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 requires improvement. At this assessment the rating has remained as 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 did not always learn lessons from incidents, staff did not involve people to manage risks, the service did not always detect and control potential risks in the care environment, andpatients’medicines were not always appropriately prescribed,suppliedand administered.

However,the service worked withpatientsand healthcare partners toestablishand maintain safe systems of care,staff assessed and managed the risk of infection, and staffdemonstrateda strong understanding of safeguarding.

The service is in breach of regulations in relation to safe care and treatment.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The service did not consistently demonstrate a learning culture where safety was a priority for everyone, including staff and people using the service.

Staff knowledge and understanding of the Patient Safety Incident Response Framework (PSIRF) was limited. Training records showed that only 38% of staff working on the wards we visited had completed Level 1 PSIRF training. Leaders told us the training had only recently been added to the mandatory training programme and that ward managers were supporting staff to complete it.

The service shared learning from incidents with patients through community meetings. However, these meetings did not take place consistently across all wards. This limited opportunities for patients to be involved in discussions about safety, learning and improvements to care.

The service did not always learn from identified risks or previous incidents. Staff did not always recognise and address risks as opportunities to improve safety. On Redwood 2, we found concerns relating to the management of risk items that had also been identified during the previous inspection in April 2025. This indicated that the service had not fully embedded learning or sustained improvements following previous concerns.

Learning and improvement in practice in relation to food and fluid chart completion had not been fully embedded following a patient death on Beech Ward. On Fir Ward, we reviewed the care records of two patients who required staff support to monitor their food and fluid intake. Staff had not completed food and fluid monitoring charts correctly as they had not always recorded intake and had not totalled amounts consumed. This meant staff could not be assured that patients were receiving appropriate monitoring and demonstrated that opportunities to learn and improve practice following a serious incident had not been fully acted upon.

Staff told us senior leaders were not supportive of them attending reflective practice sessions. On Fir ward staff had not attended for 2 months due to staffing pressures.

We were not assured that all staff understood how to complete incident reports accurately or investigate, record and learn from incidents effectively. Staff were required to complete incident reports which ward leaders reviewed and approved. We reviewed incident records across the wards we visited. On Willows, we compared two incident reports with corresponding closed circuit television (CCTV) footage and found that the written accounts did not accurately reflect what we observed. This meant incidents were not always recorded accurately, limiting opportunities for effective learning and improvement. We raised these concerns with senior leaders, who told us they would investigate further.

The evidence showed a good standard. The service worked with people and healthcare partners toestablishand maintain safe systems of care, in which safety was managed ormonitored. They made sure there was continuity of care, including when people moved between different services.

The service prioritised continuity of care throughout patients’ care journeys. Staff followed referral and admission processes that ensured they received sufficient information to determine whether they could safely meet patients’ needs. On all wards we visited, staff gathered relevant information about patients’ histories and support needs before admission and followed the trust’s admission procedures.

The trust had introduced an electronic system, ‘SAFE Now’, to support ward management and oversight. The system alerted ward leaders to documentation that required completion, review or updating. This helped leaders maintain oversight of key admission and discharge documentation and supported continuity of care.

Staff worked with healthcare and social care partners to plan and coordinate care. They involved relevant services in discharge planning and worked with external agencies to support patients' ongoing needs. Staff and leaders understood the importance of post-discharge support and were able to describe how they worked with partner organisations to help ensure patients experienced continuity of care when they left the service.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There was a strong understanding of safeguarding and how to take appropriate action. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. We saw evidence of staff recording this in patients’ care plans and risk assessments. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

There were effective systems, processes and practices to make sure patients were protected from abuse and neglect. Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. The trust reported 33% of staff completed level 1 safeguarding training and 95% completed level 3 safeguarding training.

Staff followed safe procedures for children visiting the service. Both Sherwood Oaks and Highbury had suitable areas to facilitate visits with children.

We found blanket restrictions in place on the wards we visited but these were in accordance with health and safety and in line with restrictions required on acute wards. Staff logged and reviewed all blanket restrictions at regular intervals. Staff understood the impact blanket restrictions could have on patients. Information on restrictions for patients were available in a patient information leaflet.

Mental Capacity Act

• The trust reported 84% of staff completed training in the Mental Capacity Act.
• Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles
• The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.
• Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.
• Staff took all practical steps to enable patients to make their own decisions
• For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.
• When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.
• Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies.
• The service had arrangements to monitor adherence to the Mental Capacity Act.
• Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients were not always informed about risks and how to keep themselves safe. Patients on Fir ward did not know what a risk assessment was.

Staff did not always assess or always understand or mitigate risks on all wards. In addition, the management of risk items on some of the wards was not effective. During the inspection of Redwood 2 we checked all 16 patients’ lockers. Although staff completed inventories of risk items on the day of the inspection visit, there were items that were not recorded or missing. During the locker search we found items of risk that were not recorded, including carrier bags, vape liquid, nail clippers, lighters, vapes, cables and glass bottles. This meant that staff did not know these items were present and would not be able to risk assess patients access to them. We found 3 risk items that were recorded on the inventories but not present in the lockers, this meant there were risk items unaccounted for on the ward. We reviewed incidents reported on Redwood 2 ward for the past 3 months. There was evidence that restricted items (lighters) had been found on the ward. We found similar issues on Fir ward at Sherwood Oaks.

Staffs’ management of ligature risks were concerning. We were not assured that ligature risks had been addressed to keep patients safe. For example, we identified recent incidents of patients tying ligatures with shoe laces on Fir ward. We reviewed incidents on Fir ward for the past 16 days and found staff reported 8 incidents of self-harm, 4 of which involved the use of tying ligatures with shoe laces.

We were not assured that staff were keeping patients safe on Fir ward. We spoke with 4 patients and 3 had been able to abscond from the ward. Patients on Elm ward did not feel safe as they had seen another patient with a dinner knife on 3 separate occasions. Patients raised this with staff who did not take any action. Patients even asked the staff team during the community meeting we observed and staff did not give any assurances on how they would address their concerns. On Cedar ward we watched CCTV footage of an incident where staff stood back whilst a patient upturned tables and threw chairs around with other patients present in the room. We were not assured that staff had taken appropriate action to mitigate risks to the patient and others.

Staff did not always use restraint as a last resort and did not always follow best practice. Staff on all wards were trained in the Management of Violence and Aggression (MVA) which meant that staff were equipped with essential skills in de-escalation, personal safety and safe physical intervention. We observed CCTV footage of 2 restraint incidents, one on Willow ward and one on Elm ward. It was not evident in either incident that physical restraint was required to manage any risks. The patients were not posing any physical risk to others during these incidents. We raised this with the trust who reviewed the CCTV and confirmed that the restraint had been used was reasonable, necessary and proportionate to the risks being presented at the time. The review found that staff acted in accordance with their training.

Physical restraint should only be used as a last resort as any restraint can pose a risk to patients’ physical health. The trust reported staff physically restrained patients 154 times between 1 December 2025- 31 January 2026. Redwood 2 ward reported the most with 33. Of the 154 restraints reported, the trust advised staff restrained patients in the prone position 13 times. Cedar and Redwood 2 wards reported the highest use at 5. The trust reported the average duration of patients being restrained in the prone position was 4 seconds. The CQC expects providers to ensure staff only use prone restraint in exceptional circumstances and for the shortest time possible.

The trust reported staff secluded patients 16 times between 1 December 2025- 31 January 2026. The Willows PICU reported the most at 6. The trust reported staff administered rapid tranquillisation medicine 58 times between 1 December 2025- 31 January 2026. Redwood 2 reported the most at 10.

Staff completed risk assessments for patients in the 14 care records reviewed, however staff had not completed safety plans in 2 of the care records.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Patients were not always cared for in safe environments that were designed to meet their needs. We identified potential ligature risks on Elm ward that staff were not aware of. For example, a trailing wire in the unlocked quiet room. There were blind spots on Elm ward with a mitigation that staff would observe via CCTV, however, during our visit staff were not doing this. Staff on Fir ward were unable to locate the ward ligature risk assessment. It was found later during our visit. We escalated this concern to senior leaders as staff should have easy access to this information.

On the other wards, layouts allowed staff to observe all parts of ward. There were convex mirrors in place to make sure every area was covered. Each ward had CCTV in communal areas. Staff had easy access to alarms which they could use to summon help when required. Patients had call systems in their bed spaces and in communal bathrooms on each ward. The trust had no mixed gender acute wards or PICU’s. For the other wards that had seclusion rooms, these rooms allowed clear observation and two-way communication and had toilet facilities and a clock.

Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

There were effective arrangements to monitor the safety and upkeep of the premises. Each ward employed an ‘Environmental care co-ordinator’ and part of their role was to audit and review the wards and to report any issues. Staff completed regular risk assessments of the care environment on each ward we visited. These included ligature risk assessments. Staff identified and mitigated ligature risks adequately on most wards.

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

The trust provided vacancy rates as of the 31 December 2025. The trust reported 7% nursing vacancies across the service. The ward with the highest number of nursing vacancies was Beech ward with 19% and Redwood 2 ward reported the lowest at 6.5%. The trust reported a vacancy rate of 13% for HCAs across the service. Willows PICU reported the highest vacancy rate for HCAs at 22% and Redwood 1 ward reported the lowest at 3%. The trust reported the following vacancies for other roles; 1 part-time psychologist for Willows ward, a temporary part time psychologist vacancy on Rowan 2 ward, a part time Speech and Language Therapist (SaLT) vacancy to cover the whole service and a part time Occupational Therapy (OT) vacancy across the service. The trust reported 5% of qualified shifts were filled by bank staff and 4% by agency staff between 1 February 2025- 31 January 2026. The trust reported 23% of HCA shifts were filled by bank staff and 2% by agency staff between 1 February 2025- 31 January 2026. The trust reported 13% of shifts were unfilled between 1 February 2025- 31 January 2026.

The trust reported an average sickness rate of 7% between 1 February 2025- 31 January 2026. Elm and Rowan 2 wards reported the highest at 13%. The trust reported a turnover rate of 11% across the service between 1 February 2025- 31 January 2026.

The service did not always make sure there were enough qualified, skilled and experienced staff. Patients told us that there were more bank staff at night. One patient reported a member of bank staff had fallen asleep on their observations. Staff confirmed on Elm ward that bank staff often fall asleep when on patient observations. Local leaders used to have more autonomy over staffing levels and were able to increase staffing when required, but this changed and staffing decisions were now made by senior leaders, which could delay additional staffing being available when required. Staff told us senior managers had not responded to concerns raised about staffing. High use of bank and agency staff on some wards could impact on the safe day to day running of the ward.

During our inspection of Fir ward we found a the nursing team was a mixture of permanent staff and bank staff. The nurse in charge (NiC) did not have access to electronic care records as there was a delay getting this sorted out. This meant they did not have access to all the information about patients that would be required to keep patients safe. Staff often worked up to 14 hours without a break, this impacted on their ability to work safely. Staff on Elm ward were often moved to cover other wards, we reviewed records of this for December 2025 and noted 13 occasions when staff had been moved to cover another ward. A member of staff on Fir ward shared concerns that there were sometimes insufficient female staff to provide personal care to female patients. Another staff member on Fir ward told us about a patient banging their head out of frustration as there were not enough staff to facilitate their planned leave off the ward.

Most staff received the support they needed to deliver safe care. This included supervision, appraisal and support to develop, improve services and, where needed, professional revalidation. Between 1 February 2025- 31 January 2026., the trust reported a compliance rate of 86% for clinical supervision, 83% for management supervision and 88% for appraisals.

Most staff received training appropriate and relevant to their role. The trust reported a mandatory training compliance of 82% as of January 2026. Staff completed 25 different mandatory training courses, which included safeguarding adults and children, Hospital Life Support: 93%, Resuscitation level 1: 84%, Infection Prevention and Control (IPC): 81%, Management of Violence and Aggression: 90% and Learning disability and autism: 83% for level 1. The trust reported 2 mandatory training courses compliance to be below 75%; Learning disability and autism level 2 at 37% and PSIRF level 1 at 36%.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. All ward areas were clean, had good furnishings and were well-maintained. We saw improvements on Willows ward since our last inspection were we found maintenance issues with patients’ furniture.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. This included the clinic rooms and visiting areas.

Staff adhered to infection control principles, including handwashing. Staff were bare below the elbows when required.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff did not always follow systems to safely prescribe, administer and store medicines. Medicines administration records showed that patients generally received their medicines safely, and allergies were clearly documented. However, for one patient, the record indicated a sensitivity to a medicine that continued to be prescribed. The noted sensitivity stated that the medicine had previously caused seizures, yet clinical records did not demonstrate that this had been reviewed. In addition, the person’s care plan lacked guidance for staff on how to respond should the patient experience a seizure.

Staff did not always monitor the side effects of patients’ medicines in line with National Institute for Health and Care Excellence (NICE) guidance. Recognised side effect rating scales were used for those prescribed clozapine (an antipsychotic requiring additional blood monitoring) but these tools were not routinely used for patients taking other antipsychotic medicines. When required (PRN) medicines included clear indications and maximum doses. However, care plans lacked person centred information to guide staff when patients were prescribed more than one PRN medicine for the same indication. We observed a nurse in charge on Fir ward administer PRN medication to a patient without completing an assessment of the patient or offering any other strategies, other than medication, first.

Mental Health Act authorisation forms were available to staff when prescribing and administering medicines. When rapid tranquilisation was administered, we saw that staff had documented the rationale for this and monitoring had taken place to ensure that people were safe.

Medicines reconciliation was carried out by the pharmacy team who also provided clinical support on the wards. Staff reported a positive incident reporting culture. Medicines related incidents were reviewed in monthly medicines meetings, and learning was shared in team meetings.