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 good. At this assessment the rating has changed to requires improvement: This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent. Staff did not always deliver evidence-based care and treatment, staff did not always work effectively together, staff did not always monitor outcomes, staff did not always ensure patients consented to treatment.

However, staff supported patients to live healthier lives.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Assessments were not always up-to-date and did not evidence staff understood all patient’s current needs. On Elm ward staff had not completed care plans that reflected assessed needs for 2 patients and on Willows ward staff had not completed a care plan that reflected 1 patient’s specific needs.

However, staff assessed most patients needs using a range of assessment tools to ensure their needs were reflected and understood. We reviewed care records for 14 patients and found staff assessed patients’ needs in 12 of them and kept care plans updated in 11.

The evidence showed some shortfalls. The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Patients did not always receive care, treatment and support that was evidence-based and in line with good practice standards. We reviewed care records for 3 patients with identified food allergies which catering teams were not aware of. There was no written guidance for staff to follow in relation to patients suffering an allergic reaction. Other care plans we reviewed did not always contain sufficient detail on how to support patients with physical health conditions such as diabetes or hypertension.

Patients’ nutrition and hydration needs were not always met in line with current guidance. On Fir ward we reviewed care records for 2 patients staff assessed as requiring additional food and fluid monitoring. Staff had not recorded a target input for either patient and the total inputs recorded did not match the individual inputs on the food and fluid charts.

However, the trust’s systems ensured that staff were up-to-date with national legislation, evidence-based good practice and required standards. Staff were able to describe how they used National Early Warning Signs (NEWS2) guidance, Malnutrition Universal Screening Tool (MUST) and Glasgow Antipsychotic Side-effect Scale (GASS) to monitor patients’ physical health and potential deterioration.

Mental Health Act

• The trust reported 84% of staff received training in the Mental Health Act.
• Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.
• Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.
• The provider had relevant policies and procedures that reflected the most recent guidance.
• Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.
• Patients had easy access to information about independent mental health advocacy.
• Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.
• Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.
• Staff requested an opinion from a second opinion appointed doctor when necessary.
• Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.
• The service displayed a notice to tell informal patients that they could leave the ward freely.
• Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

The evidence showed some shortfalls. The service did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Not all staff had access to the information they needed to appropriately assess, plan and deliver patient’s care, treatment and support. On the day of the inspection, the nurse in charge on Fir ward was from an agency and did not have access to the electronic patient record system. There was a delay in leaders sorting this out.

Information was not always effectively shared between teams to ensure continuity of care. Although all wards had arrangements in place to hand over information between shifts, the quality and format of handover processes varied across the wards we visited. On Rowan 1, staff completed detailed handover documentation and discussed patients’ needs, risks and recent incidents thoroughly during handovers. However, other wards within the same assessment service group did not use the same approach. This meant staff did not always receive information in a consistent format, which increased the risk of important information being missed.

However, when patients were due to move between services, all necessary staff, teams and services were involved in assessing their needs to maintain continuity of care. Staff involved community team colleagues, social work colleagues and third sector providers to support patients’ transitions between services.

The evidence showed a good standard. The service supported people to manage their health and wellbeing tomaximisetheir independence,choiceand control.The service supported people to live healthier lives and where possible,reducetheir future needs for care and support.

Patients were encouraged and supported to make healthier choices to help promote and maintain their health and wellbeing. Staff supported patients to access smoking cessation support and support from substance misuse services.

Patients were involved in regularly monitoring their health, including health assessments and checks where appropriate and necessary with health and care professionals.Staff completed and recorded regular physical health observations of patients. Leaders on Fir ward allocated a member of staff to be the physical health lead and part of this role was to ensure patients received appropriate physical health monitoring. We saw evidence in most care plans that staff had sought input from specialist healthcare professionals when required, for example to support patients with diabetes.

When receiving feedback about the food and drinks available, the patients on each site we visited said that the food was good. We saw evidence of menus which included dietary and cultural options available for patients to order. However, whilst on Willows ward a patient who was lactose intolerant was offered soya milk as an alternative, staff told us that the patient was fine with that choice, but we saw no evidence of the patient being offered lactose free milk rather than a daily free alternative.

The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

There were not always effective approaches to monitor people’s care and treatment and their outcomes. On Fir Ward, we reviewed records for a patient who required food and fluid monitoring and found that staff had not completed the documentation accurately. Staff had not totalled the patient's intake as required, which reduced their ability to effectively review the patient's needs and progress. We were not assured that leaders had effective oversight of this monitoring. Staff had not identified or addressed the recording omissions, despite the importance of accurate food and fluid monitoring for patients with eating disorders. Although we found no evidence that this had adversely affected the patient, we were concerned that staff had not applied learning from a recent serious incident elsewhere in the hospital that involved similar issues.

However, we found that staff used recognised rating scales to assess and record severity and outcomes for example, Health of the Nation Outcome Scales (HoNOS). This also included the use of Malnutrition Universal Screening Tool (MUST) and National Early Warning Score (NEWS2). All these rating scales where visible to leaders of the wards on the SAFE now system so if any patient was requiring a review or a review had been missed it was highlighted.

Both at Sherwood Oaks and Highbury the acute wards and PICU had access to 24/7 duty specialist doctors. There was also an on-call doctor arrangements for out of hours support and a doctor would attend the ward when required.

Staff used technology to support patients effectively with the use of handheld computer devices that enabled prompt access to blood test results. Staff on all wards had access to computers for easy access to patient care records.

The evidence showed some shortfalls.The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Staff did not always understand the importance of ensuring that patients fully understood what they were consenting to and the importance of obtaining consent before they delivered care or treatment. When reviewing patients medical records we saw medical staff had prescribed rapid tranquillisation for patients who had capacity to consent to treatment with no evidence that patients had consented to this form of treatment if it was required. This was raised to nursing staff on the wards. On Fir ward staff had concerns about a patient’s capacity to consent to care and treatment and an MCA assessment was advised, but staff had not completed this.

However, for other patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. We found examples of this in patient care plans and risk assessments. We also found evidence in patients ward rounds and MDT meetings. We found evidence of staff making best interest decisions in relation to medication for a patient on Fir ward. During handovers on each ward staff were made aware of any change in a patient’s capacity, this was found to be documented in care plans and patient’s daily notes.