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 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.

Staff had all appropriate training in place and supported patients well upon admission and at discharge. Wards areas were clean and there was adequate space for therapies to take place. Patients and carers were involved in care planning and were actively encouraged to be part of wards rounds. However, we found staff did not know who their Controlled Drug Accountable Officer (CDAO) was, and an out of date poster showed it to be someone who had left a year earlier. Managers did not ensure three-monthly checks of controlled drugs were undertaken in line with the trust Medicines Management Policy and no annual controlled drugs audit. Controlled drug registers contained crossing out (which is not permitted under legislation) and some Controlled Drugs waiting for destruction were not being checked daily as per policy. We found a breach of regulation under safe care and treatment as staff did not always follow national guidance around the ordering and management of controlled drugs. We have asked the trust to produce an action plan in relation to this area.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with told us there was a 6 week wait for a speech and language therapy referral, which they thought was unacceptable given the type of service they provided.After the assessment the trust told us there were no delays in internal speech and language services, there was no evidence of detrimental impact on patients due to delays and any delays in external support were not due to the service.

Managers told us they were concerned regarding inconsistencies in pharmacy provision across the two hospices, which could cause delays in patients receiving their medication.

We saw staff worked with other agencies such as social care to ensure timely transfers and advice on complex care packages.

We were told how staff supported patients upon admission and discharge. A welcome pack of basic toiletries were provided if required along with a discharge pack of essential items. This included toilet roll, bread milk etc to last a couple of days if the patient was unable to shop or did not have timely support in the community.

Staff we spoke with told us there was a 6 week wait for a speech and language therapy referral, which they thought was unacceptable given the type of service they provided. However, when we spoke with patient’s and carers this was not an area of concern.

Managers told us they were concerned regarding inconsistencies in pharmacy provision across the two hospices, which could cause delays in patients receiving their medication.

We saw staff worked with other agencies such as social care to ensure timely transfers and advice on complex care packages.

We were told how staff supported patients upon admission and discharge. A welcome pack of basic toiletries were provided if required along with a discharge pack of essential items. This included toilet roll, bread milk etc to last a couple of days if the patient was unable to shop or did not have timely support in the community.

All staff we spoke with were able to demonstrate how they would identify and raise a safeguarding issue. They also told us how they would support the patient and family throughout the process.

We saw noticeboards that were dedicated to safeguarding on both hospice sites.

We looked at 13 patient care records and saw in 1 record staff had identified safeguarding concerns, which they had raised appropriately and sought appropriate specialist advice.

All patients and carers we spoke with told us they were actively encouraged to attend ward round meetings and felt they were always listened to. They told us there was an emphasis on acknowledging the preferences and wishes of the patient and there was a focus on medication and side effects before prescribing.

We looked at 13 patient care records, staff recorded individual specific requests, which included symptom management.

Staff completed subjective, objective, analysis and plan assessments (SOAP) which was the assessment of the patient's status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems.

We saw staff involved carers in decisions regarding care when the patient was unable to do so.

We assessed the environment at Bassetlaw and John Eastwood hospices. Both were clean and fit for purpose. Cleaning audits had been completed, and the results were displayed in communal areas.

There were adequate numbers of rooms for individual, group activities, and therapies.

There were 2 open 4 bedded single sex bay areas at John Eastwood hospice with curtains around each bed. There was no door between the bays and the corridor used by staff and visitors. This could have compromised privacy and dignity at the end of a patient’s life. After the assessment the trust told us all patients were offered a private room, if available.

Carers we spoke with said the environments were “warm and welcoming and always spotlessly clean”.

Staff we spoke with told us both hospices were often short of staff and relied upon bank staff and redistributing staff between site, to ensure patient needs were met.

Staff at Bassetlaw hospice told us they were concerned as they had recently become aware of the trusts’ intention to cease holding the contract for hospice services in Bassetlaw. They were worried about their job security.

Managers told us vacancies at both hospices had not been approved by the trust vacancy control panel. This was due to the proposed changes to the end-of-life provision and this possibly leading to a need for jobs for any displaced staff.

Medical staffing varied across both hospice sites. Senior medical cover was provided 3 days a week with no junior medical cover at Bassetlaw hospice whilst there was a senior medical cover available. There was junior medical staff available 24 hours a day, 7 days per week at John Eastwood hospice.

Patients and carers we spoke with told us the ward areas were “spotless” and the housekeeping staff were brilliant.

We saw staff adhered to infection control practices and staff adopted the trust standards for handwashing techniques.

Managers completed infection, prevention, and control audits and displayed the results in communal areas.

The service had systems for prescribing, administering, handling and storing medicines. We found that pharmacy services had already been identified as insufficient to manage the medicine optimisation risks across both hospices. The Misuse of Drugs Regulations 2001 were not being followed.

People were prescribed and administered their medicines by staff, and this was recorded on a treatment chart. People’s allergies were recorded, and medicines were prescribed with maximum doses and clear indications to respond to symptoms when required. There were mechanisms in place to allow staff to respond to minor ailments.

Although the trust had their own self-administration policy in place, we found the staff at John Eastwood hospice were using a policy from a different trust for guidance. During a review of patient notes we found one of the top concerns raised by a patient was around the ability and support to manage their medicines at home once discharged. However, this concern was not addressed during their stay at the service. After the assessment the trust told us they would ensure a more formal local standard operating procedure would be developed.

Pharmacy services were provided by four different providers across the two hospices. The pharmacy service was on the risk register following a review in April 2024 which concluded that the level of clinical pharmacy support to both hospices was minimal, not in line with the clinical pharmacy service to other parts of the organisation and insufficient to manage the risks. We were told by staff that pharmacy services continued to be complicated and confusing and sometimes led to delays in supplying medicines especially when people were discharged. A pharmacist visited both sites but when they were on annual leave there was no cover, and the service was inconsistent. At one site the pharmacy provided a stock management service but at the other site it was the responsibility of the nurses to manage the stock medicines.

Medicines were safely stored in locked cupboards or fridges within the treatment room although not all medicines were labelled appropriately if they were given to patients. i.e. inhalers. The standard operating procedure for temperature monitoring was out of date and the remote monitoring system was no longer being supported. The provider issued instructions to staff to restart manual temperature monitoring.

Prescription stationery (FP10s) was securely stored which only authorised staff could access and it was audited appropriately.

Emergency medicines to treat anaphylaxis were available and monitored on both sites. Only one site had an emergency box for the treatment of hypoglycaemia (low blood sugar) but both sites did have an injection used for treatment available. Naloxone, a drug used in an emergency to reverse the effects of too much opioid medication, was held on both sites but there was no guidance in place for staff on how to use it appropriately in end of life patients.

The supply at one site was labelled with ‘for consultant use only’ and the consultant was only available twice a week.

People receiving their medicines by injection through the skin via a syringe driver were monitored appropriately and the equipment was serviced regularly.

There was a process for medicine recalls and safety alerts within the service although it was difficult to ascertain that all the necessary actions had taken place as there was no record kept.

National Guidance for Controlled Drugs (CD) was not being followed. Staff did not know who their Controlled Drug Accountable Officer (CDAO) was, and out of date poster showed it to be someone who had left a year earlier. Managers did not ensure three-monthly checks of controlled drugs were undertaken in line with the trust Medicines Management Policy. Controlled drug registers contained crossing out (not allowed under legislation) and some Controlled Drugs waiting for destruction were not being checked daily as per policy.

Medicine reconciliation is the process where staff check that people have the correct medicines when they move between services or are admitted from home. This was not routinely audited at either hospice and while staff felt confident that the medical team are completing this in a timely way, there is no oversight of the timeliness or quality of medicines reconciliations taking place.

There was no information routinely given to people about the off-label use of medicines (when the use is not covered by the manufacturer), although staff told us they would have a discussion with patients individually if they deemed necessary.

One hospice had staff competent to administer intravenous medicines and therefore able to offer a wider range of treatments. The reference document used to ensure the correct and safe preparation and administration of these medicines was out of date and may no longer be accurate.