Nottinghamshire Healthcare NHS Foundation Trust

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

Staff demonstrated a clear understanding of the trust’s vision and values, and how these were reflected in their day-to-day work. The trust actively promoted its core values 'trust, honesty, respect, compassion, and teamwork’ through visible materials such as desktop backgrounds, staff lanyards, and posters displayed throughout the unit.

During our conversations with various staff members, we consistently observed a strong commitment to delivering high-quality, person-centred care. Staff at reception greeted patients with kindness and familiarity, whether they were arriving or leaving the ward, contributing to a welcoming and supportive environment.

The trust had recently undergone changes in senior leadership, which included restructuring how care groups were managed to align with revised strategic priorities. The unit is part of the Community Health and Specialist Services care group and works closely with the specialist community team for people with a learning disability. This collaboration supported smooth transitions for patients requiring inpatient care.

Staff had opportunities to contribute to discussions about the future direction of the service, particularly during periods of change. Leaders shared their ambition to align the unit with services for young people, with the aim of creating a comprehensive age pathway for individuals with learning disabilities.

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We do not always have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Leaders demonstrated the skills, knowledge, and experience required to perform their roles effectively. They spoke with dedication and passion about working with this patient group and clearly explained recent service developments aimed at improving patient care and treatment.

Leaders showed a strong understanding of the service they managed and were able to articulate how their teams worked collaboratively to deliver high-quality care. They appeared motivated and compassionate, particularly when discussing the needs of patients and the future direction of the service.

Throughout our assessment, leaders were visible and approachable to both staff and patients. However, senior leaders from the trust, whose offices were located nearby, were not regular visitors to the unit. Staff reported being invited to meetings held at Highbury Hospital, which shared the same site, and this was described as a way to help the service feel included. Trust leaders explained how they had implemented many options for staff engagements. However, during our assessment the staff team did not make refence to this.

We were informed of an upcoming change affecting staff at Band 8a level, a key tier of service management. Staff told us this change was announced by senior leaders without warning and no follow-up conversations had taken place to explain how the change would be implemented or its potential impact. This led to feelings of apprehension among these staff and highlighted a lack of consistent communication in relation to change management.

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 value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

The service had designated equality and diversity champions, including representatives for LGBTQIA+, Black, Asian and Minority Ethnic (BAME) groups, and broader Equality, Diversity and Inclusion (EDI). Posters were displayed in staff areas to provide accessible information and guidance on these roles.

Diversity was actively celebrated within the service, and this was reflected in how leadership addressed cultural issues among staff. Leaders expressed a strong commitment to fostering a diverse and inclusive workforce and recognised the importance of cultural awareness in delivering high-quality care.

During our assessment, we reviewed the care of a patient of African heritage. A staff member from the same cultural background spoke positively about their experience supporting the patient and highlighted the value of cultural understanding and the benefits of a diverse workforce which enhanced patient care.

We were informed of incidents involving racial abuse, which had been appropriately recorded and addressed. Staff affected by these incidents were supported by the service, and educational materials about racism were presented to patients in accessible formats. These resources reinforced the message that discriminatory behaviour was not tolerated within the unit.

We do not always have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

There was a clear framework in place to guide discussions at ward, team, and care group levels, ensuring essential information such as learning from incidents and complaints was consistently shared and reviewed. During our assessment, we observed handovers, safety huddles, and risk meetings, and reviewed previous handover documentation, which showed that key topics were discussed, and actions were recorded.

Audits were in place to support leadership oversight of the service. We were informed the unit intended to implement a system called ‘SAFE now’, which provided real-time data to enhance performance management. This system had already been adopted in other wards with reported positive outcomes. However, leaders at the unit were not yet familiar with the system or its benefits.

Although governance systems were in place, we were not assured that leaders had consistent oversight of risks within the service. For example, leaders were unaware of the risks introduced by the installation of a physical healthcare bed, and staff had not been informed of the associated ligature risks. Similarly, the replacement of plastic waste bags with cardboard bins increased infection control risks, which had not been fully recognised or addressed at the time of our assessment.

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 focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

Senior leaders demonstrated a strong commitment to the care and treatment of patients within the service. They shared examples of their vision for service development and improvement, including the involvement of patients in community-based research initiatives.

Leaders also described innovative approaches to addressing cultural issues within staff groups, such as creating safe spaces for open, non-judgemental dialogue and learning. These efforts reflected a proactive and compassionate leadership style.

However, as discussed previously in the report we found during this assessment that learning and innovation was not always consistent in terms of the infection control risks regarding the introduction of the ‘Bio bins’ on the ward. We also reported the issues around physical health beds in amental health setting without adequate ligature risk assessments in place. This showed how the trust was not always sharing learning from other incidents and assessments.