when it was not in use.
Patient community meetings did not always take place as planned on a weekly basis. Staff did not always record what patients had discussed at meetings or actions from them. There were areas for family visits, but these were not always available as these rooms were used as a place of safety when the 136 suites were unavailable.
There were dormitories on B2 ward at Bassetlaw Hospital and Orchid ward. The trust was considering how they could eradicate dormitories however there were no firm plans in place at the time of inspection.
Beds were not always available locally when needed. However, the trust had commissioned 16 male and 16 female acute beds to reduce the number of out of area placements and ensure more people received care and treatment close to their home area. There had been 314 occasions when a patient had been admitted to an out of area bed between October 2017 and September 2018. This had increased since our last inspection. The wards used the health based places of safety at Highbury Hospital and Millbrook Mental Health Unit when they could not find a bed as a short-term measure. Patients’ beds were not always available to them when they returned from leave. The trust did not have current data about how often this happened.
Staff were not familiar with the trust’s vision and values.

However:

Staff undertook regular environmental risk assessments. Wards were clean, and staff followed good practice in infection control, and checked equipment regularly.
Staff were kind and responsive when interacting with patients. Patients engaged well with staff and spoke positively about how staff treated them. Staff supported patients to access education and work opportunities. Staff were trained to work with families and carers and did this well.
Staff ensured that patients understood their rights under the Mental Health Act and followed trust policy in relation to patients’ leave. Staff ensured patients had access to an independent mental health advocate who visited the wards and worked with patients. Staff supported patients to make decisions about their care for themselves, they assessed and recorded capacity where patients had impaired capacity.
Staff understood how to protect patients from abuse and exploitation and worked well with other agencies to do so. Staff were comfortable to raise concerns about patient safety without fear of the consequences.
Staff monitored side effects of medication and audits. They completed blood tests for patients who were being prescribed medication that required additional monitoring. Staff used recognised rating scales to assess and record severity and outcomes. Staff participated in clinical audits and took part in quality improvement activities.

The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high and staff managed waiting lists well to ensure that people who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multi-disciplinary team and with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. Staff ensured all carers felt listened to and empowered patients to be actively involved in their recovery.
The service was easy to access. Staff assessed and treated people who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The service did not exclude people who would have benefitted from care.
The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However:

The team at City North had medication that had not been stored properly prior to be disposed of and a problem with the temperature gauges for recording fridge temperatures. They did not transport medication safely when completing visits in the community.
There was a lack of evidence of the involvement of patients and carers in decision making about the service.

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

The service provided safe care. The number of patients on the caseload of the teams, and of individual members of staff, was not too high. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Teams included, or had access to, the full range of specialists required to meet the needs of patients in the community. Managers ensured that staff received training and supervision. Staff worked well together as a multi-disciplinary team and with relevant services outside the organisation.
Staff understood and performed their roles and responsibilities under the Mental Health Act and the Mental Capacity Act.
Staff treated patients with compassion and kindness and understood the individual needs of patients. Staff involved patients and families and carers in care decisions.
The service was easy to access and staff and managers managed access and caseloads well. The service did not exclude people who would have benefitted from care. Staff assessed and initiated care for people who required urgent care promptly and those who did not require urgent care did not wait too long to receive help and start treatment.

However:

The trust reported that it had received no complaints from patients under the care of the intellectual and developmental disabilities services. However, staff working in this service did not routinely provide patients and carers with information about how to raise a concern or complaint. Staff were aware of the availability of complaints leaflets, but they were not clear about how patients and carers would access them without asking.
Some teams within the service had appraisal rates for non-medical staff that were significantly below the trust’s target.
Omissions were present in care planning practices. Records did not always demonstrate that staff always developed care plans to address the identified needs of patients. Additionally, records did not clearly demonstrate when staff had offered or shared care plans with patients.
Clinical audit practices were not always robust. Outcomes of audits were not always consistent with practices seen during the inspection and staff were not clear how the trust audited the application of the Mental Capacity Act.

We have not rated this service before. We rated it as good because:

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the wards who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
The service was well led, and the governance processes ensured that ward procedures ran smoothly.

However:

Staff did not always use the systems in place to keep information about patients confidential.
Staff did not all have access to specialised training in eating disorders, taking blood tests and how to care for patients on the psychiatric intensive care unit.
There were some issues relating to a new build including heating, security and parental controls for the new Wi-Fi system and inconsistent alarms, that required action to fully resolve for which the trust had actions in place to remedy. Staff were not always aware of who to contact to resolve these issues.
Staff did not update the personal emergency evacuation plans of patients who needed them when the patient moved between wards or was cared for in the seclusion room.
Staff did not ensure that medicine fridge temperatures were always within the range for safe storage of medicines.
Staff did not have access to all of patients’ paper records in the electronic patient records system, so they could use it effectively.
Patients and their carers did not have all the appropriate information available to them in an accessible format at the time of admission and throughout admission. However, the trust confirmed it was in the process of printing leaflets in different languages and formats to be made available for patients and carers using the service.

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

Clinical premises where staff saw patients were safe and clean. The number of patients on the caseload of the mental health crisis teams and of individual members of staff, was not too high. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff had provided a range of treatments suitable to the needs of the patients and staff engaged in clinical audit to evaluate the quality of care they provided.
The mental health crisis teams included or had access to the full range of specialists required to meet the needs of patients. Managers ensured staff received training. Staff worked well together as a multi-disciplinary team and with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients, families and carers in care decisions.
The mental health crisis service and the health-based places of safety were easy to access. Staff assessed people promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude people who would have benefitted from care.

However:

Staff working for the mental health crisis team at Millbrook Mental Health Unit had not always developed holistic, recovery-oriented care plans and staff at Millbrook Mental Health Unit and Bassetlaw Hospital had not offered all patients a copy of their care plan.
Managers had not ensured that staff received supervision and appraisal in line with their policy.
Staff did not always follow trust guidelines in relation to medicines management. Highbury Hospital staff did not safely deliver medication to patients as they did not secure the medicine in a safe way to transport it to a patient’s home or get patients to sign they had received it.
In the section 136 Cassidy suite the locks and bolts on the suite doors were not suitable and therefore did not provide a safe environment for patients or staff.
Although the environment at the Cassidy suite met the requirements of the Mental Health Act Code of Practice the Jasmine suite did not because there was no clock visible to patients when they were detained in the suite.
Staffing levels in the section 136 suites did not meet safe staffing levels when there were emergencies.

We only looked at parts of the four key lines of enquiry at this inspection that related to the concerns raised. These were in safe, effective, caring and well led.

We did not rate the service at this inspection as we only inspected one ward and looked at specific issues relating to the concerns we had received.

We found:

Care records contained up to date and detailed information about patients. Risk assessments and management plans were thorough. Care plans and activity timetables were personalised and indicated that staff understood patients’ needs.

There were regular and effective multi-disciplinary meetings. The team had effective working relationships with other professionals. These relationships enabled access to care for patients who required hospital treatment or other physical health care off the ward
We observed staff to be kind in their interactions with patients and responded to patients appropriately. Staff protected patients’ privacy and dignity and demonstrated that they understood each patient’s individual needs, preferences and preferred communication methods.
Staff on the ward had made changes to improve communication with carers. Carers now had opportunities to talk to staff and discuss the care of their family member or discuss concerns.
Managers had identified risks that related to the ward and these risks matched staff concerns The ward had had a robust action plan to reduce risks and updated these plans regularly.
Staff reported and learnt from incidents, complaints and feedback. Nurses had been trained in offering debriefs so that they could support staff when incidents occurred on the ward.

However:

Staff did not monitor when patients were due for an annual physical health screen which meant that patients could miss annual health screening opportunities.

When staff carried out physical health observations and there was increased physical health risks identified, they did not always complete and record increased observations; neither did they record a rationale for not completing these.

Certificates to authorise treatment were not attached to medicine cards. This meant that staff could not be sure that they had the legal authority to administer medication.

Staff indicated that morale was low and had been affected by both a high level of assaults upon staff and increased scrutiny following a serious untoward incident. Not all staff felt consistently supported and some staff had not received supervision or found it hard to find the time to complete training.

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

We rated safe and responsive as requires improvement and effective, caring and well-led as good.
Although the trust has a recruitment and retention strategy, there remained a high level of staff vacancies and turnover. The hospital had undertaken a strategic staffing review and used a recognised tool to determine the establishment of staff required on each ward. Despite this, there were often too few staff on the wards. As a result, staff could not always supervise patient activities, support patients to attend health appointments or carry out observations without cancelling other tasks, closing part of a ward or moving staff from one ward to another to maintain safety.
Although the number of instances had reduced, there were still occasions when there was only one member of staff (nurse) on a ward at night.
Staff did not keep complete and accurate records of tasks relating to patient safety. They did not always record reviews of patients in seclusion and long term segregation in accordance with the Mental Health Act Code of Practice.
Although, since the last inspection, staff had improved the way they carried out and recorded observations, we still found some errors in recording during this inspection.
Although the consistency of clinical record keeping across the hospital had improved since the last inspection, some patient care plans were still not of the high standard that would be expected of such a specialised hospital.
There was a problem with the system on which staff recorded the number and hours of activities that patients engaged in that meant that the provider did not have a true and accurate record of these.
Not all staff had a good understanding and knowledge of physical healthcare conditions in order to implement care plans effectively. This included the care of patients with, or at risk of developing, diabetes.
There were signatures missing from some medication charts and because of the movement of staff across wards, it was not always clear which nurse was responsible for administering the medication.
Some staff wore nail varnish and gel nails. This was not in line with trust policy and was also raised as a concern during the last inspection.

Our rating of the trust stayed the same. We rated it as good because:

We rated effective, caring, responsive, and well led as good for the trust and safe as requires improvement. We rated 15 of the 19 core services provided by the trust as good. Our rating for the trust took into account the previous ratings of services not inspected this time.
We rated well led for the trust overall as good.
There was good leadership at corporate level. The board understood the challenges the trust faced and made sure that plans were in place to manage these, while planning for the future. The board members challenged each other to make sure the right implementation of decisions occurred. Leaders at service level were visible.
Good partnership working continued with other organisations to help plan and meet the needs of the local people. Stakeholders were positive about the trusts contribution to the local health economy planning.
There was good multidisciplinary working within clinical teams and with external partners.
Patients and carers could still contribute to service planning and delivery through the involvement centres. Patients were positive about the care and treatment provided by staff.
Patients were still at the centre of the trust culture, which involved them through a range of initiatives. Patient needs were assessed, and care and treatment were planned;- with outcomes to measure progress monitored. There was an established recovery college for patients to learn skills in in managing their physical and mental health.
Staff continued to have good access to training and development. Staff knew how to raise safeguarding concerns to protect patients. They knew how to report incidents and were open and transparent when things went wrong.
There were effective complaint management systems, and the trust had set up good processes to investigate and learn from deaths.
Learning from incidents, audits, complaints, deaths, was publicised through a variety of methods to improve practice. The trust carried out and shared the research it had undertaken.

However:

Medicines management practice in storage and recording and effective monitoring of action plans was not consistent.
Staff recruitment and retention was a challenge and nursing fill rates of shifts did not consistently meet the trust target of 90%.
Staff did not consistently assess record and monitor patients’ physical health needs.
The physical environment on some ward were not conducive to good quality care. On some wards patients had to share bedrooms and other wards did not have disabled access. On some wards staff found it difficult to observe all areas because there were no mirrors to help them see round blind corners.
The Mental Health Act Code of Practice was not followed in relation seclusion facilities, giving patient rights and copies of leave forms.
Representatives of Black and minority ethnic staff groups interviewed said they did not feel engaged. They reported a lack of career development and opportunities and they did not feel able to speak up.
Not all staff knew about the Freedom to Speak up Guardian role in the trust.

Our rating of this service went down. We rated it as requires improvement.

A summary of our findings about this service appears in the Overall summary.

Our rating of this service went down. We rated it as requires improvement because:

A summary of our findings about this service appears in the Overall summary.

Our rating of this service improved. We rated it it as good:

A summary of our findings about this service appears in the Overall summary.

We rated Rampton Hospital as requires improvement because:

Low staffing levels meant that safety to both patients and staff was at times compromised. Because of low staffing on some shifts, staff were having to undertake unsafe practice that breached trust policy by working alone on wards.
Although the trust had a recruitment strategy in place, the whole time equivalent vacancy rate for qualified nurses was 10.4% in February 2017.
Staff did not follow the requirements of the Mental Health Act Code of Practice consistently with respect to reviewing patients in long term segregation or seclusion. The trust had not addressed the concern that we had raised at a previous inspection regarding staff passing food through an observation hatch above a toilet. Staff did not ensure that patients in long term segregation had had regular access to fresh air.
Staff were not consistent in recording the reasons that they had decided to monitor patients’ mail. Also, they did not always explain to patients what the patient had to do to satisfy staff that it was safe for them to stop monitoring the patient’s mail.
Staff across all groups reported low morale and a distinct lack of feedback or involvement from trust leadership. Staff also reported feeling unconfident in raising concerns for fear of reprisal.
Ward staff reported a lack of opportunity to progress or to be able to feedback on service developments.
Full information about our regulatory response to the concerns we have described in this report will be added to a final version of this report we will publish in due course.

The wards were clean and had a good range of rooms and facilities to meet patient needs. The staff teams had a good range of professionals and understood the individual needs of patients. Staff used national guidance and outcome measures to support their practice.
Staff interactions we observed were caring, warm, and respectful. Generally, patients were positive about staff and how staff treated them, they said staff were available. Patients knew how to complain and had opportunities for feedback.
Staff received the necessary training to do their jobs. They received appraisals and supervision. Staff received feedback from incidents and complaints, staff we met with were aware of recent changes to policies. Staff were happy in their roles and felt supported.

However,

There was on-going pressure on the beds available. All wards we visited had in excess of 100% bed occupancy for the three months prior to inspection. The trust had admitted patients to out of area placements, locally patients had ‘slept out’ on other wards. The trust had taken actions to address this but it remained an issue.
The trust was in the process of reviewing all ligature points on the wards we inspected and rolling out a new risk assessment and observation policy. During the inspection, we highlighted a concern, which could have increased ligature risk; the trust confirmed this would be included in future risk assessments.

Specialist community mental health services for children and young people:

young people and their families felt listened to, respected and treated with dignity
young people and their carers told us staff involved them in planning, reviewing and updating their care
the service provided access to advocacy and plenty of age appropriate leaflets and posters in the waiting area
the service involved young people in the recruitment process for new staff
there were enough rooms for young people to meet with professionals
rooms were clean, bright and created a relaxed, therapeutic environment
staff told young people if things went wrong
people with disabilities, including wheelchair users, could access the unit
the multi-disciplinary team consisted of a good range of disciplines, who were happy working in the team.
the service had systems to ensure staff received mandatory training, appraisal and supervision
staff received specialist training in recognised and recommended psychological interventions
staff had a working knowledge of the Mental Health Act and Mental Capacity Act
staff received safeguarding training and had a clear understanding of their responsibilities in relation to this
risk assessments were comprehensive and up to date
staff used clinical outcome measures to monitor young people’s progress
the service had a process for dealing with complaints and made sure staff learned lessons from them
staff could describe the duty of candour and the importance of it
staff informed us they felt confident raising concerns without fear of victimisation
staffing levels were adequate, and at the levels commissioned. Vacancies were actively being recruited to
staff knew who the senior managers were within the organisation
managers were supportive and visible
staff understood and followed the procedures on lone working.

However:

Four out of seven care records we reviewed did not contain a current plan of care.
Six out of seven records were incomplete and inconsistent with limited up to date information and, in some cases, gaps of up to two years in the notes
care plans were not recorded electronically, which made it difficult to access all information
staff recorded notes on an electronic system so each young person had two sets of notes making it difficult to access all the information. The different types of notes put young people and staff at risk because vital information could be missed
there were no records of face to face contacts, assessments or therapy sessions.

Staff delivered person centred care in a kind and respectful way.
Staff completed patient assessments and reviews in a timely manner.
Patients and carers told us the service was good.
Patients had current care plans and risk assessments.
Care plans were recovery and outcome focussed.
Patients had a physical health assessment on admission to the ward and this was monitored throughout the patient admission.
Patients and carers told us the staff treated them with kindness, dignity and respect.
The staff team was made up of a range of professionals who worked effectively as a team.
Staff had good practical knowledge of the Mental Health Act and the Mental Capacity Act.
Staff told us they felt supported and confident about raising concerns.
Staff told us they felt happy and valued as team members.
Staff reported incidents and had systems to share learning.

However:

Identified staffing levels were not always met.
Activities only ran on Monday to Friday 9 – 5 and could be cancelled if staff shortages occurred. Patients told us they were bored without activities to do.
The seclusion and long term segregation facilities at Orion unit did not fully support patients’ privacy and dignity.
Staff did not always complete mandatory training.
Patients did not always feel their complaints were acted upon.
Patients were not always given feedback on issues that they raised.

The ward was clean and comfortable. There was a range of rooms available. Staff ensured the building was fit for usage by completing environmental audits.
Staff completed mandatory training. Staff had good practical knowledge of the Mental Health Act and the Mental Capacity Act. Staff knew when and how to raise a safeguarding alert meaning that they knew how to keep young people safe.
Young people and carers told us the service was good. They told us the staff treated them with kindness, dignity, and respect.
Young people had current care plans and risk assessments. Staff completed patient assessments and reviews in a timely manner.
Care plans were recovery and outcome focused.
Young people had a physical health assessment on admission to the ward. Staff monitored young people’s physical health throughout their stay.
Staff provided activities, trips out, music groups and cooking. Young people received 25 hours of education each week in school time provided by staff.
Young people knew how to raise concerns and said they would be confident to do this.
The staff team consisted of a range of professionals who worked effectively as a team. Staff members felt happy, valued, and supported.
Staff delivered person-centred care in a kind and respectful way.
Staff used national guidance to inform the young people’s care.
Staff told us they felt supported and confident about raising concerns.
Staff reported incidents and had systems to share learning.

However:

The ward did not have a separate female-only lounge. Staff were aware of this and, given the constraints of the building, did what was possible.
Staff did not allow young people in the low stimulus area to leave. A low stimulus area is to give young people a chance to be away from others if they are becoming distressed. We were concerned the young people were subject to unfair restrictions if staff prevented them from leaving when they wished.
The service did not follow a specific child and adolescent mental health service CAMHS care pathway. This would have directed staff about the care they provided and indicated timescales to aim for.
Young people said bank staff were not as good as the ward staff.

Nottinghamshire Healthcare NHS Trust provides a range of inpatient and community services for people who have a learning disability or autism. These include the Orion Unit assessment and treatment service, Alexander House locked rehabilitation service, Hucknall House short break respite service, and a range of community teams.

We found that staff across the services were caring and compassionate. They worked positively with people and supported them well. In the Orion Unit, we were concerned that one person was segregated on a long-term basis, but their records did not show the reasons for this or how staff could ensure their safety and wellbeing. In addition, there were no plans in place to show staff how to support people who use the service when they became aggressive, and in turn ensure their safety and that of others. The physical health of people who used the services was also not monitored and recorded.

Alexander House had a good range of activities and used community services. However, activities and community services were limited in the Orion Unit and Hucknall House.

In all services, professionals worked together to meet the needs of people who used the services.

We saw examples of good and innovative practice being used in community services, but psychological services did not have a link to the trust board. This could mean that they were not used or given a high enough profile that would benefit people who used the service.

Staff, particularly in inpatient services, felt that learning disability and autism services were not involved and were the forgotten link in the trust.

Each inpatient service worked on their own and did not share good practice with other inpatient services.

Nottinghamshire Healthcare NHS Trust provides a specialist eating disorder service. This includes community and clinic-based treatments for adults with a severe eating disorder.

We found that the eating disorders services provided by Nottinghamshire Healthcare Trust were delivered in a safe and caring environment.

Comprehensive risk assessments, which involved the people who used the service, were completed. These included assessments of the person’s medical and psychiatric health care needs.

There were enough staff to meet the needs of the people who used these services.

Services provided were effective, and treatments were delivered in line with NICE (National Institute for Clinical Excellence) guidance. The trust measured the service’s outcomes, including gathering feedback from people who used the service.

Observations and discusions confirmed that the services provided were caring. This was supported by evidence we found in individual treatment records, as well as the trust’s and external agencies’ quality monitoring systems. We also saw good examples of individualised and person-centred care being provided.

The service responded well to people’s needs. Care and treatment records showed how the service had reviewed and amended treatments to meet people’s changing needs. During the inspection, we also reviewed some good examples of responsive and patient-centred care.

Local leadership was proactive and we saw good examples of leadership that led to effective service delivery. Staff told us that they felt well supported by their line manager.

Nottinghamshire Healthcare NHS Trust employs nearly 9,000 staff and provides a wide range of care services from many separate locations. Despite this, the trust had a clear ‘brand’ with a set of values that was embedded and visible throughout the organisation.

We were impressed with the strong leadership from the Board, the executive team and senior managers. There were clear lines of authority, responsibility and accountability, senior managers, the executive team and the Board demonstrated and encouraged supportive relationships, there was a culture of collective responsibility and teams had clear objectives and worked towards achieving them. One of the vehicles to achieving this cohesion was the trust’s leadership programme that ran through all the directorates. This encouraged staff to engage in discussions about the strategic direction of the trust and the challenges it faced.

The trust demonstrated to us that people using services were treated with dignity, respect and compassion. The great majority of the service users and carers that we spoke with said that staff were kind and we observed many positive and respectful interactions between staff and service users. We also saw examples across all services of the trust responding to people’s spiritual, cultural and ethnic needs; including at Rampton Hospital.

At all levels, the trust actively engaged and involved people who use services in their own care and in the development of the service itself. With the exception of information about how to complain not being consistently provided in the Healthcare Partnerships division, the trust had mechanisms in place to hear and act on feedback from people who use services and the board itself received and monitored information from the analysis of complaints. We were impressed by the Recovery College and the Involvement Centre; which are both national exemplars.

The trust had good systems in place to report, record and learn from incidents and ensured that this was embedded in practice at all levels across the three divisions. Staff used past incidents as a means of learning to ensure the safety of people using services. This learning was shared with all staff.

There were good and regular training opportunities (including induction and mentoring) and the content was appropriate to staff roles, responsibilities and areas of work.

The trust had clear safety related goals that the majority of staff understood and were working towards across all three divisions. There was a culture of openness and transparency and staff understood the need for investigations in order to learn from, and develop, improved practices. The trust had identified a number of priorities in relation to safety and we concluded that they had developed after consistently reviewing data from a wide range of sources. Despite this, we identified a number of safety concerns. These included:

the presence of ligature points that might pose a risk to people who are at risk of suicide on wards at Broomhill House, Newark Community Rehabilitation Unit, Mansfield and Thorneywood Mount;
wards that did not adhere to national guidance on same-sex accommodation in the CAMHS Thorneywood service and in two of the acute admission wards; B2 at Bassetlaw and Orchid ward at Millbrook Mental Health Unit;
poor medicines management in the Children’s Development Centre at Nottingham City Hospital campus and at Bassetlaw Hospice.

Across all of the divisions we found that care provided was evidence based and followed recognised national guidance. There were good examples of positive outcomes for people using services across the divisions. This included a significant reduction in acquired avoidable pressure ulcers, where the trust exceeded its own target.

Overall, trust staff adhered to the requirements of the Mental Capacity Act 2005 to assess capacity to consent. We visited most of the wards at each location where detained patients were being treated. In the majority of the care records we reviewed, which related to the detention, care and treatment of detained patients, the principles of the Mental Health Act (MHA) had been followed and adhered to. The long stay wards were an exception; here we found inconsistencies in the application of the MHA and a failure to undertake risk assessments of service users given leave under Section 17 of the Act. We also found that the trust did not have a robust system in place to ensure that patients in seclusion at Arnold Lodge had a four-hourly review by a doctor. There were systems and procedures in place to safeguard vulnerable people and to identify, assess and manage risks. However, the divisions varied in how they fed back safeguarding concerns and the outcome of findings from investigations.

We had a number of concerns about the learning disabilities service and concluded that they did not have a high profile within the trust. We saw examples of restrictive practices, institutional environments at Alexander House and Hucknall House and a lack of physical health checks on the Orion Unit.

In the majority of services we visited, people did not experience long waits for assessment or treatment. However, some service users did report difficulty accessing crisis mental health services at night. The crisis team offered only telephone contact at night. Those who needed immediate assessment were directed to the Emergency Department at Queen’s Medical Centre; where they might have to wait a long time to be assessed by the liaison psychiatry team.

We saw that the trust had introduced night time confinement at Rampton Hospital. We concluded that its use was in line with the Department of Health High Security Psychiatric Services (Arrangements for Safety and Security) Directions 2013 and the associated guidance. However, some people who used the service, and some staff, were concerned about the provision of physical healthcare during night-time confinement. During our unannounced, night time visit to Rampton Hospital we observed two patients receiving treatment through the ‘hatches’ in their bedroom doors. One was given insulin for diabetes and one was provided with stoma care. We raised this with the trust which stated that it is not normal practice to provide physical healthcare through the hatch and undertook to investigate the circumstances of the care and treatment provided on this occasion.

Across the three divisions we identified that there were some concerns about the different clinical information systems, which did not enable information to be shared effectively and at the right time. This could lead to information regarding risks not being available to all staff. We found the trust recognised the difficulties and had plans in place to improve facilities and functioning of systems.

Nottinghamshire Healthcare NHS Trust has several teams that together provide an adult community-based service:

Newark and Sherwood Flexible Assertive Community Treatment (FACT) Team is a recovery-orientated service that provides mental health services for people in Newark and Sherwood aged 18 to 64 years.
Rushcliffe Mental Health Team helps people aged 18 to 64 in Rushcliffe to cope with periods of mental illness and severe distress.
Gedling Mental Health Team works with people in Gedling with a wide range of mental health difficulties, who require short-and long-term intervention.
City Recovery Team helps people aged 18 to 64 years, who have a GP within the boundary Nottingham City Council, to cope with periods of severe mental illness and to develop recovery pathways.
The Early Intervention Psychosis Team provides early detection, assessment and treatment of psychosis for people who show symptoms of a first episode psychosis.

We found that the adult community-based mental health services provided by Nottinghamshire Healthcare NHS Trust were delivered effectively. People told us that staff were kind and skilful in the way they dealt with them.

Staff understood the risks to the health and welfare of the people they cared for. However, we found that records were not up-to-date or regularly reviewed for risk. This meant that staff unaware of a person’s history may not have access to their current needs or risks.

Staff understood how to follow the local multi-agency policies and procedures for safeguarding adults and children. The teams we visited worked well with other teams and agencies, both in the trust and externally, such as primary and secondary healthcare.

We saw that staff were compassionate and respectful towards people who used the services. Outcomes and aims were discussed with people during their meetings, and people told us that they felt involved in making decisions about their care.

We were told that there were issues with out-of-hours care, which meant that people’s preferences for receiving care close to home were not always met. However, assessments could be made by phone, or people could have a face-to-face consultation at the Queen’s Medical Centre if needed.

People knew how to give feedback about the service.

Staff told us that they enjoyed their work and felt supported by their managers. However, some staff said that they felt detached from the wider trust issues and were not involved in meetings about its vision and values.

The Crisis Resolution Resolution/Home Treatment teams (CRHTTs) aim to provide care and treatment for people who are experiencing a severe mental health difficulty in their own home.

The CRHT services are based on two hospital sites at Millbrook Mental Health Unit and Highbury Hospital. They are purpose built facilities and provide mental health services for adults aged 18 to 65 years.

We found that the CRHT services provided by Nottinghamshire Healthcare Trust were delivered safely. Safety bulletins and good policies and procedures were available on the trust’s intranet, and staff knew how to access them. Staff also shared learning from incidents and accidents through team meetings and handovers.

People experiencing severe mental illness were treated quickly and in a professional manner. Clinicians assessed patients well and were able to offer a range of options to people being assessed.

There were good systems in place for keeping people safe and protecting them from abuse. Staff were trained in protecting vulnerable adults and children.

The service worked well with the homeless charity Framework to help people sort out their financial issues and to get accommodation.

People being treated at home could attend a range of group therapies provided by the crisis team. If they could not get to the group on their own, a member of the crisis team would help them to get there.

Crisis services were available seven days a week, 24 hours per day, however no home visits were made between 9pm and 9am. Telephone advice and support was available to people on home treatment or experiencing a crisis.

As the service did not provide home visits after 9pm, people told us they did not always get the response they wanted. Access to mental health practitioners out of hours was through the accident and emergency department (A&E) at Queen’s Medical Centre, Nottingham University Hospital. We met with staff from the emergency department of Nottingham University Hospital and carried out a second unannounced visit on 19 May 2014. We found that people at night in the Emergency Department with a mental health crisis experienced delays with people assessed as requiring an inpatient mental health bed waiting a number of hours. There was no data collection or detailed incident reporting on these delays.

New referrals were seen within 24 hours. The service was specifically for adults aged 18 to 65 years, but it did help older adults who were already known to them, as well as children aged 17 to 18 years old.

Staff told us they felt well-supported in their roles, and felt able to raise concerns and report incidents.

People who used the long stay services and their carers were happy with the care and treatment they received. We observed that staff were kind and had a caring, compassionate attitude. They built positive relationships with people using the service and those close to them.

The service proactively sought feedback from people who used the service and their carers, and we found evidence that it had acted on feedback and implemented changes as a result.

We found that some requirements of the Mental Health Act were not adhered to. For example, there was no evidence to show in the care records we looked at that risk assessments had been carried out before people were granted leave under Section 17 Mental Health Act, or on their return.

Some wards at Broomhill House, Newark Community Unit, Mansfield Community Unit and Thorneywood Mount Unit had not completed an annual ligature risk assessment as per trust policy. We found ligature risks on all the wards we visited with the exception of Bracken House.

This meant that people were exposed to unacceptable and avoidable risk on these wards.

The wards had a clear pathway of care that focused on helping people to recover. The care plans we looked at also focused on people’s needs and demonstrated knowledge of current, evidence-based practice. Overall, we found that the quality of care plans was very good and some plans were outstanding.

Access to occupational therapy, psychology and consultant psychiatrists varied across the services, and was dependent on which ward people were staying on.

The service had strong governance structures in place, which were fully embedded on most of the wards. We also saw evidence of shared learning across the wards. The service was committed to improving its performance and the quality of care provided. For example, the rehabilitation wards were putting new care pathway and care plan documentation in place.

The Forensic Service Division of Nottinghamshire Healthcare NHS Trust provides the following high, medium and low secure mental health services:

High secure services – Rampton Hospital provides services for people who suffer from mental disorders and have dangerous, violent or criminal tendencies.
Medium secure services – Wathwood Hospital and Arnold Lodge are purpose built medium secure facilities that provide inpatient mental health services for adults aged between 18 upwards.
Low secure services – Wells Road Centre is an inpatient service for men and women detained under the Mental Health Act, and who have a mental illness or learning disability.
Forensic community services – the Criminal Justice Liaison Team provides services for people with a mental illness and who come into contact with the criminal justice system. The Personality Disorder and Development Network is a community-based, group therapy service.

High secure services

During the inspection, we heard mixed views about the care and treatment at Rampton Hospital. However, we found that people who used the service viewed staff as caring, respectful and responsive. While most people accepted confinement at night and said they felt safe, some people did not like it and this was reflected in their care plans..

Some people were concerned about aspects of their care. When we brought these to the attention of the ward manager, they were already aware of the issues and told us how they were trying to resolve them.

People using the service and staff said that they felt safe, but people were worried that there were not enough staff. This had led to cancelled activities or events.

The environment was clean and welcoming, and there were systems and processes in place to monitor it. The standard of decoration was good, but some corridors needed minor repairs.

Care at the hospital met CQC national standards. There was an audit programme in place to monitor standards, and people and their carers were involved in planning and reviewing their care.

We were told, and we saw reports that showed, staff received appropriate training. This included night staff who spent time on day shifts to complete mandatory training. Most staff had received safeguarding training and were aware of the safeguarding processes. All staff said they could speak to their manager about their concerns, and said they thought these would be addressed.

Overall, the wards were well-led by the managers. However, we saw differences in how well wards were run, with some ward managers taking a stronger approach than others.

Medium secure services

The majority of services provided by the two medium secure hospitals (Wathwood Hospital and Arnold Lodge) were outstanding. However, we have rated services as ‘good’ in safety and responsiveness because there were blanket rules in place for the shop, and improvements were needed in the out-of-hours medical reviews of seclusion. This is the supervised confinement of a patient in a room, which may be locked. Its aim is to contain disturbed behaviour which is likely to cause harm to others (Code of Practice, 15.43).

Care at both sites was person-centred and was assessed, planned and delivered on an individual basis. People also had the opportunity to comment on the services, as well as have changes made. The care was recovery focused, and therapy and education were available to support this.

Staff morale was very high and the multidisciplinary teams worked well together. Staff were proud of the care they delivered. They also felt supportive of, and supported by, their colleagues, management and the trust.

The facilities were very good and were well-maintained, safe and secure.

The services were safe and effective. There were clear reporting procedures and systems in place, which enabled staff to learn from incidents

Low secure and forensic community services

Although we heard mixed views about the standard of care at Wells Road during our inspection, overall people thought it was good.

The majority of people and staff said they felt safe, and people told us about the different ways in which they were encouraged to be involved in their care. However, some said that at times there were not enough staff, and that their care and treatment were affected as a result.

Staff told us that they attended a mandatory induction programme when they started working for the trust. The majority of staff also felt that they received a good level of professional development and that training was actively encouraged.

The Rapid Response Liaison Psychiatry team is based in the Queen’s Medical Centre at Nottingham University Hospital. The team assess people who walk in to the service for help and those that are referred by the community crisis resolution services.

We found that team members were compassionate and skilful when assessing people experiencing mental health problems. They worked closely with hospital staff and were proactive in dealing with referrals, prioritising them on a need and risk basis. The team also had good risk management strategies in place to make sure people were safe.

People’s wellbeing and safety was central to making decisions about care. The team worked closely with staff in the emergency department (ED) to manage any delays. When there were delays in transferring people to inpatient beds, facilities were used resourcefully as they are not purpose built. This was jointly managed by the team and ED staff, as they remain responsible for people while waiting on hospital premises.

Staff understood the trust’s policies and procedures for safeguarding adults and children, but had difficulty using the trust’s recording systems as both paper and electronic records were used. This made finding information about previous risks, as well as more up-to-date information, difficult and could cause delays for people being referred to the team.

We found that there was not much feedback from people using the service. This was because of the nature of the teams’ work, which was often a one-time contact when people were experiencing high levels of emotional and psychological distress. The team was working with an external organisation to address this, as they were keen to develop the service according to local need and discuss areas for improvement.

Staff told us that they enjoyed working in the service and that they felt well supported by their manager. Information including wider trust issues, as well as visions for the organisation, was regularly shared with staff in team meetings and via email.

The psychiatric intensive care units (PICUs) and health based place of safety are based on two hospital sites at Millbrook Mental Health Unit and Highbury Hospital. They provide inpatient mental health services for adults aged 18 to 65.

We found the intensive care units and place of safety service provided by Nottinghamshire Healthcare Trust provided people with a safe place to have their mental health needs assessed. There were also good systems for transferring people to the right areas for care. Staff were skilled to work with the service users and were trained to keep people safe during disturbances. The trust also ensured that they worked within the Mental Health Act Code of Practice. There were good systems in place to monitor care provided, but seclusion facilities did not protect people from the risk of infections.

People’s physical health was regularly assessed; however, we saw examples where their privacy and dignity was not always protected.

The different services involved in the place of safety, including Crisis Resolution Home Treatment teams, worked well together. Services were planned and delivered to meet the needs of vulnerable people and risk assessments were completed.

Staff understood how to follow the local multi-agency operational policy for safeguarding adults and children. This governed the use of the place of safety and the transfer of patients.

Staff told us they were well supported by their managers and regularly received supervision and appraisals.

Perinatal services provided by Nottinghamshire Healthcare Trust were delivered in a safe and caring environment. People told us that staff were kind and interacted well with them and their families. Referrals to community teams were sometimes delayed, but the team did provide a good service.

Although some of the records were not up-to-date, staff understood the risks to people’s health and welfare. Managers also had a good understanding of the service and the areas that needed more improvement.

We found that staff understood how to follow the local multi-agency policies and procedures for protecting adults and children. They worked well with other teams and agencies, both within the trust and with external organisations, such as primary and secondary healthcare. However, not all the teams were multidisciplinary. Some groups had established good links with, for example, midwives and health visitors, but there was little involvement from occupational therapy services and there were no social workers in the teams. There was little input from clinical psychologists across the inpatient and community services, and staff told us that inpatients found it difficult to access to GPs.

People on the ward and in the community were able to provide feedback on the service, and people said that they felt involved. Staff told us that they enjoyed working in the service and felt supported by their managers. However, we heard that there had been many changes in the management structure above the ward manager level and that this had been unsettling. Most staff we spoke to, however, felt that this was improving.

Nottinghamshire Healthcare Trust provides a specialist Child and Adolescent Mental Health Service (CAMHS). The service consists of community and inpatient care for young people with mental health needs. There is a 12-bedded ward for inpatient treatment, but only 10 beds were being used on the day of our inspection. The inpatient service was commissioned through NHS England.

We found that the CAMHS services were delivered in a safe and caring environment. However, the trust needs to make improvements to ensure that risks to people using the service are fully reviewed, understood and managed.

The trust provides an effective service. We saw some good examples of care, and teams working together, both in the inpatient unit and community services.

The services provided were caring. We saw good examples of individualised and person-centred care in the inpatient unit and within community services.

The services provided by the trust were responsive. We found that individual needs and wishes were met when assessing, planning and delivering care and treatment, and there was an emphasis on avoiding admission wherever possible.

These services were well-led by the trust. Most staff we spoke with felt well supported by their immediate line manager and were aware of the senior leaders within the trust. They also felt that communication from ‘board to ward and community’ was effective.

Overall, people received a good service from the adult admission wards. The service had a clear vision and staff were positive about working towards this. The quality of the service delivered was also monitored on an ongoing basis, where areas for development were identified, clear action plans were put in place and progress was monitored. Staff were generally supported in their roles and were supervised regularly. In addition, patients told us, and we observed, that staff were caring and compassionate.

There were some particular areas of good practice across the wards:

The skills of staff were being developed to meet the needs of patients. Across the wards staff were allocated link roles in specialty areas in order to support people appropriately.

The supervision structure. This helped staff to feel well supported and enabled lessons learnt to be shared.

Clear working practices across acute admission wards, and clear learning from incidents across the trust and within the adult admission service as a result.

There were good links with community care coordinators from the point of a people’s admission. Staff described working to the least restrictive practice with patients and confirmed a low use of restraint was used as a result. Sometimes this was in order to prevent people harming themselves or when treatment was being provided. This way of working underpinned the adult mental health service line’s recovery focus model. De-escalation techniques were used first with restraint used as a last resort. This practice was echoed throughout all of the adult inpatient services we visited.

However, we found that there were some areas where the service could make some improvements, including:

There were noted staffing level pressures on Redwood 1 and Redwood 2. For example on Redwood 2 there was one qualified member of staff on at night. Staff had reported challenges with this and it was felt that the cost improvement had a direct impact on these staffing pressures. We were told there had been increased staff sickness and patient complaints and a lot of pressures to complete ward related tasks on time. On Redwood 1 some staff we spoke with expressed feeling stressed on shift and felt that due to staffing level pressures on the ward this could impact on quality of time they spent with patients, and whether their leave was accommodated. We found that leave was usually accommodated however. Staff informed us that it was not always easy to fill the day shift and that a lot of ringing around was involved to get someone at short notice.

Across the adult admission wards staff confirmed that access to occupational therapy and psychology had been reduced.

There was an air of anxiety about the potential closures of A42 and A43 wards at the Queen’s Medical Centre. The service director for these wards told us that this had not yet been confirmed, and that staff had been told about developments so far. Plans for moving services to a virtual ward in the community had been considered, but staff remained unclear where this left them in the trust.

The dispensing of medicines on Orchid Ward, Millbrook Mental Health Unit was not always carried out in line with the trust’s medicines policy.

We found there was an area where the service must make some improvements. The trust had not adhered to national guidance on gender separation at Bassetlaw hospital (B2 ward) and Millbrook Mental Health Unit (Orchid ward).

Nottinghamshire Healthcare Mental Health services for older people provide both inpatient and community services for people over 65 with functional mental illness, and people of all ages with organic mental health illness.

These services for older people were good. They had a clear vision and staff where positive about working towards this. The quality of the service delivered was monitored on an ongoing basis using a range of measures. Where areas for development were identified, clear action plans were in place and progress monitored. Staff were supported in their roles and received regular supervision. People using the service and their carers and relatives told us, and we observed, that most staff were very caring.

We found that there were a number of areas where the service should make improvements. The medical staff felt they were not empowered and did not always have enough time for direct clinical care with people using the service. The communication between the community and inpatient teams was not always working effectively to ensure that information was shared at all times. Do not attempt resuscitation documentation was not consistent.

The Health Partnerships Division of the trust works closely with primary care services to provide community health services for Nottinghamshire and Bassetlaw. The division is a partnership model, with services in Nottinghamshire provided by County Health Partnerships, and services in Bassetlaw provided by Bassetlaw Health Partnerships. The trust delivers community services to people with long-term conditions. This included the integrated community teams, falls prevention clinics and continence clinics.

The service covers Nottingham City and Nottinghamshire with an estimated population of over 1 million people. There are a number of areas with lower than average levels of deprivation; Nottingham City is ranked 20th out of 326 local authorities. Additionally, 24 out of 32 health indicators are significantly worse than the England average. Services are delivered in people’s homes and from over 80 clinics across the city and county. As you would expect from a service of this size and complexity, we found some levels of inconsistency in the provision of care.

There were systems and procedures in place to safeguard vulnerable patients and to identify, assess and manage risks. However, there was no consistent system to give staff feedback or learn from safeguarding investigations. There were systems and procedures in place to safeguard vulnerable patients and to identify, assess and manage risks. However, We found some inconsistencies in the level of feedback given to staff.

There were arrangements for comprehensive assessment of patients on referral, communication among members of the multi-disciplinary team was effective and supported the planning and delivery of care. The trust was moving to a “paper light” records system, we found there could be potential risks whilst records are held in written format and electronically. Some teams reported inconsistent access to equipment.

We saw many examples of care, compassion and kindness. Patients were involved in making decisions about care and treatment, privacy and dignity was maintained although the physical layout of some clinics made this challenging. Patients were offered emotional support to enhance their care.

Services were planned and delivered around local need. Staff were responsive and the introduction of integrated care pathways was working well. There were systems in place to receive feedback from patients. However patients were not always told how to complain if they were unhappy with the care they received.

Services were well-led. Staff were well informed, felt supported by their managers, and were engaged.

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.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

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.

All Inspections

High secure services

Medium secure services

Low secure and forensic community services