Nottinghamshire Healthcare NHS Foundation Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained Requires Improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients. However, patients did not always have shorter term goals that were reviewed and that could evidence how they were progressing through their treatment plan. Staff did not provide a range of treatment and care for patients based on national guidance and best practice. Staff did not always inform patients of their rights under the Mental Health Act. Staff did not always have regularly managerial and clinical supervision in place. We have asked the trust to submit an action plan to address the concerns raised.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff at both services told us they were able to assess patients prior to admission and were able to decline admissions if they felt the service could not meet the patient’s needs.

We reviewed 12 patient care and treatment records across both locations. We found at Bracken House staff assessed patient needs and reviewed them regularly, setting goals and reviewing them with a multi-disciplinary approach. At Thorneywood Mount we found staff completed initial care and treatment plans well, set long term goals, accounted for cultural preferences and assessed physical health needs regularly. However, none of the 6 care plans we reviewed showed shorter term goals and only 1 showed assessments completed by an occupational therapist. The records did not show if or when patients had been offered this assessment and if they had declined to complete it. We raised this with leaders after our assessment, and they provided assurances around ensuring staff were aware of expectations to set goals and monitor outcomes, using screening tools and completing patient records accurately.

Within the patient care and treatment records we reviewed, we found the staff at Bracken House used nationally recognised tools including the Health of the Nation Outcome Scale (HoNOS) to assess and review patient treatment and progress. However, we found there were no clinical outcome scales being used to assess and review patient needs at Thorneywood Mount. This meant there was no clinical oversight of patients progress or decline in health. Although all patients had monthly multi-disciplinary ward round reviews there were no clinical outcome scales used to measure patients treatment journey.

Staff provided a range of care and treatment interventions suitable for the patient group. These included medication, psychological therapies, activities, and training and work opportunities intended to help patients acquire living skills. We saw a patient at Thorneywood Mount was supported to access and complete their university course and another patient accessed a local gym. However, access to other activities was limited at Thorneywood Mount. Patients we spoke with at Thorneywood Mount told us they waited weeks for a cooking session. When we spoke with therapists at this service, they felt this was due to other hospital staff not always actively taking part in activities.

Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. Although the responsible clinician at Thorneywood Mount was not a medical clinician the service had a set up access to a GP weekly to ensure patients physical health needs were met. We observed 1 patient ward round meeting at Bracken House. We saw a collaborative approach to this meeting; we saw the patient and carer were involved in discussions and staff team took a collaborative approach. They considered all multi-disciplinary team members views including those that could not attend in person and had sent written feedback to the meeting.

Staff did not always participate in clinical audit, benchmarking and quality improvement initiatives. At Thorneywood Mount leaders told us they were not accessing accreditation as the process required them to have a medical Registered Consultant, which was not the model they followed. However, they often discussed quality and accreditation guidance at the risk and quality meetings to allow them to embed best practice.

The team included or had access to the full range of specialists required to meet the needs of patients in the service. As well as a GP, nurses, occupational therapists, an occupational therapy assistant, community health teams, social workers, and peer support workers were available.

Managers at Thorneywood Mount provided staff with supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development) and appraisal of their work performance. The percentage of staff that had had an appraisal in the last 12 months was 97% at Thorneywood Mount. The percentage of staff that received regular managerial and clinical supervision was above 90% at Thorneywood Mount. However, the compliance rates at Bracken close were lower. The percentage of staff that had had an appraisal in the last 12 months was 88% at Bracken House. The percentage of staff that received regular managerial supervision was 63% and clinical supervision was 72% at Bracken House. This meant staff did not have regular access to management and clinical support and there was not always a consistent opportunity for managers to address performance concerns.

Managers ensured staff had access to regular team meetings. These meetings involved discussions around incidents, lessons learnt, performance, training and updates.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge.

Staff held regular and effective multidisciplinary meetings. Staff shared information about patients at effective handover meetings within the team between each shift. We observed a multi-disciplinary morning meeting at Thorneywood Mount, where the last 24 hours of care for each patient, any appointments, groups bloodwork, reviews and enhanced observations were discussed by the multi-disciplinary team. We saw handover meeting notes from both Thorneywood Mount and Bracken House, which showed each patient was discussed and the discussions included patient mood, medication compliance, physical health observations, leave arrangements and any current risks.

The teams had effective working relationships, with other relevant teams within the organisation including care co-ordinators and community mental health teams. These teams were able to attend monthly patient ward round meetings, and we saw examples of this multi-disciplinary approach when we reviewed patient care plans. However, the internal staff team did not always work well together. At Bracken House we found all staff facilitated and led patient activities, whereas at Thorneywood Mount all staff told us it was just the occupational therapy team and recovery worker that delivered activities. One staff member told us they could support with cooking if the occupational therapist communicated this to them.

The teams had effective working relationships with teams outside the organisation, including the local authority social services, housing teams and GPs. We saw examples of when staff had been in contact with housing teams when patients were ready for discharge.

Staff supported patients to live healthier lives, through participation in smoking cessation schemes, healthy eating advice, managing cardiovascular risks through physical health monitoring, and accessing the gym.

Ward activities helped promoted a healthy lifestyle for patients, for example walking groups and cooking healthy meals. However, patients and staff told us accessing support with cooking could take weeks due to the lack of an activity coordinator at Thorneywood Mount. The only individuals who supported with activities was the occupational therapist, occupational therapy assistant and recovery worker. This team had started to offer a weekend support too, to help increase the level of access.

Staff at Bracken House told us links to speech and language therapists and dieticians were not strong which meant patients often missed out on these services. There were numerous restrictions in place around mealtimes at Bracken House including patients not being able to have seconds. We raised this with the trust, and they addressed these restrictions immediately.

Staff used recognised rating scales to assess and record severity and outcomes at Bracken House, for example, Health of the Nation Outcome Scale and Model of Human Occupation Screening Tool. However, these were not in use at Thorneywood Mount. No patient care records we reviewed showed the Health of the Nation Outcome Scale had been completed once the patient had come to the service. Patients that had this assessment completed had it done at a previous service. Only 1 patient had a Model of Human Occupation Screening Tool completed. When we asked staff about the completion of assessment, they told us patients had been given the opportunity to complete these but had declined. However, there was no record to show this had been offered. Limited or no use of outcome measures in this service meant best practice was not followed and it did not allow a clinical measure of a patient’s treatment journey. When we raised this with the trust, they accepted the need for a more structured approach in assessing and reviewing patient treatment. As a fundamental part of their improvement work, they were in the process of introducing a new system. This would include elements of both care planning and outcome measures that would be produced with patients. Alongside this, they were planning to introduce outcome informed care plans for patients in rehabilitation services, and the use of goal based outcomes measures would be explored. However, this was due to be launched in September 2025 in the Local Mental Health Teams services with a roll out programme across all services following this.

The trust also told us they were communicating with staff to ensure they consistently recorded when patients are offered the Model of Human Occupation Screening Tool, if they had declined and compliance would be monitored.

Staff took all practical steps to enable patients to make their own decisions. Patients knew of their rights. The service had both formal and informal patients. Thorneywood Mount was a Level 1 rehabilitation service (which is a unlocked rehabilitation service) and Bracken House is a level 2 rehabilitation service (which has locked doors), and both had notices on the door informing patients of their rights of being able to leave the ward. We found consent to treatment documents had been completed within all patient care records we reviewed. Where patients had requested family members to be involved in their care they were invited to attend ward round meetings.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Within 1 patient’s care plan we found it was noted that this patient was Muslim and accessing the mosque was important to them and it was important to them to pray regularly. We saw staff had offered them to access an Imam at the service, but they had declined this.

Staff did not always explain to each patient their rights under the Mental Health Act in a way that they could understand, repeated as necessary and recorded it clearly in the patient’s notes each time. There was no effective system in place at Thorneywood Mount to ensure patients were read their rights on a regular basis. We requested evidence of the when informal patients had been read their rights and found this was only at 60% of compliance. After we had requested this information the service ensured all patients were aware of their rights and put a system in place to ensure this was reviewed regularly. Bracken House had an effective system in place and patients had been read their rights in line with legislation.