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 stayed the same.

Staff did not consistently protect people from abuse and improper treatment. Staff did not always assess risks to people's health and safety or mitigate them where identified.

This meant some aspects of the hospital were not always safe and there was some limited assurance about safe and effective staffing levels. There was an increased risk that people were not always accessing the right care and treatment.

The hospital is in breach of legal regulations in relation to safe care and treatment, safe environments and safe management of medicines.

This service scored 39 (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 have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate or report safety events. Lessons were not always learnt to continually identify and embed good practice.

Incidents and complaints were not always appropriately investigated or reported. Staff were required to complete incident forms to record incidents, and the hospital classified activity cancellations as incidents. However, staff told us they did not always complete incident forms when activities were cancelled. As a result, leaders may not have had a full understanding of the extent of these issues. This reflected concerns we identified during previous assessments, when non-ward staff were similarly redeployed to cover staffing gaps.

The hospital did not always demonstrate that it learned lessons from concerns raised through independent reviews. Following the Secretary of State for Health and Social Care's announcement that all patients with a learning disability and autistic patients in long-term segregation would receive an independent review of their care through the Independent Care (Education) and Treatment Reviews (IC(E)TR) programme, colleagues from the CQC Mental Health Act team conducted several reviews at the hospital.

These reviews identified several concerns about patient care and treatment. We found occasions when the hospital had not fully recognised the seriousness of concerns raised and had not acted with sufficient urgency to implement changes that would improve outcomes for affected patients. For example, when CQC inspectors returned to review progress against actions agreed following an IC(E)TR, they found limited or no evidence of improvement in some cases.

Although the hospital took positive action in response to some concerns identified through IC(E)TRs, progress remained inconsistent. In some cases, the hospital did not implement actions identified through independent reviews within a reasonable timeframe, which resulted in limited improvement for the patients concerned. Consequently, we were not assured that the hospital consistently translated learning from the review process into meaningful change.

The hospital did not always learn lessons from safety incidents or complaints. Leaders told us how the service is using the Patient Safety Incident Response Framework (PSIRF) to initiate patient safety incident investigations, and after-action reviews which they told us were intended to identify learning and to ensure this is shared. We were told of learning from recent expected deaths which have been widely disseminated through the "hot topic" briefings and via the hospitals learning forum.

However, previous inspections had identified daytime confinement as a concern, patients continued to experience it. When we reviewed incident data, we found that the hospital had recorded 19 occasions of early confinement since our last assessment in March 2025. However, we saw evidence that staff had appropriately documented and escalated the rationale for these decisions.

Daytime confinement meant patients were confined to their bedrooms outside their routine overnight confinement period. As a result, patients could not always access fresh air, communal areas, or opportunities to socialise with others. Depending on the timing of the confinement, patients sometimes received meals and medication through the hatch in their bedroom door. The hospital told us it made these decisions only after exhausting all other options.

During this assessment, we met with the site management team, which oversaw the hospital's day-to-day operations. The team managed staff deployment, monitored staff sickness levels, and coordinated responses to emergencies and incidents. Team members explained how they made strategic decisions when staffing levels were low and described the escalation process they used when considering patient confinement. These arrangements represented an improvement on those we found during our assessment in June 2023.

During our assessment in June 2023, we found that daytime confinement occurred regularly and affected most wards across the hospital. Since then, senior leaders had strengthened escalation processes and improved the decision-making framework used when considering patient confinement, recognising the negative impact that confinement could have on patients.

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

Following our assessment in June 2023, we took enforcement action against the hospital and imposed a restriction on admissions. The hospital responded to CQC action by improving its admission review and management processes to ensure it better considered the needs of patients, wards and staff. However, we found that one person had been assessed as suitable for admission to a ward. The plan was the patient to be nursed in seclusion to manage risk and then when safe to do so more to the ITA. However, the ITA was not ready due to delays in remedial work taking place. We were concerned that this prolonged the patients time in seclusion and prevented them from moving forward with their identified plan of care.

We removed the admission restriction in January 2025 because we were assured that the hospital had significantly improved its systems and processes.

The hospital accepted admissions from prisons, courts, general mental health hospitals, and other medium or low secure hospitals. Patients stayed at the hospital for an average of five years, although some remained longer depending on the section of the Mental Health Act under which they were detained. The hospital used a comprehensive admission process that involved multidisciplinary decision-making and multiple levels of review and oversight. This process helped staff manage admissions safely and effectively.

During their stay, patients sometimes moved between wards. Patients told us staff managed these transitions well. Staff transferred care plans, risk assessments and other key information with the patients. This enabled staff on receiving wards to access information immediately and reduced delays in care.

Staff working on the mental health intensive care ward told us that admissions tended to be complex. However, they described improvements leaders had made to reduce restrictive practices at the point of admission. Staff explained that patients had previously entered long-term segregation (LTS) more frequently on admission, but leaders had actively worked to reduce this practice.

Within the learning disability service, we reviewed the admission of a patient who joined the hospital in January 2026. We examined the admission documentation, care plans and risk assessments available to staff and found them detailed and comprehensive. Records showed that staff involved relevant health and social care professionals throughout the admission process to support continuity of safe care.

We also heard examples from other wards about recent patient discharges and how staff worked with external hospitals to maintain continuity of care following discharge.

Leaders described several recent discharges and explained how they had successfully supported patients to move directly from the hospital into community-based settings. Ward staff told us they aimed to maintain contact with patients after discharge to monitor their progress and wellbeing.

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. The service shared concerns quickly and appropriately.

Staff at the hospital were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. We found that 83% of staff were trained to Level 1 in both safeguarding adults and children, and 96% of staff were trained in safeguarding children.

When speaking with staff, they were able to discuss and provide examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff were also able to explain the security restrictions in place due to the nature of the hospital.

Due to the location and nature of the hospital, patients can access ‘Purple Visits’. Purple Visits is a secure, monitored video-calling system that ensures only approved visitors can participate in calls. Staff provided examples of occasions where calls had been cancelled when an unapproved individual joined the call.

Patients have access to social workers based at the hospital, providing an additional level of safeguarding support and oversight.

When reviewing patients' care plans, we saw how the hospital documented safeguarding concerns and how these were discussed during patient ward rounds and multidisciplinary team (MDT) meetings.

Mental Capacity Act

The trust reported 88% of staff had training in the Mental Capacity Act.

Staff we spoke to 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. We saw evidence of this in patients care plans.

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. We saw evidence where these discussions happened in MDT meetings and ward rounds. Staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The hospital had arrangements to monitor adherence to the Mental Capacity Act. We reviewed audits which regularly take place. At the time of our assessment there were no or overdue actions resulting in recent audits.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We were not assured that the hospital consistently worked with patients to understand and manage risk. Throughout the assessment, we found examples where the hospital adopted a risk-averse approach and did not always consider, document or clearly explain the rationale for decisions that restricted patients' choices.

During our visit to the women's service, we found a blanket restriction across all wards that prevented female patients from having sanitary bins in their en-suite bathrooms. Staff had not documented a rationale for this restriction in patients' care plans and had not completed individual risk assessments to justify it. Ward staff told us that some patients could safely have sanitary bins in their en-suite facilities, but they understood that hospital policy required the restriction.

One patient told us that after an incident involving their hearing aids staff had not returned them. Staff managed access to certain personal items due to the patient’s risk. However, the patient was not clear on these plans or given timescales when they hearing aids would be returned to them or replaced.

Patients also raised concerns about restrictions associated with the high-secure environment. However, Staff took action to ensure that patients could have access to restricted items when individual risk assessments indicated it was safe to do so. For example, hair pieces to promote people’s personal choice and individuality. However, staff did not complete these risk assessments in a timely way. The initial concerns from there patients were raised during a MHA visit on 26 November 2026. Staff did not complete the individual risk assessments and allow patients to have their pieces in their rooms at night until after the inspection.

During our assessment, we reviewed 55 care plans and associated risk assessments. Staff completed and regularly updated detailed forensic risk assessments for people with a learning disability and autistic people. However, on other wards, some risk assessments addressed only basic risks and lacked sufficient detail.

Most patients told us that staff involved them in developing their care plans. However, a small number of patients told us that staff had not involved them in this process.

Between January 2026 and March 2026, staff recorded 75 episodes of seclusion and 37 episodes of long-term segregation. These interventions appeared proportionate to the level of risk presented by patients. However, we did find an incident were a patient needed to be secluded had to be escorted, under restraint to another ward’s seclusion room as the seclusion room on their ward was occupied.

Despite these concerns, we found evidence of improvement in the support provided to patients subject to restrictive interventions. Since our last assessment, the hospital had introduced a Reducing Restrictive Practice Team. The team worked directly with patients in long-term segregation and supported ward staff to deliver specialist interventions.

During this assessment, we saw evidence that the team had successfully supported some patients with a learning disability who were in long-term segregation. Their work had reduced the amount of time some patients spent in long-term segregation and promoted more therapeutic approaches to care.

We scored the service as 2. 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.

We were not assured that the hospital maintained all areas of the environment to a standard that consistently supported patient safety.

Whilst the trust had taken action to address some of potholes and uneven kerbs that had been identified in our inspection in March 2025, some still remained as did the risk to patients and staff.

During the assessment we raised concerns that as Aldwick ward was the only ward operating within ward blocks A and B and that this could delay patients receiving support from other wards in an emergency. Leaders reassured us that this was not the case. The trust provided evidence that sufficient staff had responded to incidents on Aldwick ward.

We also found that some bedrooms on Adwick Ward did not have en-suite facilities, unlike most other patient rooms across the hospital. Adwick Ward operated as an admissions ward, and many patients were subject to long-term segregation to maintain their own safety and that of others. As a result, 3 patients did not have direct access to a shower in their room. The trust told us following the inspection that they ensured that patients were not delayed in accessing a shower in the mornings, the Reducing Restrictive Practice team (RRP) prioritise supporting the ward patients to access the shared shower on the ward from 0830hrs each morning.

Patients also raised concerns about the condition of the ward environment. Patients told us the wards were often uncomfortable because of temperature fluctuations and described conditions as "either hot or cold". Patients on other mental health wards raised similar concerns. On Hambleton Ward, patients showed us areas of the ward garden where water leaking from the roof had damaged the walls.

Although staff completed regular environmental risk assessments, they told us that maintenance processes could sometimes be slow. Leaders assured us that staff addressed issues posing an immediate risk promptly.

Despite these concerns, we found that staff had implemented a range of measures to support safety across the hospital. There were no wards that offered mixed-sex accommodation. The women's service operated separately from the other directorates and had access to its own outdoor space and therapy activity centre. Patients within the women's directorate could also access additional activity areas that staff booked exclusively for their use.

All staff carried personal alarms, and patients had easy access to call systems. The hospital had implemented adjustments for deaf patients to ensure they were aware when alarms activated on the ward. The hospital employed deaf staff to work specifically with deaf patients on Grampian Ward. Their alarm systems vibrated rather than emitted a sound to alert staff when an alarm activated. Each ward also had a radio system that enabled communication across all areas of the hospital.

We checked three clinic rooms and found them fully equipped with accessible resuscitation equipment and emergency drugs, which staff checked regularly.

Each ward had a seclusion room. We found that all seclusion rooms allowed clear observation, provided two-way communication, and contained toilet facilities and a clock.

As we visited every ward and all patient-facing areas across the hospital, we were able to assess each environment. The hospital comprised buildings of varying ages. The newer facilities housed the Personality Disorder and National Deaf Services, the Women's Service, and the National Learning Disability Service. The Mental Health Directorate occupied the oldest buildings.

Apart from Cambridge Ward, which had recently undergone refurbishment and redecoration, the wards within the Mental Health Directorate appeared dated. The wards had windows fitted with restrictors that allowed them to open only slightly. The layout and design of these wards also presented challenges for observation. Some wards contained long corridors, which increased the distance staff needed to travel to reach patients during an emergency. Leaders had mitigated these risks by ensuring staff could observe all ward areas and by installing mirrors to reduce blind spots.

We toured all off-ward activity areas, including the gym, swimming pool, horticulture area, woodwork workshop and library. Each area had local processes in place to promote patient safety. Staff clearly explained how they managed tools and equipment within higher-risk environments. We observed a balanced approach that maintained security while recognising that patients' needs and risk levels could change over time.

Because of its secure nature, the hospital had robust systems in place to ensure patients remained within the appropriate environment for their safety. Clear protocols governed situations where patients needed to leave the hospital, such as attending a general hospital for treatment.

The hospital also operated its own physical healthcare department. It maintained specialist equipment to support the monitoring and treatment of patients' health needs, including dental chairs and associated equipment. Local protocols supported the safe delivery of care and protected both staff and patients.

Staff told us that they contacted the security team directly if they identified concerns relating to security arrangements.

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

We remained concerned that persistent staffing shortages, the routine redeployment of staff and limited uptake of specialist training reduced continuity of care. Due to staff not all having the specialist knowledge required they could not meet their individual needs safely and effectively.

In previous assessments, we raised concerns about the hospital's ability to provide safe and effective staffing. Although leaders had taken steps to address these issues, concerns remained. During the assessment, we reviewed staffing data after hearing from both staff and patients that staffing shortages continued to negatively affect patients' experiences of the hospital.

At the time of assessment, the overall vacancy rate stood at 7.95%. Ward-based vacancies, including qualified and unqualified posts, accounted for the largest proportion of vacancies, with 43 posts vacant. Management vacancies accounted for 24.7% of all vacancies and included social work, psychology, administration and management roles. Vacancies within Therapies and Education Services (TES) accounted for 22.3% of the total.

As of 31 March 2026, the Nursing Pathways had 35 healthcare assistant vacancies. Although four successful candidates started in April 2026 and 19 candidates had accepted employment offers, the hospital still needed to recruit a further 12 staff. The hospital also had nine Band 5 and Band 6 nursing vacancies. Recruiters actively recruited to five of these posts and continued efforts to fill the remaining vacancies. Leaders also recruited an additional six nurses to account for anticipated turnover during the remainder of the year.

Staff and patients told us that staffing shortages continued to affect care delivery. Between 1 January 2026 and 29 April 2026, the hospital recorded 4,499 incidents. Of these, 364 related to red flag staffing events, including 303 cancelled therapy sessions. This meant staff cancelled 303 therapy sessions during a 119-day period because of staffing pressures.

During the assessment, staff from the TES and Active Lifestyles teams described how managers had redeployed them for many months to cover ward staffing shortages. They told us these redeployments frequently resulted in cancelled patient sessions. Staff described feeling "broken" and "demotivated" and reported that managers regularly expected them to undertake duties outside their contracted roles. Although the hospital employed these staff to provide specialist therapeutic and recreational interventions, managers routinely used them to provide ward cover, support observations and monitor patients in seclusion or long-term segregation.

Managers also routinely redeployed ward-based staff. Staff told us they were frequently moved away from patients they knew to work on unfamiliar wards and services. They explained that this created challenges because they often lacked knowledge of patients' presentation, risks and support needs.

We observed movement sheets displayed at ward entrances that site managers used to notify staff of redeployments. Staff told us that uncertainty about where they would work at the start of each shift caused anxiety. Although they understood that redeployments aimed to maintain safety, they felt the practice had become routine rather than exceptional and had seen little evidence of improvement.

We were concerned that the frequent redeployment of ward staff and extensive use of non-ward staff reduced continuity of care. This increased the risk that patients received support from staff who lacked the knowledge, skills or experience required to meet their needs. Although TES and Active Lifestyles staff completed mandatory training, this provided only broad knowledge and included awareness-level training in learning disabilities and autism.

One patient told us that unfamiliar staff made them feel "more anxious". The patient used a traffic-light flashcard system to communicate their emotional state and indicate when they were at risk of self-harm. The multidisciplinary team had developed this approach to support communication and ensure staff responded appropriately. The patient described an occasion when an unfamiliar staff member escorted them off the ward but did not understand the flashcard system. Another staff member reportedly commented, "That's one of the problems we have when we don't always have a member of staff on shift who has that knowledge and doesn't hand it over."

The hospital provided three national services: the National Deaf Service, the National Women's Service and the National Learning Disability Service. We therefore expected staff working within these services to receive specialist training relevant to the needs of the patient groups they supported.

Although ward leaders had significantly increased access to British Sign Language training following the Section 48 review, and patients provided positive feedback about improvements in communication, we were not assured that sufficient numbers of staff within the other national services had received specialist training.

The trust told us it had adopted Oliver McGowan training as its preferred model for meeting the requirements of the Code of Practice. However, only 25% of relevant staff had completed Tier 1 Oliver McGowan training and only 28% had completed Tier 2 training. Within the learning disability service, Tier 2 compliance reduced further to 11.8%.

The trust also acknowledged that it had no formal process for assessing competence following training. We found that implementation of the Oliver McGowan Code of Practice remained slow and did not assure us that staff would receive appropriate training within a timeframe that met the needs of this complex patient group.

At the time of our assessment, 191 staff worked within the National Learning Disability Service. We found that staff did not routinely access training identified as best practice for supporting people with a learning disability and autistic people.

During our assessment of the Women's Service, we observed information promoting Trauma-Informed Care. Leaders recognised the importance of this approach and told us that the Trauma and Self-Injury Service had delivered training since 2007. However, leaders acknowledged that workforce pressures had limited delivery of the full two-day training programme in recent years.

Leaders acknowledged that staffing levels were not correct after conducting a review of the established staffing figures, which recommended a uplift of 17.7 WTE posts. Despite this, staff consistently identified insufficient staffing as the primary operational challenge affecting the hospital.

We found that the hospital maintained a consistent framework for supervision, appraisal and team meetings across directorates. However, staff told us that managers often delivered supervision informally because redeployments and staffing pressures made regular planned sessions difficult. Although leaders recognised the importance of supervision and appraisal, they often relied on ad hoc meetings to maintain staff engagement.

Some directorates offered weekly reflective practice sessions, which staff valued. However, patients told us that staff sometimes asked them to remain in their bedrooms to allow staff to attend reflective practice sessions or meetings. We had previously raised concerns about this practice with leaders. During this assessment, patients told us that staff also asked them to remain in their rooms during medication rounds and periods of staffing pressure. Although leaders told us patients understood the arrangements and could leave their rooms if they wished, we remained concerned about the impact of these practices on patients' freedom of movement.

Despite these concerns, we found evidence that leaders understood the staffing challenges facing the hospital and had taken steps to address them. Leaders described several initiatives introduced over the previous 12 months, including wellbeing programmes, enhanced support for staff returning from sickness absence and education programmes to improve understanding of the impact of short-term sickness absence.

Leaders also planned to introduce a peripatetic team to respond to staffing shortfalls. However, ward and site managers told us they had not heard about these plans, which further raised questions about internal communication.

Leaders identified sickness absence, increased patient acuity, enhanced observation requirements and high numbers of escorts for off-site leave as the main contributors to staffing pressures. Trust Board records showed that leaders had recognised these issues and reported ongoing work to address them.

Senior leaders launched a quality improvement project to strengthen sickness absence management and introduced dedicated employee-relations support and sickness absence clinics. Although leaders acknowledged that further work was required to meet the Trust's 5% sickness absence target, sickness absence had reduced from 10% to 8.5%.

Leaders also completed a review of ward establishments, which identified increasing patient acuity and dependency as key pressures on staffing levels. In response, they introduced the Dynamic Environmental Risk Management project to reduce reliance on enhanced observations and identified a requirement to recruit an additional 17.7 whole-time equivalent staff to the peripatetic workforce.

We reviewed Person in a Position of Trust (PiPoT) referral data. Between April 2025 and the date of assessment, the hospital made 330 referrals and concluded 305 cases with no further action required. We were assured that managers addressed concerns regarding staff conduct and performance appropriately and without unnecessary delay.

The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

On Coral Ward in the Women's service, we found a toilet seat in a patient's shower room covered in dried faeces. Staff told us the area was awaiting a deep clean. We were concerned that the delay compromised the patient's privacy, dignity and wellbeing. We raised the issue with leaders, who told us it related to an ongoing incident involving the patient. However, we were not assured that staff had implemented appropriate cleaning and infection prevention and control measures promptly.

We also identified concerns about the management of sanitary waste within the Women's service. Patients did not have access to individual sanitary bins in their bathrooms. As a result, they had to place used sanitary products in paper bags, carry them across the ward and hand them to staff for disposal. This practice compromised patients' privacy and dignity and created a potential infection prevention and control risk.

During our visit to the Personality Disorder Service, two patients raised concerns about the condition of Hambleton Ward. They showed us an area of the ward corridor where water leaked through the roof onto the floor, leaving visible staining. This did not demonstrate that the environment was maintained to an appropriate standard.

Despite these concerns, we found that most wards were clean and well maintained. We observed domestic staff working across all wards we visited, and staff told us they followed cleaning schedules during every shift, including overnight shifts. We also found that staff maintained equipment appropriately across the hospital.

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

In previous assessments, we raised concerns about medicines management at Rampton Hospital. During this assessment, we identified further concerns and were not assured that staff always managed medicines safely and effectively.

We found that staff did not always follow medicine management processes consistently. For example, we found one emergency bag that staff had not sealed and had not checked since 5 April 2026. Staff could not clearly explain who was responsible for calibrating blood glucose monitoring equipment, and we saw no documentation to demonstrate that staff had completed these checks. Staff completed clinic room checks inconsistently across the wards we visited. One ward used a Trust-issued checklist detailing required checks, such as cleaning logs, while other wards did not. Staff also did not consistently record the date on which medicines were opened, which meant we could not always be assured that medicines remained fit for use.

We found that records did not always document the rationale for administering sedative medicines and staff did not always have protocols to guide decisions about when to administer them.

Care plans were not always in place for medicines that required enhanced monitoring, including medicines used to treat seizures and antipsychotic medicines that required regular blood level monitoring. Although some patients had care plans in place for medicines associated with constipation and bowel obstruction, staff did not always complete daily bowel monitoring. Staff also did not always measure blood glucose levels in line with individual care plans.

When we reviewed Mental Health Act documentation, these forms did not always accurately reflect current prescriptions. A Trust-wide consent to treatment audit completed in July 2025 reported compliance of 94% against a target of 100%.

We also found that staff were not aware that medicines prescribed for physical health conditions could not be administered through an enteral feeding tube under Section 63 of the Mental Health Act without the patient's consent. Medical staff clarified this requirement immediately during the assessment and confirmed that staff would seek patient consent before administering these medicines via enteral feeding tubes.

We were not assured that all patients prescribed high-dose antipsychotic therapy (HDAT) received appropriate annual reviews. A June 2023 HDAT audit found that 20% of inpatients had not received an annual treatment review. Although the Medicines Optimisation Group had started developing an electronic system to improve monitoring and oversight, we did not receive assurance that all patients prescribed HDAT had received the required annual review. Given the increased risk of physical health complications associated with HDAT, this raised concerns about oversight and monitoring arrangements.

During our visit, we observed staff experiencing problems when administering depot injections because needles became detached from syringes during administration. This resulted in patients not receiving the full prescribed dose and increased the risk of sharps injuries. The Trust recorded seven similar incidents between April 2025 and January 2026. Although the Trust issued an urgent safety notice in February 2026 to remove affected needles from circulation, we found that this risk remained present.

We also identified governance concerns within medicines management. Each care group operated a Medicines Optimisation Group, overseen by the Trust Medicines Optimisation Group (TMOG). However, the trust identified challenges in maintaining quoracy at forensic medicines optimisation (FMOG) monthly meetings. In the interim, appropriate oversight had been maintained by ensuring that reports continue to be reviewed and discussed at TMOG, providing ongoing governance and assurance.

Staff regularly reviewed patients' medicines as part of multidisciplinary team meetings and provided medicine information in easy-read formats where required. However, pharmacists could not always attend these meetings because of staffing pressures, and pharmacy staff told us they were often only able to undertake core functions.

We found that the hospital had established decision-making processes to prevent staff from controlling patients' behaviour through excessive or inappropriate use of medicines. We did not identify any inappropriate use of rapid tranquillisation (RT) and found that staff appropriately monitored patients following administration.

Audit data showed that the use of rapid tranquillisation had reduced significantly over the previous 12 months, from 107 episodes in May 2025 to 29 episodes in April 2026. Use remained highest within the Women's Service and the intensive care setting. Staff demonstrated awareness of the principles of STOMP (Stopping the Over-Medication of People with a Learning Disability, Autism or Both) and incorporated these principles into practice.

We found examples of effective medicines review processes and a significant reduction in the use of rapid tranquillisation, weaknesses in record-keeping, monitoring, consent processes, governance arrangements and medicines administration meant we were not assured that medicines management consistently operated safely across the hospital.