Nottinghamshire Healthcare NHS Foundation Trust

On this page

• 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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

Staff were supported after incidents and regular structured meetings for staff to discuss and focus on learning and safety issues were in place. Managers managed referrals into the service well, ensuring they knew all essential information about patients before determining if they could meet their needs effectively. Ward environments were suitable, safe and clean. Managers ensured and sufficient and suitably trained staff were in place to meet patient needs. Patients were involved in care planning, received medicines as prescribed, were able to speak with staff if needed and felt safe on the wards.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders we spoke with told us about regular structured meetings for staff to discuss and focus on learning and safety issues. This included staff meetings, daily huddle meetings and safety huddles.

Leaders were passionate about how they had implemented ways to engage staff in the focus on learning. Collaborative work with wards had produced using a ‘safety cross’ where any incidents were recorded in a visual way. This practice had been shared with other services in the trust. We were told about ‘Meaningful Mondays’ and ‘Learning Fridays’, where staff were debriefed and received support after serious incidents. Staff we spoke with told us reflective practice was offered, which gave staff a safe space to discuss incidents and possible concerns. There was evidence that changes were made as a result of learning after incidents. When reviewing patient care plans on Robin ward we saw how after a recent serious incident the team had now implemented further risk assessments for patients in bedrooms with profile beds.

The service’s referral and admission processes ensured all essential information about patients was received to determine if their needs could be met safely. Silver Birch ward which was a ward for patients living with dementia had an allocated number of beds for patients with mental health needs to combat the bed pressures in the area. Leaders had made this decision carefully and the admission protocol and criteria were in such a way that only low risk mental health patients were admitted. They carefully considered this as the ward presented with ligature risks. Patients with mental health needs we spoke with on this ward told us they understood that the other patients had more needs. They told us ‘They wonder around but I feel safe’.

Staff involved all the necessary health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Staff we spoke with told us about the continuing work they did with the local general hospital wards and with the delayed transfer of care teams. Leaders spoke with knowledge and acceptance of the pressures of bed numbers and how they worked hard to find ways to address this.

Staff had safeguarding training in place, knew how to make safeguarding referrals, and did this when appropriate. Whilst reviewing care plans on the wards we saw how safeguarding was recorded in risk assessments. We observed how safeguarding was discussed daily within multi-disciplinary team meetings and in daily demand meetings. Staff understood the complexity of how this patient group could be more vulnerable.

During our observations and conversations with staff and leaders we heard how they had learnt from previous sexual safety issues and how this was a priority for the service. They had effective processes in place to protect patients due to the mixed sex accommodation.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

Restraint, restrictive practice and blanket restrictions were reviewed regularly. Clear policies and procedures were in place.

We found on Silver Birch and Cherry wards the information for informal patients accessing leave was not clear enough for patients to understand. An informal patient who spoke with us told us ‘I’m unsure if I can leave the ward or not, do I have to ask staff permission?’. Managers actioned these concerns immediately by displaying posters explaining leave on the wards to make it more understandable.

A patient we spoke with on Robin ward told us their bathroom wasn’t big enough to fit their walking aid. They told us ‘It won’t fit, I have to use a toilet down the corridor, at night I have to use a urine bottle’. After reviewing this patient’s care plan, we saw they had support from physiotherapy and occupational therapy. However, this specific issue had not been recognised. The patient was at risk of falling in their bathroom and potentially harming themselves. After alerting leaders to this issue, they promptly actioned making the patient safe.

Staff involved patients in care plans and risk assessments. We reviewed patient care plans and found patients’ history was captured and recorded. We saw how a patient’s voice was also documented. However, a patient on Cherry ward discussed how their specialist diet wasn’t being managed well. The patient required a specialist menu to prevent becoming physically unwell. It was recorded in all care notes and the patient had many conversations with managers, dietitians and catering staff. The patient told us that even with all the involvement they were still receiving meals where they couldn’t eat due to not knowing what was in them and they were choosing not to eat due to fear of becoming unwell. The patient told us that they were not going to eat lunch as they were unsure of what was on offer. They wanted a sandwich but told us that the catering team are unable to produce a specialist sandwich for them. However, we found specialist sandwiches were being sold in the main canteen for visitors and staff. After informing leaders they assured us they were going to action this issue.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with additional communication needs. We observed positive interactions with patients on each ward we visited which showed understanding and how communication varied to suit each patient. We saw examples of appropriate signage and information sheets were on each ward. Leaders informed us on continued work in relation to the development and improvement of patient information boards.

Staff enabled patients to make advance decisions when appropriate. We saw examples of ‘do not resuscitate’ documents in patients care files.

All ward areas were clean, had good furnishings and were well-maintained. Robin ward was a newly opened ward in response to previous wards at Blossomwood being dormitories and having shared bed spaces. Robin ward was spacious with access to a communal garden, fresh air and spacious day rooms. The décor was bright, and the furniture was well maintained. Leaders told us that there was more work to be done on the central fresh air area and discussed with us how they would like patient involvement in planting flowers and painting a mural.

Staff completed regular risk assessments of the care environment including ligature risk assessments. Each ward had an environmental care co-ordinator who undertook daily checks on the care environment.

All ward layouts allowed staff to observe all parts of wards. We saw each ward we visited had curved mirrors and CCTV in communal areas including ward garden areas.

There were no potential ligature anchor points on Cherry and Robin wards. However, leaders explained that anchor points were identified on Silver Birch ward as this was a ward for patients living with dementia. Staff had mitigated the risks adequately. The decision to leave the anchor points were patient focused due to the nature of living with dementia.

The wards complied with guidance on eliminating mixed-sex accommodation. All wards we visited were mixed sex but consisted of single sex bedroom corridors and separate lounges for male and female patients. Leaders told us work was still being done to irradiate dormitories and was still placed high on their risk register.

Staff had easy access to alarms and patients had easy access to nurse call systems. Nurse call systems were placed in accessible areas. Patients told us ‘I know how to use my alarm if I need to’.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Managers had calculated the number and grade of nurses and healthcare assistants required. Each ward held ‘daily demand meetings’, where staffing, admissions or any other changes were discussed.

The ward manager could adjust staffing levels daily, dependant on patient needs.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. On Silver Birch ward we observed a high level of agency health care assistants. Staff we spoke with told us they received a good handover, so they understood the needs of each patient on the ward. We observed positive support and interactions between patients and staff on this ward. Agency staff were using patient names correctly and were kind and caring in their interactions.

Staffing levels allowed patients to have regular one-to-one time with their named nurse. Patients we spoke with told us ‘I speak to a nurse if I need to’.

There was adequate medical cover throughout the day and a doctor could attend the ward quickly in an emergency. We observed a ward round where medical staff were present. Proactive approaches where being discussed to support patients with physical health needs. Results of tests were discussed, and actions were agreed.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service.

Staff maintained equipment well and kept it clean. We observed domestic assistants on each ward we visited. Staff we spoke with told us they had all the equipment they needed to maintain a clean environment.

Cherry ward had shared bed spaces and TheNational Institute for Health Research (NIHR)recommendations state wards that have dormitory accommodation should make specific plans for the management of infection, prevention and control in these areas. We saw these dormitories had beds that were two metres apart which met NIHR recommendations. Leaders told us work was still being done to irradiate this situation and was still placed high on their risk register.

The service had responded to the risk of having plastic bags on wards, including clinical waste bags. They had been replaced with cardboard ‘Bio bins’ which were safer and better for the environment. However, there were issues with the closing mechanism which meant any clinical waste was exposed to patients and staff. The shape of the new bins could also confuse patients living with dementia as they did not look like bins. Leaders took this on board and informed us they were already aware of the bins not closing effectively and the bins were being replaced shortly.

Staff adhered to infection control principles, including handwashing and being bear below the elbows practice.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance.

We reviewed 2 out of the 4 clinic rooms at the service and found them to be clean, organised and all equipment was routinely checked.

Emergency medicines and equipment were fully stocked and regularly reviewed.

Pharmacy teams were present on the wards daily and effective communications channels were in place to raise any issues.