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Provider: Nottinghamshire Healthcare NHS Foundation Trust Requires improvement

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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

Requires improvement

Updated 27 May 2020

  • 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.
Inspection areas

Safe

Requires improvement

Updated 27 May 2020

Inspected not rated

  • Staff had access to personal alarms and knew how to use them in case of an emergency. Ward areas and patient bedrooms were visibly clean. Furniture and equipment were well maintained.
  • Patients had a detailed positive behaviour support plan and health action plans. Patients spoken with told us they were involved in creating their plans and felt staff followed them.
  • The clinic rooms were well maintained and stocked. We saw the clinical team regularly reviewed health monitoring equipment that included resuscitation equipment in line with the manufacturer’s guidelines.
  • Managers calculated the number of staff required to meet the needs of the patients. Staffing levels fluctuated in line with level of patient observations and bed occupancy. Ward managers were able to increase staffing numbers if required.
  • Staff followed best practice following the use of rapid tranquilisation. We saw staff had completed all physical health monitoring following the use of rapid tranquilisation in line with the National Institute for Health and Care Excellence guidelines.
  • Wards had provision in place for children and other visitors. There were designated visitor rooms outside of patient areas which meant visitors did not have to enter the ward when visiting.
  • Staff received feedback about incidents during team meetings, supervision and also via email. This meant that the learning from these were shared with front line staff.
  • Security was a key priority on the wards. Staff spoken with knew the security procedures well.
  • Managers took part in serious incident investigations. We saw evidence of changes being made based on the outcomes.

However

  • Patients in long term segregation did not always receive a 24-hour review in line with the Mental Health Act Code of Practice. We found no evidence in patient notes as to why staff were deviating from the code.
  • Staff did not always use the electronic recording keeping system to document patient allergies. This meant we were not assured all staff had access to key information needed to safely care for patients with allergies.

Effective

Good

Updated 27 May 2020

Inspected not rated

  • Staff regularly reviewed and updated coproduced care plans and positive behaviour support plans when patients' needs changed. We saw evidence of patient and carer involvement throughout the care plans and positive behaviour support plans.

  • Staff used recognised rating scales to assess and record the severity of patients’ conditions and care and treatment outcomes.
  • Clinical staff took part in clinical audits, benchmarking and quality improvement initiatives.
  • Patient’s had access to a psychological interventions and psychology led groups in line with National Institute for Health and Care Excellence guidance.
  • Ward managers arranged specialist training for ward staff when required. For example, staff received specialist learning disability and autism training.
  • Staff held regular and effective multidisciplinary meetings. We saw evidence clinical staff discussed all patients during these meetings which included a comprehensive review of their needs and progress made. Records showed that patients their family and carers, where applicable, were encouraged to take part in their review meetings.

  • Staff understood their roles and responsibilities under the Mental Health Act and the Mental Health Act Code of Practice.

Caring

Good

Updated 27 May 2020

  • We observed staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. Staff were engaging in meaningful activities and showed they had a good understanding of the patient’s needs.

  • Staff introduced patients to the ward and the services as part of their meaningful admission process.

  • We saw evidence staff involved patients to coproduce their care plans and risk assessments.

  • Patients could give feedback on the service and their treatment and staff supported them to do this.

  • Patients had access to advocacy services.

  • Staff supported, informed and involved families or carers. For example, we saw where the trust had invited families or carers to attend the patient’s reviews.

Responsive

Requires improvement

Updated 27 May 2020

Well-led

Requires improvement

Updated 27 May 2020

Inspected not rated

  • Leaders had the skills and abilities to run the service. They were able to demonstrate an understanding of key issues, priorities and challenges the service faced and managed them effectively.
  • Leaders were visible in the service and supported staff to develop their skills, and take on more senior roles, and responsibilities.
  • Staff felt positive and proud to work for the hospital. Staff spoken with told us they felt their team morale was good.
  • Ward managers and senior managers had oversight of the hospital. Ward performance was monitored by completing regular audits and the outcomes were recorded on key performance indicator dashboards.

However

  • Staff told us they were not always kept up to date with strategic changes within the hospital. Staff were aware of some planned changes. however, they did not know when the changes were due or how it would impact on them.

  • At the time of inspection, we found supervision rates were below the trusts own target, however this was recording error as staff did not always update their supervision dates.

  • Not all activities which patients took part in were recorded and monitored. We could not be assured all patients were access 25 hours of meaningful activity in live with best practice.

  • Staff did not always have access to patient physical health monitoring information prior to administering medication. For example, where a patient was on high dose anti-psychotic monitoring, the physical health records that were stored on the physical health system were not always transferred to the patient note system because two electronic systems were not integrated.
Checks on specific services

Community health services for children, young people and families

Updated 30 October 2015

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

Requires improvement

Updated 23 September 2020

  • 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.

High secure hospitals

Inadequate

Updated 24 January 2020

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.

Mental health crisis services and health-based places of safety

Good

Updated 24 May 2019

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.

Community mental health services with learning disabilities or autism

Good

Updated 24 May 2019

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.

Forensic inpatient or secure wards

Requires improvement

Updated 24 May 2019

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.

Community-based mental health services for adults of working age

Good

Updated 24 May 2019

  • 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.

Child and adolescent mental health wards

Good

Updated 24 May 2019

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. 

Wards for people with a learning disability or autism

Good

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.

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.

Community health services for adults

Updated 30 October 2015