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

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 changed to Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation under safe care and treatment. We found staff were not effectively assessing environmental risks and updating risk assessments accordingly. We found infection, prevention and control was not always managed effectively. We found a breach in regulation under privacy and dignity. Staff did not always maintain patients’ dignity and respect, when the wards extra care facilities were in use.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We do not always have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

During our assessment, we observed handovers between staff teams and reviewed handover documentation from previous shifts. These meetings covered each patient's needs in detail, including their condition over the past 24 hours. Although a significant amount of information was shared, it was presented in a structured manner. The nurse in charge consistently checked whether staff had any questions or feedback.

At our previous assessment, we raised concerns about inconsistent handovers, we noted a marked improvement in this area since the concerns were raised.

We also observed daily safety huddles involving service leaders, the multidisciplinary team (MDT), and the nurse in charge. These meetings included detailed discussions of each patient, with particular attention to physical health concerns. The physical health lead was present and actively involved. For example, when a patient showed signs of deteriorating health, the lead promptly coordinated appropriate support. These meetings were documented in the patients’ care records.

We saw medical staff responded promptly to a patient that had physical health issues.

Staff reported debriefs were conducted following incidents. An agency nurse told us, “I’m told when I come on the ward how the patients are, if anything has happened, and what is happening.” This staff member was able to accurately describe an incident that occurred overnight, having received the information during handover.

However, our assessment identified instances of potential harm to patients that had been overlooked by service leaders. These issues were acted upon promptly once raised. For example, the trust had previously been made aware of infection control risks associated with the introduction of replacement clinical bins in the eradication of the use of plastic bags. The trust had also been made aware of a recent sad death of a patient where they had utilised their physical health bed to cause harm. The trust had been made aware of these issues in another services and learning had not been shared effectively enough to find the most appropriate way to handle waste and the risk associated with physical health beds in a mental health setting. Leaders at this service told us they were disappointed they had not been informed about the action taken in the other service and took steps to address the issue.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

The service’s referral and admission processes were designed to ensure all essential information about the patient was obtained to assess whether their needs could be safely met. Staff worked closely with local commissioning groups and community learning disability teams to support effective admissions.

We reviewed a recent case that involved a patient in crisis and found clear communication and prompt decision-making enabled the patient to be admitted into a safe environment in a timely manner. The patient, who had recently experienced the loss of their partner, was receiving comprehensive wraparound care. Staff made considerable efforts to support the patient to manage the practical and emotional impact of their bereavement. This included assistance with administrative tasks related to their partner’s death.

The patient shared, “Staff are coming with me to get the death certificate, they are going with me to my house as I left washing on the line.” Staff demonstrated compassion and sensitivity, they recognised the importance of helping the patient secure their home during the admission period.

We saw evidence of effective coordination with health and social care services to ensure continuity of safe care both during the admission and in preparation for discharge. The appropriate professionals were invited to discharge planning meetings, which ensured decisions were well-informed and patient centred. Leaders acknowledged delays in discharge were primarily due to challenges in arranging suitable social care packages, which were essential to support patients transitioning safely out of the service.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Staff were trained in safeguarding procedures and demonstrated a clear understanding of how to raise safeguarding alerts when appropriate. Safeguarding was a standing item during handovers, ensuring staff were consistently informed of any concerns relevant to patient safety.

Our review of care plans showed safeguarding concerns were appropriately documented and acted upon. We observed compassionate and person-centered care in practice. One patient shared staff supported them to spend time alone to engage in personal activities that helped relieve tension, stress, and anxiety. Staff respected the patient’s dignity and privacy and arranged an appropriate gender mix during these times. This sensitive and non-judgmental approach reflected the service’s understanding of how such support could help prevent complex or inappropriate behaviours.

During our assessment, some patients were prescribed high levels of enhanced therapeutic observations. The trust had recently implemented a system to review and justify any restrictive practices, with clear plans in place to reduce them where possible. We observed one of these review meetings during our visit.

We saw evidence of how the trust and service responded to allegations of abuse or harm involving people in positions of trust. Policies relating to Persons in Positions of Trust (PIPOT) were in place, and correct procedures were being followed.

We do not always have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

During our assessment, we observed handovers between staff teams and reviewed handover documentation from previous shifts. These meetings covered each patient's needs in detail, including their condition over the past 24 hours. Although a significant amount of information was shared, it was presented in a structured manner. The nurse in charge consistently checked whether staff had any questions or feedback.

At our previous assessment, we raised concerns about inconsistent handovers, we noted a marked improvement in this area since the concerns were raised.

We also observed daily safety huddles involving service leaders, the multidisciplinary team (MDT), and the nurse in charge. These meetings included detailed discussions of each patient, with particular attention to physical health concerns. The physical health lead was present and actively involved. For example, when a patient showed signs of deteriorating health, the lead promptly coordinated appropriate support. These meetings were documented in the patients’ care records.

We saw medical staff responded promptly to a patient that had physical health issues.

Staff reported debriefs were conducted following incidents. An agency nurse told us, “I’m told when I come on the ward how the patients are, if anything has happened, and what is happening.” This staff member was able to accurately describe an incident that occurred overnight, having received the information during handover.

However, our assessment identified instances of potential harm to patients that had been overlooked by service leaders. These issues were acted upon promptly once raised. For example, the trust had previously been made aware of infection control risks associated with the introduction of replacement clinical bins in the eradication of the use of plastic bags. The trust had also been made aware of a recent sad death of a patient where they had utilised their physical health bed to cause harm. The trust had been made aware of these issues in another services and learning had not been shared effectively enough to find the most appropriate way to handle waste and the risk associated with physical health beds in a mental health setting. Leaders at this service told us they were disappointed they had not been informed about the action taken in the other service and took steps to address the issue.

We do not always detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

The unit was spacious, clean, and bright, with large corridors and natural light entering in through big windows. The environment was free from clutter and hazards, contributing to a safe and welcoming atmosphere.

The layout of the unit enabled staff to observe all areas of the ward effectively, supported by a combination of curved mirrors and CCTV. The use of CCTV was appropriately managed and solely intended to enhance patient safety. Leaders had identified the current CCTV software required updating, and this was recorded on the service’s risk register.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency medicine, which staff checked regularly. The ward complied with guidance on eliminating mixed-sex accommodation. It consisted of 2 separate corridors. One for male patients and 1 for female patients and each corridor was accessible only via key fob. Communal areas were located between the corridors, and both male and female patients had access to their own garden and lounge spaces.

During our visit, we observed that the door to the female corridor had been left open, allowing access between the male and female areas. This was promptly addressed and secured by staff.

Staff conducted regular risk assessments of the care environment. We reviewed the most recent environmental risk assessment, which included ligature risks. The document was due for its annual review shortly after our assessment. However, we identified a concern around a patients specialist bed that presented multiple ligature anchor points. This had not been written up on the current environmental risk assessment. The patient’s bedroom was accessible to others, yet this risk had not been included in the ligature assessment. The trust had also been made aware of a recent sad death of a patient where they had utilised their physical health bed to cause harm. We raised this with service leaders, who responded immediately. The issue was rectified, staff were informed, and we confirmed that no incidents had occurred since the bed was installed. Leaders were open and transparent about the oversight and took swift action to address it.

The unit contained 1 seclusion room adjacent to a long-term segregation room. Both rooms allowed for clear observation and included toilet facilities. Staff communicated with patients through hatches located in the observation room. One patient in seclusion told us, “I get my drink and food through the hatch.” We observed both patients moving soft furnishings to sit near the hatches and engage with staff.

During our observation of the seclusion and long-term segregation areas, we noted the layout allowed patients in these rooms to hear each other. Although a visual barrier was in place to prevent them from seeing one another, the patient in seclusion was undergoing a nursing and medical review through the hatch, during which personal questions were asked. The other patient was able to hear both the questions and responses. Additionally, the patient in long-term segregation had developed a method of communicating with staff, which the patient in seclusion began to imitate, further indicating they could hear and understand the interaction.

We raised this concern with service leaders, who expressed disappointment that both hatches had been open simultaneously. They also questioned why the medical review was conducted through the hatch. The issue was addressed promptly, and we observed the next medical review was carried out through the open seclusion room door, as it was deemed safe to do so. This was a breach of regulation and we have asked the trust to provide an action plan on how they will amend this issue.

We have breached the Trust due to the lack of privacy and dignity and the Trust will provide an action plan on how they will amend this issue.

We do not always have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

During our assessment, we observed handovers between staff teams and reviewed handover documentation from previous shifts. These meetings covered each patient's needs in detail, including their condition over the past 24 hours. Although a significant amount of information was shared, it was presented in a structured manner. The nurse in charge consistently checked whether staff had any questions or feedback.

At our previous assessment, we raised concerns about inconsistent handovers, we noted a marked improvement in this area since the concerns were raised.

We also observed daily safety huddles involving service leaders, the multidisciplinary team (MDT), and the nurse in charge. These meetings included detailed discussions of each patient, with particular attention to physical health concerns. The physical health lead was present and actively involved. For example, when a patient showed signs of deteriorating health, the lead promptly coordinated appropriate support. These meetings were documented in the patients’ care records.

We saw medical staff responded promptly to a patient that had physical health issues.

Staff reported debriefs were conducted following incidents. An agency nurse told us, “I’m told when I come on the ward how the patients are, if anything has happened, and what is happening.” This staff member was able to accurately describe an incident that occurred overnight, having received the information during handover.

However, our assessment identified instances of potential harm to patients that had been overlooked by service leaders. These issues were acted upon promptly once raised. For example, the trust had previously been made aware of infection control risks associated with the introduction of replacement clinical bins in the eradication of the use of plastic bags. The trust had also been made aware of a recent sad death of a patient where they had utilised their physical health bed to cause harm. The trust had been made aware of these issues in another services and learning had not been shared effectively enough to find the most appropriate way to handle waste and the risk associated with physical health beds in a mental health setting. Leaders at this service told us they were disappointed they had not been informed about the action taken in the other service and took steps to address the issue.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

Staff adhered to infection control principles, including effective hand hygiene and compliance with the 'bare below the elbows' policy. The unit was clean, free from clutter and hazards, and well-maintained, with good-quality furnishings and no malodours.

Domestic staff were observed completing cleaning tasks throughout the day and had access to sufficient equipment to carry out their duties effectively.

The service had taken steps to reduce risks associated with plastic bags on the ward, including clinical waste bags, by replacing them with cardboard 'Bio bins'. These bins were safer and more environmentally friendly. However, we identified issues with the closing mechanism, which resulted in clinical waste being exposed to both patients and staff. One bin in use contained used incontinence products and gloves, and its contents were visible due to the faulty closure. We brought this to the attention of ward leaders, who assured us that the issue would be addressed promptly. Due to the infection control risk being present to patients and staff we have breached the Trust and have requested an action plan.

We do not always have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

During our assessment, we observed handovers between staff teams and reviewed handover documentation from previous shifts. These meetings covered each patient's needs in detail, including their condition over the past 24 hours. Although a significant amount of information was shared, it was presented in a structured manner. The nurse in charge consistently checked whether staff had any questions or feedback.

At our previous assessment, we raised concerns about inconsistent handovers, we noted a marked improvement in this area since the concerns were raised.

We also observed daily safety huddles involving service leaders, the multidisciplinary team (MDT), and the nurse in charge. These meetings included detailed discussions of each patient, with particular attention to physical health concerns. The physical health lead was present and actively involved. For example, when a patient showed signs of deteriorating health, the lead promptly coordinated appropriate support. These meetings were documented in the patients’ care records.

We saw medical staff responded promptly to a patient that had physical health issues.

Staff reported debriefs were conducted following incidents. An agency nurse told us, “I’m told when I come on the ward how the patients are, if anything has happened, and what is happening.” This staff member was able to accurately describe an incident that occurred overnight, having received the information during handover.

However, our assessment identified instances of potential harm to patients that had been overlooked by trust leaders. These issues were acted upon promptly once raised. For example, the trust had previously been made aware of infection control risks associated with the introduction of replacement clinical bins in the eradication of the use of plastic bags. The trust had also been made aware of a recent sad death of a patient where they had utilised their physical health bed to cause harm. The trust had been made aware of these issues in another services and learning had not been shared effectively enough to find the most appropriate way to handle waste and the risk associated with physical health beds in a mental health setting. Leaders at this service told us they were disappointed they had not been informed about the action taken in the other service and took steps to address the issue.