Nottinghamshire Healthcare NHS Foundation Trust

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 carried out the assessment of Phoenix and Pegasus wards 8 and 22 July 2025. Overall, we found the wards to be safe. Staff we spoke with said there was access to additional specialist training, therapeutic pathways and a focus on staff wellbeing. The ward environments were visibly clean and well decorated, with a variety of rooms for therapies. However, we found that care records did not always describe in detail the rationale for not removing items that could pose a risk of harm to young people. We provided this feedback to the provider, and when we visited for the second time on 22 July 2025, we reviewed the care records again and found that appropriate action had been taken to ensure that the service had addressed these risks effectively.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with said they could access specific specialist training such as cognitive behaviour and trauma informed therapy.

We looked at community meeting minutes and “you said, we did” notice boards. Both described improvements following feedback and suggestions from young people.

We saw evidence that staff received monthly supervision as well as reflective practice sessions and peer supervision groups.

Young people we spoke with told us staff completed intermittent observations at regular intervals. They rarely varied the time of the checks on their welfare which they said made observations predictable and presented an increased risk of self harm outside these times. We provided this as feedback to the provider, highlighting the risk of predictability and deviation from evidence-based practice. The provider responded to the feedback and we were told that the service would take necessary steps to explore this matter further and ensure that therapeutic engagement observations are being carried out at irregular intervals.

Staff we spoke with said the acuity and complexity of clinical need of young people had significantly increased in recent months.

Whilst clinicians from the community were regularly invited to care reviews staff told us that consistent attendance was a challenge due to the distances involved along with workload pressures.

Leaders told us that the lack of formal support from local paediatricians led to delays in young people receiving specialist advice and care.

Staff we spoke with told us that the Prevention and Management of Violence and Aggression (PMVA) team provided bespoke sessions on nasogastric feeds however this still presented a challenge when young people dropped to the floor and needed to be moved into a safe position.

Staff we spoke with told us that the nursing staff complete daily environmental checks to identify and mitigate risks in the ward environment and that a ligature checklist was completed weekly. Staff told us that the weekly checklist is documented, however, the daily environmental check is not formally recorded. We provided this as feedback to the provider, and we were told that the service would take steps to improve oversight of how staff record that they have monitored the environment for ligature risks.

We spoke with 4 patients, they said they felt safe on the ward, however one said they were scared when they first arrived.

Staff we spoke with were able to demonstrate how they would identify and raise a safeguarding issue. We were told there was a safeguarding lead at the trust that they could contact for advice. We also saw posters displayed on the ward dedicated to safeguarding.

We looked at 14 care records, one did not describe in detail the rationale for not removing items that could pose a risk of harm or how the risk of harm would be managed. However, we also saw that other care plans included person-centred approaches to safety planning, such as personalised triggers, warning signs and how to support the young person in heightened periods of distress.

We spoke with 4 young people; they told us they were involved in developing their care plan and were invited to attend the individual weekly care plan meeting prior to their care review with the multi – disciplinary team. Young people told us they were able to predict when staff completed intermittent observations as they almost always completed them at regular intervals and rarely deviated from this. This meant that the effectiveness of observations was potentially reduced and opportunities to observe risk-related behaviours could be missed.

Staff told us they completed observations on a 30-minute or 10-minute basis, depending on assessed risk, but sometimes carried out additional “welfare checks” between scheduled observations if they were concerned about a young person’s safety. However, this was not clearly described in the provider’s observation policy and could be open to misinterpretation if a staff member was asked to complete welfare checks between scheduled observation intervals.

Whilst we were assured that observations were being carried out, we provided feedback to the service regarding the "welfare checks" practice and the risk of predictable observation intervals. The provider gave us assurance that the service would take the necessary steps to explore this matter further and ensure that observations are being carried out in line with local and national guidelines.

Ward environments were designed to meet the needs of young people and were bright and colourful. We saw blind spots along the bedroom corridors which were not mitigated by mirrors. Managers completed ligature risk assessments which were up to date.

The wards offered a variety of rooms for young people to use for example a quiet room, a sensory room, garden, activity room, ensuite bedrooms and a large communal living and separate dining room. We saw additional rooms off the ward including a music and games room.

Staff we spoke with said staffing had improved significantly over recent months, vacant posts had been recruited to, and several staff were due to join the teams imminently

Managers said they occasionally used bank and agency staff to cover short term sickness

We were told about the daily meeting whereby staffing across the hospital was reviewed and staff deployed according to the clinical need on that day.

Staff we spoke with said they could access specific specialist training such as cognitive behaviour and trauma informed therapy.

We looked at community meeting minutes and “you said, we did” notice boards. Both described improvements following feedback and suggestions from young people.

We saw evidence that staff received monthly supervision as well as reflective practice sessions and peer supervision groups.

Staff used an electronic prescribing system.

We spoke with 4 young people; they said staff were always available to dispense as required medication

We saw all medicines were stored appropriately. Staff completed temperature checks of the clinic room and the medicines fridge. We saw one instance where the consent to treatment under the Mental Health Act 1983 was not in place for a young person subject to Section 3.