Nottinghamshire Healthcare NHS Foundation Trust

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the hospital met people’s needs.

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

The design, layout, and furnishings of the ward did not always support patients’ treatment, privacy and dignity.

There was an inconsistent approach to Positive Behaviour Support Plans for patients on the National Learning Disability Service. There was an inconsistent approach to the provision of accessible documents and environments.

The hospital did not always meet the needs of all patients – including those with a protected characteristic. Staff did not always help patients with communication. However, patients were supported in accessing advocacy and cultural and spiritual support. The hospital treated concerns and complaints seriously, investigated them but did not always act on lessons from the result.

The hospital is in breach of legal regulations in relation to person centred care.

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 were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

During our review, we identified inconsistencies across directorates in how staff recorded patients' individual needs and preferences. Although staff demonstrated a good understanding of patients and their individual needs when speaking with us, this knowledge was not consistently reflected in the care records we reviewed. As a result, patient records did not always provide a comprehensive account of patients' needs, preferences, and the support required to meet them.

On the personality disorder directorate, staff completed care plans containing only basic information. We also had concerns about the quality and detail of Positive Behaviour Support (PBS) plans within the learning disability service.

We found that staff within this service did not consistently use PBS approaches to fully understand people with a learning disability and/or autistic people, identify the causes of their distress, or minimise restrictive practices. Some patients did not have a current PBS plan. Where plans existed, staff had not always developed them to an acceptable standard. PBS plans often lacked information from assessments of sensory needs, communication needs, functional assessments, and ongoing support requirements. Consequently, the plans did not reflect good practice guidance. Staff did not routinely analyse incidents involving individual patients through ongoing functional assessment approaches to inform future PBS plans and interventions.

During our visit to the women's service, we found that the high levels of patient observation required resulted in some ward areas feeling cramped and congested. Leaders told us they planned to begin a quality improvement programme during the summer to support a reduction in observation requirements where clinically appropriate.

In the learning disability service, we found communal areas to be echoing and noisy. The hospital had not installed sound-reducing features that could have helped minimise sensory overstimulation, particularly for patients who were sensitive to noise.

Each patient had an individual bedroom containing a fixed bed. These beds were generally standard single size. However, some patients were over six feet tall, while others required bariatric equipment. Standard-sized beds did not adequately meet these patients' needs.

Although the hospital had made efforts to provide appropriate beds, staff told us that at least two patients did not have beds suitable for their requirements. One patient chose to sleep on a mattress placed on the floor, while another slept in an incorrectly sized bed. Leaders acknowledged these concerns but stated that the patients would have continued to sleep in the same way even if larger beds had been provided.

However, during our review of patient care records, we saw examples of staff recording patients' individual needs and preferences. Staff demonstrated a good understanding of patients' needs, likes, and dislikes and discussed them knowledgeably. We also observed staff discussing patients' preferences during ward rounds and multidisciplinary team (MDT) meetings.

Within the women's service, staff completed comprehensive care plans in collaboration with patients and ensured that patients' views were included. The care plans we reviewed were underpinned by a trauma-informed approach, with clear recognition and acknowledgement of patients' trauma histories and the impact these experiences had on their wellbeing.

The hospital had set up a trauma and self-injury team (TASI) specifically for the woman’s service. Nursing staff from each ward were seconded to the TASI team and had a role in embedding the trauma informed work. They facilitated psychoeducation groups such as coping skills for patients. Groups such as the women’s education and self-help group had been running for a few years. This looked at access to menstrual/sanitary products and other issues relevant to females.

In one care record, staff demonstrated a strong understanding of how a patient's menstrual cycle and diagnosis of Premenstrual Dysphoric Disorder (PMDD) affected their mood and increased risks at certain times of the month. Staff supported the patient to maintain a mood diary, which enabled the MDT to monitor and review the relationship between the patient's menstrual cycle and mental state. The patient's responsible clinician discussed treatment options with them and prescribed medication to support the management of menstrual symptoms and low mood.

In another care record, staff clearly documented the patient's views regarding mood changes associated with their menstrual cycle, physical premenstrual symptoms, and diagnosis of PMDD. The patient actively participated in discussions about treatment with their responsible clinician, and staff implemented a menstrual mood cycle plan to support their care.

When reviewing how staff supported women with their physical health, we found that they had completed a ‘My Cervical Screening Test Passport’ with patients. This document included information about patients' communication needs, signs that they were becoming distressed, and the support they wanted before, during and after their appointment.

We also reviewed the written information provided about cervical screening. The information explained what a smear test was, described the human papillomavirus (HPV), and outlined the procedure involved. It emphasised patient choice and reassured patients that only female staff would carry out the procedure. Patients retained the right to refuse cervical screening.

Staff provided an example of how they had successfully supported a patient to attend an off-site cervical screening appointment. TASI developed a person-centred care plan to support this intervention and meet the patient's individual needs.

We reviewed the care plans of a patient who had recently undergone cervical screening. The staff team had included support measures for before, during and after the procedure. The care plans were person-centred and trauma informed. The patient's named nurse supported them throughout the intervention. Following the procedure, the patient accessed the sensory room, requested a hot drink and snack, and chose not to discuss the experience further. Staff respected the patient's wishes.

The evidence showed some shortfalls. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff and patients told us that staffing pressures continued to affect both the delivery of care and the support available to patients. We heard and observed how these pressures impacted patients and the staff caring for them. For example, cancellation of ground leave and access to fresh air. Leaders recognised these challenges and as discussed elsewhere in this report, actively explored a range of options to reduce staffing pressures. Despite these efforts, staffing shortages continued to affect the hospital's ability to consistently deliver services in line with patients' needs and preferences.

Despite these challenges, we found that staff recognised the importance of creating a sense of community for patients who could not access the wider community. Staff explained that the hospital itself formed an important community for patients. For example, patients who attended the horticulture group had grown Christmas trees for many years and, at Christmas, cut them down so that each ward could have its own hospital-grown tree. This demonstrated a meaningful effort to promote a sense of community, belonging and shared experience among patients.

We also found that the hospital sought to deliver services that reflected the needs and preferences of different patients, including those with protected characteristics under the Equality Act. Staff and leaders demonstrated an understanding of the importance of providing personalised care and maintaining patients' choice and continuity of care.

In relation to discharge planning, we were assured that patients had access to appropriate post-discharge care and support. We spoke with a patient whose discharge had been delayed due to factors outside the hospital's control. The patient told us that staff had kept them informed throughout the process and continued to provide updates on progress towards their discharge. Although the patient felt disappointed and frustrated by the delay, they said that staff had explained the reasons for the delay and kept them informed about developments.

The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

During the assessment we found inconsistencies in how staff met patients' communication needs across the hospital. While examples of good practice were evident, this approach was not applied consistently within all directorates. Patients told us that difficulties accessing interpreters sometimes resulted in missed visits and reduced opportunities to communicate effectively. They also told us about how staff trained in British sign language were also moved to other wards when required to fill staff shortages.

However, we also saw improvements in the adaptations made for deaf patients, demonstrating the hospital's commitment to improving accessibility and ensuring patients could engage with their care and treatment.

When reviewing patient care records, we saw that staff kept commissioners updated on patients' progress and care. Where appropriate, staff also kept families informed and involved in care planning. At the same time, staff respected the choices of patients who did not wish to share information with their families or carers. The hospital further supported family and carer involvement by offering dedicated carer events, providing opportunities for families and carers to hear about developments within the hospital.

We found evidence that the collection, storage, and sharing of patient information met data protection legislation requirements.

The duty under the Mental Health Act to provide patients with information about their legal position and rights was generally well met.

The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Throughout the assessment, patients shared their frustration about activities being cancelled because of staffing pressures.

Before the assessment, we had also received several complaints from patients raising similar concerns. This demonstrated that patients knew how to raise concerns and access external complaints processes. The complaints reflected patients' frustration about the impact staffing pressures were having on their daily experiences.

Leaders told us that the hospital use surveys in patient and carer experience (PACE) and that the information from surveys shapes improvements.

We saw examples of leaders listening and responding to patient feedback. In one case, staff kept a patient informed about actions taken in response to their concerns. Although the patient remained dissatisfied with the outcome, leaders carefully considered the issues raised and proactively engaged with the patient throughout the process.

We also saw evidence of staff involving patients in planning and coordinating their care to address concerns they had identified. For example, one patient found night-time confinement challenging. Staff worked collaboratively with the patient to develop a care plan that focused on managing their anxiety. The patient identified that using a particular make-up item helped them remain calm and reduced their anxiety. Staff supported the patient to access this coping strategy, alongside the use of essential oils and techniques learned through psychology sessions.

Despite these positive examples of patient involvement and responsive leadership, patients consistently told us that staffing pressures affected their ability to access planned activities. The number of complaints received before the assessment reinforced these concerns and highlighted the ongoing impact that staffing shortages were having on patients' experiences within the hospital.

The evidence showed significant shortfalls. The service did not make sure that people could access the care, support and treatment they needed when they needed it.

We were not assured that leaders had sufficiently listened to and learned from previous assessments, during which we raised concerns about the hospital's ability to meet the needs of patients with limited mobility. At the time of this assessment, some patients with mobility needs remained accommodated on wards that were not located on the ground floor.

We were also not assured that the hospital provided equitable access to care, treatment and support for people with a learning disability and autistic people. The trust had made some adaptations in some areas to meet people's sensory needs, such as sound dampening in corridors, reduced clutter, quietened alarms and adjustable lighting in one bedroom. However, it had not meaningfully adapted all relevant ward environments to meet the sensory needs of people with a learning disability and/or autistic people.

This included a ward designated for autistic patients that lacked soundproofing, adjustable lighting, such as dimmer switches and other sensory-friendly adaptations across the ward areas.

We also identified concerns regarding access to care and support for patients within the learning disability service. Because staff had not consistently completed sensory assessments, we were not assured that patients always received the care, support and treatment required to meet their individual needs.

The hospital did not consistently meet the needs of people with a learning disability and autistic people. For example, it did not always provide appropriate equipment and environmental adaptations to support sensory needs, nor did it consistently provide information in accessible formats. The hospital did not use easy-read care plans or hospital passports. Leaders told us this was due to limitations within the hospital's electronic care planning system. As a result, the hospital did not meet best practice guidance issued by NHS England or align with the expectations set out in the Right Support, Right Care, Right Culture statutory guidance.

One patient with a physical disability showed us how a lack of equipment and staff awareness meant they could not use the bathroom within their bedroom and instead had to use a communal bathroom. During periods of night-time confinement, the patient told us they had to wait until sufficient staff were available to unlock their bedroom door and escort them to the communal bathroom. Staff also had to obtain authorisation from the site manager before deviating from the prescribed confinement routine.

The patient told us they felt "discriminated against under the Equality Act 2010" and believed the adjustments made to meet their needs were unreasonable. They also described the arrangement as a risk to their mobility because they could not access their own bathroom.

We spoke with staff who questioned why the patient had not been moved to another ward that contained fully accessible bedrooms and bathrooms.

During our review, we found that staff had made some reasonable adjustments to support patients with mobility needs. For example, staff provided walking aids, wheelchairs and shower chairs where required. However, some patients continued to use en-suite facilities that had not been adapted to meet their needs. In one example, a patient who used a wheelchair could not access their own private bathroom because it was not wheelchair accessible.

We also identified concerns regarding timely access to healthcare. Although the hospital had adequate medical cover during both the day and night, one patient experienced a significant delay in receiving treatment because the hospital could not access secure transport and escorting staff in a timely manner. As a result, the patient waited more than 24 hours to attend the general hospital, where staff subsequently diagnosed a fractured wrist.

However, the hospital maintained adequate medical cover throughout the day and night, and doctors could attend wards promptly in an emergency. In addition, the hospital was located within a reasonable travelling distance of the local general hospital, helping to support access to urgent medical care when required.

The evidence showed some shortfalls. Staff and leaders did not always actively listened to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Patients did not always find their care, treatment and support accessible, timely, or fully aligned with best practice, quality standards and legal requirements, including those relating to equality and human rights. This included making reasonable adjustments for disabled people, addressing communication barriers and ensuring that premises were fully accessible.

As highlighted elsewhere in this report, some patients experienced poorer outcomes and less positive experiences because the hospital did not consistently meet all of their needs. We raised similar concerns during our previous assessment, not only in relation to patients with limited mobility but also for patients who were subject to long-term segregation.

Although the introduction of the Reducing Restrictive Practice Team had led to improvements, we remained concerned that some patients continued to experience restrictions that affected their quality of life. We found instances where patients did not have opportunities to leave their bedrooms to access fresh air or use shower facilities because of staffing pressures.

When reviewing data relating to patients in long-term segregation, we found that staff frequently recorded patients as having refused opportunities to spend time outside of segregation. However, we did not consistently see evidence that staff made further attempts later in the shift or on multiple occasions. This limited our assurance that staff had explored all reasonable opportunities to support patients to access meaningful time outside of their bedrooms.

We also remained concerned about the environment within the learning disability service. As discussed elsewhere in this report, the lack of soundproofing may have disadvantaged patients with sensory sensitivities and did not fully support the needs of people who experienced sensory processing difficulties.

As part of our assessment, we reviewed the care of a patient who had remained in long-term segregation for approximately two and a half years due to violence and aggression. The patient was mute, creating a significant barrier to communication. When we asked staff about a communication plan, they were unaware of one. Although the care plan referred to the use of emotion cards to support communication, staff told us that the patient did not consistently have access to these. We found no detailed communication plan to guide staff in supporting the patient's communication needs. Staff rotation and movement across the hospital were likely to have exacerbated this issue.

We also identified concerns about access to interpreting services. One patient who required an interpreter told us, " Interpreters are needed for visits, but they are not always booked. That means you miss a visit." The trust confirmed that 2 visits had been cancelled due to the interpreter not being given access to the hospital as they did not have the correct identification in line with high secure hospital security processes.

The arrangements used to manage staffing shortages had also affected patients' experiences. Staff told us that working on unfamiliar wards meant caring for patients they did not know well and working alongside teams with whom they had limited experience. We also found that four wards regularly closed communal lounge areas to reduce the number of staff required to observe these areas safely. This restricted patients' access to communal facilities and increased dissatisfaction among patients, who told us that these restrictions limited their ability to participate in ward activities and spend time in shared spaces.

We found some gaps in the provision of faith-based support. Although the hospital supported Muslim patients to observe religious celebrations, cultural practices and dietary requirements, at the time of our inspection the two regular Imam’s provided by the trust were unavailable to patients. However, leaders told us that a cover Iman from a local institute was established and they told us that support was uninterrupted albeit not from their regular Iman’s.

Staff received training in equality, diversity, inclusion and human rights. Training records showed that staff had achieved a completion rate of 94%.

Staff generally communicated with patients in ways that helped them understand their care and treatment. They also adapted their communication methods to meet the needs of patients who experienced communication difficulties.

We also saw improvements within the women's service, where staff had worked to ensure that patients with protected characteristics received appropriate support and consideration.

For example, staff on one ward had completed an ‘Understanding Survival Formulation Framework’ with each patient. Staff developed these frameworks collaboratively with patients and included information about difficulties they had experienced throughout their lives, including trauma, loss, bereavement, abuse and bullying. The frameworks provided comprehensive information about each patient, including protective factors, strategies they found helpful or unhelpful, and their individual needs. Staff used this information to inform care planning and support personalised care. In one patient's record, staff had developed schema cards with the patient to help them communicate their needs more effectively.

We also found that the hospital provided a fully functioning multi-faith area that was welcoming and accessible to patients of different faiths. Patients told us how the hospital supported their religious beliefs, and several described positive experiences of engaging with chaplaincy services. Patients told us that chaplains regularly visited the wards and provided valued support.

The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

At the time of our assessment, we learned that staff were supporting patients whose physical health had deteriorated to make informed decisions about their care, treatment, and future wishes, including decisions relating to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders.

We saw a positive example of person-centred care for a patient who was receiving end-of-life care. Staff and leaders listened to the patient's wishes and acted on them. The patient's family were able to visit while they were in the general hospital, and familiar staff provided consistent support throughout their care. We heard that staff also supported other patients on the ward during this difficult time, doing so with compassion, dignity, and respect.

We saw evidence that the hospital supported the wellbeing of both patients and staff following a patient's death. Staff recognised the impact such events could have on the wider hospital community and took steps to provide appropriate support.

We also reviewed the records of a recent patient death involving an individual with complex physical health needs who died following a deterioration in their health. Staff had reflected on the circumstances and shared learning with the relevant team. This learning focused on ensuring that patients' preferences and wishes are clearly identified, documented, and communicated to those involved in their care.