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Provider: Nottinghamshire Healthcare NHS Foundation Trust Good

Our recent report on: High secure hospitals - Rampton Hospital, published 8 June 2018 is available as a British Sign Language video.

Our recent report on: High secure hospitals - Rampton Hospital, published 15 June 2017 is available as a British Sign Language video.

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Good

Updated 8 February 2018

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.
Inspection areas

Safe

Requires improvement

Updated 8 February 2018

Our rating of safe stayed the same. We rated it as requires improvement because:

  • We rated eight of the 19 core services provided by the trust as requires improvement for safe, and one service as inadequate.
  • Medicines management practice was not consistently good. There were issues of; a lack of recording medicine fridge temperatures or not taking action when fridge temperatures exceeded ranges, lack of signing for medicines administered, medicines not always being securely stored and medical teams not consistently reviewing and acting on advice provided by the pharmacists. There was a lack of monitoring of action plans to make sure consistent improvements occurred in medicines management.
  • Staffing levels were a consistent challenge to the trust, despite proactive recruitment and retention plans for all types of staff, in particular nurses and psychiatrists. 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. Although trust policy was to treat patients identified with sepsis promptly, this did not happen. Staff did not consistently complete and record patient National Early Warning Scores.
  • 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. Two locations had not completed environmental risk assessments and ligature audits since July 2015. There was lack of disabled access for people in community child and adolescent services, and lack of soundproofing in consultation rooms in the community.
  • The Mental Health Act Code of Practice requirements were not met in relation to the seclusion facility at the Willows and Lucy Wade.

However:

  • Safeguarding practices were good. Staff had training in safeguarding and knew how to make a safeguarding alert appropriately. Staff accessed safeguard leads for advice. Policies and ward offices displayed adult and children referral processes to assist staff.
  • Staff knew what incidents to report and how to report them. Staff received debriefing following incidents. Staff were open and transparent and explained to patients when things went wrong. There was evidence of changes made following learning.

Effective

Good

Updated 8 February 2018

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

  • We rated 16 of the 19 core services as good and three as requires improvement.
  • Patients received a range of treatment options that followed national guidance. Use of recognised outcome measures enabled monitoring of individual recovery journeys.
  • The trust participated in a range of national and local audits to monitor and improve practice. Monitoring of action plans occurred and the trust shared learning shared in a variety of ways.
  • There were good multidisciplinary team meetings to discuss patient needs which involved discussion of physical and mental healthcare.
  • Staff received regular supervision and appraisals. Supervision was available individually or in groups.

However:

  • The Mental Health Act Code of Practice requirements were consistently not met for example Patients were not provided with information in accordance with Section 132 of the Act about their rights, particularly those on community treatment orders. Leave forms were not complete with all details and staff did not give copies to the patient or their families.
  • Not all staff had a good understanding of the Mental Capacity Act 2005. For patients who might have impaired capacity, staff did not consistently assess and record capacity to consent on a decision specific basis.
  • Information needed to deliver care was not easily available to staff when they needed it, because there was a lack of coordination between different electronic and paper based systems.

Caring

Good

Updated 8 February 2018

Our rating of caring went down. We rated it as good because:

  • We rated 16 of the 19 core services provided by the trust as good for caring. Two core services as outstanding (not inspected this time) and the rating fell due to one requires improvement.
  • Staff attitudes and behaviours when interacting with patients were responsive, discreet, and provided appropriate practical and emotional support. Patients reported staff treated them with respect and dignity. Staff showed good understanding of individual needs of patients.
  • People were able to give feedback on the service they received through surveys or community meetings, and the patient involvement centres let people get involved in decisions about their service. This was evident for example in the new build for the child and adolescent mental health and perinatal service.
  • There was good carer involvement and feedback. Carers were given information on how to access carer assessments.

However:

  • Care plan records did not consistently demonstrate recording of patients’ active involvement and participation in care planning and risk assessment, nor whether they had access to a copy of their care plan.

Responsive

Good

Updated 8 February 2018

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

  • We rated 16 of the 19 core services good for responsive and three as requires improvement.
  • Patients knew how to complain or raise concerns and the trust provided a policy and procedure to support this. Staff knew how to respond to complaints or concerns raised with them. Staff shared feedback and learning from complaints through handovers, emails or during team meetings.
  • The trust provided information in a range of formats for patients with communication difficulties and those whose first language was not English.

However:

  • Wards did not always have beds available in their catchment areas and out of area, placements were used.
  • The trust had dormitories in some ward areas. Staff were not aware of any plans to eliminate dormitory accommodation.

Well-led

Good

Updated 8 February 2018

Our rating of well-led stayed the same. See the section headed ‘Is this organisation well led’ for more information. We rated it as good because:

  • Local leaders were visible, staff delivered care that demonstrated behaviour in line with the trust values.
  • There was excellent service user engagement and carer involvement.
  • There was good partnership working with other agencies to meet the needs of the population.
  • There was a strong culture of learning and recognition of staff for innovative practice occurred.

However:

  • Not all staff were aware of the Speak up Guardian and not all staff felt able to raise concerns.
  • The trust recognised leadership investment in middle managers was crucial to managing significant change.
Checks on specific services

Wards for people with a learning disability or autism

Updated 14 August 2018

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.

Acute wards for adults of working age and psychiatric intensive care units

Requires improvement

Updated 8 February 2018

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.

Child and adolescent mental health wards

Updated 23 December 2015

  • 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.

Community health services for adults

Requires improvement

Updated 8 February 2018

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.

Community-based mental health services for adults of working age

Requires improvement

Updated 8 February 2018

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.

Specialist community mental health services for children and young people

Updated 23 December 2015

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.

High secure hospitals

Requires improvement

Updated 8 June 2018

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.

Reference: not found

Updated 30 October 2015