Nightingale Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence on how the service provided safe care and treatment. During an inspection in June 2022, we rated this key question as requires improvement. At that inspection, the service was in breach of regulation 12 (safe care and treatment). At this inspection, the rating has changed to good. This meant people were safe and protected from avoidable harm.

Ligature risk assessments and risk mitigation plans were now clear. We found one ligature point that had not been identified by the provider. Action was taken to address this in the assessment period. Staff had a good understanding of ligature risk management.

National Early Warning Scores charts were now being completed in full, and staff were able to describe the process that they would follow to escalate any concerns. The electronic patient record system flagged any scores that required escalation. However, we found that NEWS scoring was not carried out consistently on each of the wards. We did not find any impact on patient care with these inconsistencies during our inspection.

Medication administration records were now being completed in full.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety based on openness and honesty in which concerns were listened to, patient safety incidents were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

The service had no serious incidents in the previous 12 months.

All staff knew what incidents to report and how to report them using the electronic incident reporting system. Staff told us that they would report any incident of harm, potential harm and/or risks to safety in line with hospital policy.

Staff told us incidents and never events were discussed in handover, multidisciplinary team meetings, in reflective practice, supervision, clinical governance, clinical improvement and staff meetings. This was to ensure that any actions were taken to manage or remove risks.

Managers reviewed and analysed incidents at clinical governance meetings to understand themes and trends, how to reduce these and implementing action plans to put things right.

Staff we spoke with were able to tell us about recent incidents and the learning that came from those incidents, for example following an incident a risk assessment was now completed for all patients that were on leave from the hospital. Staff also carried out a safety briefing before they escorted any patients outside the hospital.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Arrangements were in place for de-brief sessions to take place for both staff and patients following a serious incident. This was to ensure that staff and patients were provided with appropriate support.

When something went wrong there was a thorough review or investigation which involved members of the multidisciplinary team, patients and their family members as appropriate.

The service worked with people and partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The service ensured continuity of care, including when people moved between different services.

Patients and carers told us they were involved in discharge planning.

We spoke with 12 patients All patients we spoke with confirmed that they were provided with an admission booklet which provided key information about the service.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. All referrals were received through the Patient Service’s Team. Patients could self-refer to the hospital or be referred by a clinician. Out of hours referrals were managed by clinical staff. The service had an admission risk exclusion criterion that included a high-risk history of violence to others that may require a seclusion. Nightingale hospital does not have a seclusion suite.

All referrals, admissions and discharges were discussed at the morning meeting with leaders within the service.

At our last inspection staff did not always document discharge plans or approximate dates of discharge. At this inspection we found improvements. Patient discharge planning started at the point of admission. We looked at 8 care plans. All of them contained a comprehensive discharge plan and potential discharge date. Patients confirmed they were involved in completing a comprehensive discharge booklet.

Staff referred patients to external agencies when required, including GP, accident and emergency departments and hospitals to ensure patients had continuity of safe care.

The service worked with people to understand what being safe meant to them as well as partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The wards had a calm and welcoming environment.

Staff understood how to protect people from abuse and the service worked well with other agencies to do so. The service had a safeguarding policy and clear processes in place for staff to follow. All staff said they had training appropriate for their role on how to recognise and report abuse, and they knew how to apply it. Staff felt confident that if they did raise concerns they would be listened to and action taken.

At the time of the inspection 88% of staff were up to date with their level 2 safeguarding adults and children training.

Staff could give clear examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act, for example for patients who identified as non-binary.

Staff followed safe procedures for children visiting the service.

The service worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that matter to them.

Patients told us they were involved in managing risk and contributed to their risk management plans.

The provider had made improvements to care planning and risk assessment documentation since our last inspection. We reviewed 8 care plans and risk assessments. These were detailed and contained sufficient details to ensure that the individual needs were met. The service was no longer in breach of regulation.

Staff involved patients in care planning and risk assessment. Staff told us that care plans were co-produced with patients and were discussed in ward rounds and reviews.

Staff completed risk assessments for each patient on admission / arrival, using a recognised tool, and reviewed this regularly, including after any incident. Consultant psychiatrists identified any risks as part of their pre-admission assessment.

Staff knew about any risks to each patient and acted to prevent or reduce risks. All staff we spoke with had a good understanding of each patient and the risks they posed. Patient risk and management were discussed in the morning meeting, at handovers and in the multidisciplinary meetings. This enabled staff to focus on the current risks and review how effective management and mitigation plans were working.

Consultant psychiatrists took account of patients' histories and significant risk incidents that had occurred in the past as part of the pre-admission assessment.

Staff had open conversations with patients concerning their risks and produced a collaborative care plan and risk management plan. This was updated if there was a change in current risks.

Staff identified and responded to any changes in risks to, or posed by, patients. For example, where required additional observations were carried out, medicines were reviewed, leave suspended or additional staff rostered on shift.

Staff used National Early Warning Score (NEWS2) track and trigger system. NEWS2 is a tool used to score a patient's vital signs to identify those at risk of physical deterioration. At our previous inspection NEWS charts were not being completed in full. At this inspection we found improvements. Charts were being completed in full. However, we found that further work was required across all four wards to ensure a consistent approach with the frequency of scoring. We did not find any impact on patient care with these inconsistencies during our inspection.

NEWS scores were audited to ensure that appropriate action had been taken when scores were elevated. There had been no incidents where escalated scores had not been followed up.

Leaders monitored the use of restraint and any restrictive practices.

Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe.

Levels of restrictive interventions were low. In the twelve months before the inspection there had been 14 incidents involving restraint across the four wards. There was one episode of prone restraint.

All incidents of restraint and rapid tranquilisation were reviewed at the clinical governance meeting. Managers were also able to access CCTV footage from communal areas to review incidents of restraint. Staff followed NICE guidance when using rapid tranquilisation.

Staff followed organisational policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm.

Staff enabled patients to give feedback on the service they received, via the healthcare patient satisfaction survey.

Patients told us they could access support from the advocacy service. All patients had access to an Independent Mental Health Advocate (IMHA) during their stay at the hospital. Information about how to access the advocate was displayed around the wards and given to patients on admission. We spoke with the advocate for the service. They told us they worked well with the ward teams.

People were cared for in safe environments that were designed to meet their needs. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care.

Ward areas were clean, well maintained, well-furnished and fit for purpose. The service had a comprehensive renovation plan for each ward.

Staff did regular risk assessments of the care environment. Staff told us that they regularly completed daily security and environmental checks to ensure the environment was safe for patients. We noted that the environmental checklist form did not include the patient call bell system. This was resolved at the time of the inspection when raised by the inspectors.

Staff could not observe patients in all parts of the wards. The layout of the wards did not allow for clear lines of sight in every area. Where there were blind spots, these risks were mitigated by convex mirrors, closed-circuit television to improve visibility and staff observations.

Staff completed ligature risk assessments for each ward. At our previous inspection we found shortfalls with the ligature risk assessments and ligature management documents. At this inspection ligature risk assessments and ligature management had now improved. Staff confirmed that they knew where ligature risk assessment, heat maps and ligature cutters were located. However, we found one ligature anchor point that had not been identified on the ligature audit on ward 4. The service took immediate action to remove the ligature point.

Staff had a good understanding of ligature management on each of the wards. Staff reported that they mitigated ligature risks by using observation, engagement and individual risk management plans. They understood the ligature response protocols, knew where to locate the ligature risk assessment, heat maps and the location of the ward's ligature cutters. Staff participated in emergency simulation training each month. Simulation training included ligature scenarios.

Staff had easy access to personal alarms and patients had easy access to nurse call systems in every room.

The service had closed-circuit television (CCTV) in all communal areas and corridor areas. CCTV was recorded and was used to review incidents across the entire hospital.

Fire safety arrangements were in place. 88% of eligible staff were up to date with their fire safety training.

Desk top fire drills were carried out every three months. Where required, staff completed personal emergency evacuation plan (PEEP) for patients who had mobility difficulties. However, not all staff knew the location of the evacuation chair in the event of a fire on the second floor and fourth floors. This was addressed at the time of the inspection and staff shown where the chairs were located. When this was highlighted to the provider a very clear competency document was created to ensure compliance and understanding throughout the service

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Each patient had their own bedroom, which they could personalise. Bedrooms were clean and bright with ensuite facilities.

The service made sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that met people’s individual needs.

All patients we spoke with reported that there were enough staff on duty to meet their needs.

The service had enough nursing and support staff to keep patients safe and to provide the right care and treatment. Staffing levels across each ward were reviewed daily within the service. Vacancy rates for nursing staff were low. The service had recruited several international nurses. International nurses undertook a 6-month induction and were enrolled onto the providers preceptorship programme.

Managers had calculated the number and grade of registered and healthcare assistants required to keep patients safe. The managers ensured that there was a minimum of two registered nurses on each shift and two healthcare assistants for a minimum number of admissions. Staff had access to a staffing matrix that showed the number of staff needed for the number of patients admitted. The ward managers prioritised the safety of the patients and staff and booked additional staff as needed.

Managers reviewed staffing every morning and when necessary. Managers deployed bank and agency nursing staff to maintain safe staffing levels. The ward used regular bank staff who were familiar with the patients. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. Staff confirmed that agency staff were rarely used.

A qualified nurse was present in communal areas of the ward at all times.

Patients confirmed they had regular one to one sessions with their named nurse. Patients’ records showed that nurses had regular individual time with patients.

The service carried out employment checks on staff, including criminal background checks, qualifications and right to work. We reviewed 4 staff employment records and found that two files did not contain all the required recruitment information, for example we found references were missing for one staff member and for another we were unable to access the reference as it was password protected. The hospital carried out checks with the DBS every three years for each individual employee. Staff who required a renewal of their DBS they were followed up by the human resources department. However, the provider had already identified these gaps through internal checks and was taking action to address them. This included plans for a review of HR functions at the hospital, employing a HR consultant and auditing all staff employment records. Some of the issues identified also related to the migration of some staff records to a new IT system.

The medical advisory committee ensured that all consultant psychiatrists had all the checks and agreements in place before they were granted practicing privileges. Practicing privileges enable doctors to practice in hospitals without being employed by them. We reviewed 4 records for doctors working at the service and these contained details of all the checks that were required to be carried out.

There was adequate medical cover day and night, and a doctor could attend the wards quickly in an emergency. A duty doctor was on call at the hospital day and night, every day of the year. Staff knew how they could contact a doctor in the event of an emergency.

Staff could contact consultant psychiatrists who had practising privileges and were not based at the hospital, to update them about any patient concerns.

Staff had completed and kept up to date with their mandatory training to ensure they had the appropriate knowledge and skills to carry out their roles safely. The overall compliance rate for the service was 93%. There was no mandatory training with a compliance rate of less than 75%. Staff we spoke with said they felt confident carrying out their role and applied training to their practice. Managers monitored mandatory training and alerted staff when they needed to update their training. However, two staff reported that whilst training was offered, they felt that there was a lack of further professional development and career progression opportunities.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

All ward areas were clean, had good furnishings and were well-maintained. No concerns were raised by patients at the time of our site visit.

Staff made sure cleaning records were up-to-date, and the premises were clean. Housekeeping staff were seen cleaning high touch areas throughout the day.

Staff followed infection control principles including appropriate handwashing techniques, use of personal protective equipment (PPE) including aprons, masks, gloves, and hand sanitiser was readily available. Infection control audits were undertaken on each ward including regular hand washing audits. Audit findings and actions were discussed in handover and staff meetings if any issues were identified.

Staff accessed infection control training. All wards had training compliance of 85% and above.

The service made sure that medicines and treatments were safe and met people's needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

Medicines were safely managed. There were systems for ordering, administering and monitoring of medicines. Staff were trained and deemed competent before they administered medicines. Medicines were safely secured, and records were appropriately kept. We found that room and fridge temperatures were appropriately monitored.

The service kept prescription stationery securely and monitored its use. Medicines administration records were now recorded electronically on an Ashton's system. We found that they were recorded comprehensively and accurately.

Emergency medicines (including oxygen) were appropriately stored and monitored regularly to ensure they were easily accessible, if required.

The service carried out regular medicines audits to ensure prescribing was in line with best practice guidelines for safe prescribing as well as ensuring that people were taking their medicines (e.g. via stock counts).

We were assured that medicines related incidents were investigated properly with appropriate action plans and there were processes in place to ensure staff learned from these incidents to prevent them occurring again.

People received their medicines as prescribed. We looked at 8 people's medicines and found no discrepancies in the recording of medicines administered. The recording of medicines had improved since our last inspection. Overall, this provided a level of assurance that clients received their medicines safely, consistently and as prescribed. The service had improved this area of work since the last inspection and was no longer in breach of regulation.

We found minimal use of rapid tranquilisation, high dose antipsychotics and only one detained person on the day of assessment. Furthermore, there was no one that required a T2/T3 arrangement in place.

During the inspection, we saw several instances of where residents were prescribed PRN (as required) medicines and there were associated PRN protocols in place to manage these safely.