Nottinghamshire Healthcare NHS Foundation Trust

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

All wards were safe, clean, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well. However, we found several blanket restrictions in place around waste management and mealtimes. We raised these with the trust and when we conducted a revisit to the services these had been addressed.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

All 12 Care and treatment plans we reviewed consisted of risk management plans, where risk had initially been identified. These were reviewed regularly including during ward round meetings, handover meetings and morning multi-disciplinary meetings.

Staff did not always ensure that patients could access advocacy services. Thorneywood Mount used to have an advocate that attended the service regularly. However, this had stopped, and leaders had not contacted the advocacy service to reinstate this service or request further support. This meant patients did not have independent support if needed. We raised this with the trust and they updated the patient’s welcome packs to include information on accessing advocacy support.

During our assessment we saw blanket restrictions in place. This included dining rooms on both sites being locked outside of mealtimes and patients only being able to access drinks and snacks through the assisted daily living activities kitchen. Staff at Thorneywood Mount staff told us a Freedom to Speak up Guardian concern had recently been made due to restrictions within the dining room and that management had addressed these. Thorneywood Mount had various options on the menu including vegan and vegetarian options. However, the dining area at Bracken House had several rules on display including: “Fruit Juice only at breakfast time- one glass only”,“no seconds” and a sign indicating that clinical staff were not allowed into the kitchen. We observed a limited menu variety and lack of options for patients with cultural preferences or medical dietary needs (e.g. no Afro-Caribbean diet options or diabetic snack options). Eight out of 10 staff we spoke with at Bracken House told us patients were only allowed fruit or bread and butter for a snack between mealtimes and that the ‘meals on wheels’ food options were not suitable for their client group.Patients were not offered food that met their nutritional, cultural and clinical needs. These restrictions posed as an ongoing risk of restrictive meals, reduced dignity and autonomy. We raised this with the trust and conducted a revisit to the site, where we found all restrictions around mealtimes had been removed.

We found there was a blanket restriction that had been placed across both sites around bin liners not being permitted in patient areas. This was due a patient incident at a different location in the trust. We found these restrictions had not been assessed for appropriateness at the rehabilitation service and this had been applied as a blanket rule across the trust, without consideration of patient needs and treatment journey.

Staff enabled patients to give feedback on the service they received, via weekly community meetings. We reviewed meeting minutes, which showed patients gave feedback on issues including meals, activities and the environment. We saw patients had given feedback about bin liners not being in place and management had stated they had ordered appropriate bins but did not know “why they have taken so long to arrive”. When we visited the service again, we found both services had appropriate bins in place.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff at Bracken House told us they felt very isolated at night, due to the current staffing levels and the layout of the unit. We reviewed staffing levels at both Thorneywood Mount and Bracken House over the last 4 months, and these showed the service always met the safe staffing levels. When we raised this concern with the managers at the trust, they told us they were in the process of undertaking establishment reviews for all the services within adult mental health services care group and they used a combination of clinical judgement, safe care data and environmental knowledge to ensure the best possible outcomes for patients. The ward managers were key to these discussions, and they had asked their safety and security manager to visit the sites to review the security arrangements and to ensure the service remained a safe place for patients and staff. We also reviewed all night time incidents over the last 4 weeks and found none were related to low staffing levels.

Staff maintained equipment well and kept it clean. All ward areas were clean, had good furnishings and were well-maintained.

Staff adhered to infection control principles, including handwashing. However, infection control was not being managed effectively. The bins at the Thorneywood site did not consist of bin bags and staff were expected to pick waste from all patient area bins using their hands (with gloves and aprons) and put this into bin liners before disposing of it. Staff felt this posed as an infection control and safety risk to staff as this included food waste and on occasion sanitary waste. Managers told us replacement bins had been ordered 6 weeks ago but had not been delivered yet. Manager did not have oversight of when these would be delivered. At Bracken House we observed bins used for general waste and food disposal that did not have bin liners. Six out of 10 staff we spoke to told us a plastic bag ban meant that food waste was disposed directly into the bin without a bin liner which increased risk of infection transmission; cross-contamination; risk of pests/odour.We raised this with the trust and when we conducted a follow up visit the service had appropriate bins in place at both locations.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.