Special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust

Leadership team at Rampton

As highlighted in our section on leadership in the first part of this report, over the last 5 years there have been a lot of changes in senior leaders at NHFT. Alongside the changes at a trust wide level, the senior leadership team at Rampton Hospital has changed too. Out of the 11 senior leaders, 5 have been appointed to their roles since 2020, the others have been working at Rampton for over 5 years in various roles and grades. However, they have been employed in their current roles and grade since within the last 5 years. Five leaders started their current role in the senior leadership team in 2023; 3 in 2022, 1 in 2021 and 2 in 2020.

Although Rampton Hospital has had changes to its leadership team, NHFT told us this was to strengthen the capacity of local management and leadership at the hospital, which was required to deliver the necessary improvements. A number of senior staff have worked at the hospital for a significant period of time from 3 years to 25 years.

Linked to this and the fact that there have been repeated breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 over the last 5 years, it does raise the question of whether more support is needed to drive through the necessary improvements at Rampton Hospital.

Within the last 3 years, the trust has reviewed the governance and capacity across the forensic care group. This identified that governance of quality and processes for escalating concerns were not in place. This prevented the care group senior leadership team from effectively supporting each care unit, particularly Rampton Hospital.

As part of the trust’s review and investment into Rampton Hospital, it made changes to align the governance structures across the care group. This restructure included:

• creating an additional 8 new clinical nurse roles with responsibility for security and patient care
• introducing quality matrons who were dedicated to quality oversight
• employing a ward clerk for each ward to support with administration duties, as well as a dedicated HR lead
• introducing a dedicated recruitment lead.

Due to these changes a 12-month leadership training programme was delivered to all these staff, to support them in their new roles, working together and understanding how their roles link with the governance across the trust from ward to board.

Oversight

Following the Warning Notice we served in October 2022, NHFT set up the Rampton Improvement Group to coordinate the action plan response and monitor whether targets were being met. The group met monthly and was chaired by the deputy chief executive of the trust, and was attended by senior leadership from both the trust and the hospital.

At the point of our inspection in July 2023, we found that the necessary improvements had not been made despite the introduction of the Rampton Improvement Group. Many of the issues identified in the Warning Notice, such as staffing levels and BSL provision, were still prevalent.

Lack of staffing has been, and remains, a prominent concern at Rampton Hospital, with enforcement action taken in relation to this in 4 out of the last 5 inspections. At the inspection in July 2023, we reported that there had been times when there was a staffing deficit of between 40% to 49%. While we did not find such a large staffing deficit this time, we were concerned that governance processes and oversight of the actual required numbers of staff to meet the needs of the patients were still not fully implemented.

Since July 2023, the trust has submitted staffing situation reports to us initially on daily basis, then on a monthly basis. Looking at the data the trust has provided and evidence gathered during our initial assessment, we are not assured that leaders have recruited enough staff, with relevant qualifications, to meet patients’ needs.

As noted in our section on staffing, we continue to hear concerns from staff that there are not adequate levels of staff to operate a safe and therapeutic environment. Staff, relatives, and patients suggested wards were understaffed, with seclusion sometimes used to mitigate low staffing levels.

Short staffed on the ward again, so patients were placed in segregation for the whole day, nurses and staff have documented it as the patients having diarrhoea and sickness.

We are particularly concerned about staffing for the learning disability service. As a national service, we would expect to see a full multidisciplinary team in place to assess and meet the individual needs of the patients. However, we are not currently assured that this is case. There is only 1 occupational therapist, who works 1 day a week that is trained to carry out sensory processing assessments. This type of assessment determines how sensitive an individual is to various types of sensory information, and allows the team to plan care to meet the sensory and communication needs to of the patient.

We found that not all patients in the service had a sensory processing assessment and care plans did not reflect individuals' sensory needs. We know that the very nature of hospital environments means that they are not always suitable for the sensory needs of autistic people and people with a learning disability. The noise and bright lights of the hospital wards can cause people distress.

As highlighted in our thematic review Out of sight – Who cares? not understanding or considering the impact of the environment on people with sensory needs can lead to people expressing their distress in a way that others find challenging, and lead to staff resorting to using restrictive practices. Being placed in an inappropriate environment can be damaging and creates a pattern of distress, restraint and seclusion, which often cannot be broken.

Recruitment and retention

The senior leadership team in Rampton have recognised that recruitment and retention of staff has been a risk for a long time.

Since October 2022, the trust has reconfigured its recruitment process and reintroduced the high secure waiting payment to improve the pay offer for staff. In addition, in May 2023 the hospital appointed a dedicated head of people and culture, who has developed a workforce plan for the next 18 months with clear actions to complete in a set timescale.

The workforce plan identifies that the hospital needs to recruit the required number of staff as determined by the safer nursing care tool, which is endorsed by the National Institute of Health and Care Excellence (NICE). It is an evidence-based tool that supports organisations to determine optimal nurse staffing levels, or to deliver evidence-based workforce plans to support existing services.

Data on staff starting and leaving employment at Rampton Hospital highlight the benefits from these positive changes. Between October 2023 and January 2024 there have been 18.69 whole time equivalent qualified nurses start employment at Rampton with 12.69 whole time equivalent nurses leaving. For healthcare assistants in the same time period, there were 42 whole time equivalent starters and 8.87 whole time equivalent healthcare assistants who left.

In addition, trust-wide, sickness and turnover rates have reduced since early 2023, meaning staff have been able to deliver a higher number of care hours per patient day.

Culture

We have previously reported a culture of bullying and verbal and/or racist abuse at Rampton Hospital. While our latest review shows this has improved, it has not been eradicated, with 2 patients telling us that staff had made derogatory comments about their weight or physical health issues.

The senior leadership team has recognised that the culture in Rampton Hospital needs to be scrutinised, understood, and developed in order to not only be successful in developing the services and outcomes for patients but to bring about positive changes. In response the trust has recruited an experienced clinical psychologist, with a team of 6 psychology assistants, to carry out a review and improve the culture of the hospital.