Nottinghamshire Healthcare NHS Foundation Trust

Nottinghamshire Healthcare NHS Trust provides a range of inpatient and community services for people who have a learning disability or autism. These include the Orion Unit assessment and treatment service, Alexander House locked rehabilitation service, Hucknall House short break respite service, and a range of community teams.

We found that staff across the services were caring and compassionate. They worked positively with people and supported them well. In the Orion Unit, we were concerned that one person was segregated on a long-term basis, but their records did not show the reasons for this or how staff could ensure their safety and wellbeing. In addition, there were no plans in place to show staff how to support people who use the service when they became aggressive, and in turn ensure their safety and that of others. The physical health of people who used the services was also not monitored and recorded.

Alexander House had a good range of activities and used community services. However, activities and community services were limited in the Orion Unit and Hucknall House.

In all services, professionals worked together to meet the needs of people who used the services.

We saw examples of good and innovative practice being used in community services, but psychological services did not have a link to the trust board. This could mean that they were not used or given a high enough profile that would benefit people who used the service.

Staff, particularly in inpatient services, felt that learning disability and autism services were not involved and were the forgotten link in the trust.

Each inpatient service worked on their own and did not share good practice with other inpatient services.

Nottinghamshire Healthcare NHS Trust provides a specialist eating disorder service. This includes community and clinic-based treatments for adults with a severe eating disorder.

We found that the eating disorders services provided by Nottinghamshire Healthcare Trust were delivered in a safe and caring environment.

Comprehensive risk assessments, which involved the people who used the service, were completed. These included assessments of the person’s medical and psychiatric health care needs.

There were enough staff to meet the needs of the people who used these services.

Services provided were effective, and treatments were delivered in line with NICE (National Institute for Clinical Excellence) guidance. The trust measured the service’s outcomes, including gathering feedback from people who used the service.

Observations and discusions confirmed that the services provided were caring. This was supported by evidence we found in individual treatment records, as well as the trust’s and external agencies’ quality monitoring systems. We also saw good examples of individualised and person-centred care being provided.

The service responded well to people’s needs. Care and treatment records showed how the service had reviewed and amended treatments to meet people’s changing needs. During the inspection, we also reviewed some good examples of responsive and patient-centred care.

Local leadership was proactive and we saw good examples of leadership that led to effective service delivery. Staff told us that they felt well supported by their line manager.

Nottinghamshire Healthcare NHS Trust employs nearly 9,000 staff and provides a wide range of care services from many separate locations.  Despite this, the trust had a clear ‘brand’ with a set of values that was embedded and visible throughout the organisation.

We were impressed with the strong leadership from the Board, the executive team and senior managers.  There were clear lines of authority, responsibility and accountability, senior managers, the executive team and the Board demonstrated and encouraged supportive relationships, there was a culture of collective responsibility and teams had clear objectives and worked towards achieving them.  One of the vehicles to achieving this cohesion was the trust’s leadership programme that ran through all the directorates.  This encouraged staff to engage in discussions about the strategic direction of the trust and the challenges it faced. 

The trust demonstrated to us that people using services were treated with dignity, respect and compassion. The great majority of the service users and carers that we spoke with said that staff were kind and we observed many positive and respectful interactions between staff and service users.  We also saw examples across all services of the trust responding to people’s spiritual, cultural and ethnic needs; including at Rampton Hospital.

At all levels, the trust actively engaged and involved people who use services in their own care and in the development of the service itself.  With the exception of information about how to complain not being consistently provided in the Healthcare Partnerships division, the trust had mechanisms in place to hear and act on feedback from people who use services and the board itself received and monitored information from the analysis of complaints.  We were impressed by the Recovery College and the Involvement Centre; which are both national exemplars.

The trust had good systems in place to report, record and learn from incidents and ensured that this was embedded in practice at all levels across the three divisions. Staff used past incidents as a means of learning to ensure the safety of people using services. This learning was shared with all staff.

There were good and regular training opportunities (including induction and mentoring) and the content was appropriate to staff roles, responsibilities and areas of work.

The trust had clear safety related goals that the majority of staff understood and were working towards across all three divisions. There was a culture of openness and transparency and staff understood the need for investigations in order to learn from, and develop, improved practices.  The trust had identified a number of priorities in relation to safety and we concluded that they had developed after consistently reviewing data from a wide range of sources.  Despite this, we identified a number of safety concerns.  These included:

1. the presence of ligature points that might pose a risk to people who are at risk of suicide on wards at Broomhill House, Newark Community Rehabilitation Unit, Mansfield and Thorneywood Mount;
2. wards that did not adhere to national guidance on same-sex accommodation in the CAMHS Thorneywood service and in two of the acute admission wards; B2 at Bassetlaw and Orchid ward at Millbrook Mental Health Unit;
3. poor medicines management in the Children’s Development Centre at Nottingham City Hospital campus and at Bassetlaw Hospice.

Across all of the divisions we found that care provided was evidence based and followed recognised national guidance. There were good examples of positive outcomes for people using services across the divisions. This included a significant reduction in acquired avoidable pressure ulcers, where the trust exceeded its own target.

Overall, trust staff adhered to the requirements of the Mental Capacity Act 2005 to assess capacity to consent.  We visited most of the wards at each location where detained patients were being treated. In the majority of the care records we reviewed, which related to the detention, care and treatment of detained patients, the principles of the Mental Health Act (MHA) had been followed and adhered to.  The long stay wards were an exception; here we found inconsistencies in the application of the MHA and a failure to undertake risk assessments of service users given leave under Section 17 of the Act.  We also found that the trust did not have a robust system in place to ensure that patients in seclusion at Arnold Lodge had a four-hourly review by a doctor.  There were systems and procedures in place to safeguard vulnerable people and to identify, assess and manage risks. However, the divisions varied in how they fed back safeguarding concerns and the outcome of findings from investigations.

We had a number of concerns about the learning disabilities service and concluded that they did not have a high profile within the trust.  We saw examples of restrictive practices, institutional environments at Alexander House and Hucknall House and a lack of physical health checks on the Orion Unit. 

In the majority of services we visited, people did not experience long waits for assessment or treatment.  However, some service users did report difficulty accessing crisis mental health services at night.  The crisis team offered only telephone contact at night.  Those who needed immediate assessment were directed to the Emergency Department at Queen’s Medical Centre; where they might have to wait a long time to be assessed by the liaison psychiatry team.

We saw that the trust had introduced night time confinement at Rampton Hospital. We concluded that its use was in line with the Department of Health High Security Psychiatric Services (Arrangements for Safety and Security) Directions 2013 and the associated guidance.  However, some people who used the service, and some staff, were concerned about the provision of physical healthcare during night-time confinement.  During our unannounced, night time visit to Rampton Hospital we observed two patients receiving treatment through the ‘hatches’ in their bedroom doors. One was given insulin for diabetes and one was provided with stoma care. We raised this with the trust which stated that it is not normal practice to provide physical healthcare through the hatch and undertook to investigate the circumstances of the care and treatment provided on this occasion.

Across the three divisions we identified that there were some concerns about the different clinical information systems, which did not enable information to be shared effectively and at the right time. This could lead to information regarding risks not being available to all staff. We found the trust recognised the difficulties and had plans in place to improve facilities and functioning of systems.

Nottinghamshire Healthcare NHS Trust has several teams that together provide an adult community-based service:

• Newark and Sherwood Flexible Assertive Community Treatment (FACT) Team is a recovery-orientated service that provides mental health services for people in Newark and Sherwood aged 18 to 64 years.
• Rushcliffe Mental Health Team helps people aged 18 to 64 in Rushcliffe to cope with periods of mental illness and severe distress.
• Gedling Mental Health Team works with people in Gedling with a wide range of mental health difficulties, who require short-and long-term intervention.
• City Recovery Team helps people aged 18 to 64 years, who have a GP within the boundary Nottingham City Council, to cope with periods of severe mental illness and to develop recovery pathways.
• The Early Intervention Psychosis Team provides early detection, assessment and treatment of psychosis for people who show symptoms of a first episode psychosis.

We found that the adult community-based mental health services provided by Nottinghamshire Healthcare NHS Trust were delivered effectively. People told us that staff were kind and skilful in the way they dealt with them.

Staff understood the risks to the health and welfare of the people they cared for. However, we found that records were not up-to-date or regularly reviewed for risk. This meant that staff unaware of a person’s history may not have access to their current needs or risks.

Staff understood how to follow the local multi-agency policies and procedures for safeguarding adults and children. The teams we visited worked well with other teams and agencies, both in the trust and externally, such as primary and secondary healthcare.

We saw that staff were compassionate and respectful towards people who used the services. Outcomes and aims were discussed with people during their meetings, and people told us that they felt involved in making decisions about their care.

We were told that there were issues with out-of-hours care, which meant that people’s preferences for receiving care close to home were not always met. However, assessments could be made by phone, or people could have a face-to-face consultation at the Queen’s Medical Centre if needed.

People knew how to give feedback about the service.

Staff told us that they enjoyed their work and felt supported by their managers. However, some staff said that they felt detached from the wider trust issues and were not involved in meetings about its vision and values.

The Crisis Resolution Resolution/Home Treatment teams (CRHTTs) aim to provide care and treatment for people who are experiencing a severe mental health difficulty in their own home.

The CRHT services are based on two hospital sites at Millbrook Mental Health Unit and Highbury Hospital. They are purpose built facilities and provide mental health services for adults aged 18 to 65 years.

We found that the CRHT services provided by Nottinghamshire Healthcare Trust were delivered safely. Safety bulletins and good policies and procedures were available on the trust’s intranet, and staff knew how to access them. Staff also shared learning from incidents and accidents through team meetings and handovers.

People experiencing severe mental illness were treated quickly and in a professional manner. Clinicians assessed patients well and were able to offer a range of options to people being assessed.

There were good systems in place for keeping people safe and protecting them from abuse. Staff were trained in protecting vulnerable adults and children.

The service worked well with the homeless charity Framework to help people sort out their financial issues and to get accommodation.

People being treated at home could attend a range of group therapies provided by the crisis team. If they could not get to the group on their own, a member of the crisis team would help them to get there.

Crisis services were available seven days a week, 24 hours per day, however no home visits were made between 9pm and 9am.  Telephone advice and support was available to people on home treatment or experiencing a crisis.

As the service did not provide home visits after 9pm, people told us they did not always get the response they wanted. Access to mental health practitioners out of hours was through the accident and emergency department (A&E) at Queen’s Medical Centre, Nottingham University Hospital. We met with staff from the emergency department of Nottingham University Hospital and carried out a second unannounced visit on 19 May 2014. We found that people at night in the Emergency Department with a mental health crisis experienced delays with people assessed as requiring an inpatient mental health bed waiting a number of hours.  There was no data collection or detailed incident reporting on these delays.

New referrals were seen within 24 hours. The service was specifically for adults aged 18 to 65 years, but it did help older adults who were already known to them, as well as children aged 17 to 18 years old.

Staff told us they felt well-supported in their roles, and felt able to raise concerns and report incidents.

People who used the long stay services and their carers were happy with the care and treatment they received.  We observed that staff were kind and had a caring, compassionate attitude. They built positive relationships with people using the service and those close to them.

The service proactively sought feedback from people who used the service and their carers, and we found evidence that it had acted on feedback and implemented changes as a result.

We found that some requirements of the Mental Health Act were not adhered to. For example, there was no evidence to show in the care records we looked at that risk assessments had been carried out before people were granted leave under Section 17 Mental Health Act, or on their return.

Some wards at Broomhill House, Newark Community Unit, Mansfield Community Unit and Thorneywood Mount Unit had not completed an annual ligature risk assessment as per trust policy. We found ligature risks on all the wards we visited with the exception of Bracken House.

This meant that people were exposed to unacceptable and avoidable risk on these wards.

The wards had a clear pathway of care that focused on helping people to recover. The care plans we looked at also focused on people’s needs and demonstrated knowledge of current, evidence-based practice. Overall, we found that the quality of care plans was very good and some plans were outstanding.

Access to occupational therapy, psychology and consultant psychiatrists varied across the services, and was dependent on which ward people were staying on.

The service had strong governance structures in place, which were fully embedded on most of the wards. We also saw evidence of shared learning across the wards. The service was committed to improving its performance and the quality of care provided. For example, the rehabilitation wards were putting new care pathway and care plan documentation in place.  

The Forensic Service Division of Nottinghamshire Healthcare NHS Trust provides the following high, medium and low secure mental health services:

• High secure services – Rampton Hospital provides services for people who suffer from mental disorders and have dangerous, violent or criminal tendencies.
• Medium secure services – Wathwood Hospital and Arnold Lodge are purpose built medium secure facilities that provide inpatient mental health services for adults aged between 18 upwards.
• Low secure services – Wells Road Centre is an inpatient service for men and women detained under the Mental Health Act, and who have a mental illness or learning disability.
• Forensic community services – the Criminal Justice Liaison Team provides services for people with a mental illness and who come into contact with the criminal justice system. The Personality Disorder and Development Network is a community-based, group therapy service.

High secure services

During the inspection, we heard mixed views about the care and treatment at Rampton Hospital. However, we found that people who used the service viewed staff as caring, respectful and responsive. While most people accepted confinement at night and said they felt safe, some people did not like it and this was reflected in their care plans..

Some people were concerned about aspects of their care. When we brought these to the attention of the ward manager, they were already aware of the issues and told us how they were trying to resolve them.

People using the service and staff said that they felt safe, but people were worried that there were not enough staff. This had led to cancelled activities or events.

The environment was clean and welcoming, and there were systems and processes in place to monitor it. The standard of decoration was good, but some corridors needed minor repairs.

Care at the hospital met CQC national standards. There was an audit programme in place to monitor standards, and people and their carers were involved in planning and reviewing their care.

We were told, and we saw reports that showed, staff received appropriate training. This included night staff who spent time on day shifts to complete mandatory training. Most staff had received safeguarding training and were aware of the safeguarding processes. All staff said they could speak to their manager about their concerns, and said they thought these would be addressed.

Overall, the wards were well-led by the managers. However, we saw differences in how well wards were run, with some ward managers taking a stronger approach than others.

Medium secure services

The majority of services provided by the two medium secure hospitals (Wathwood Hospital and Arnold Lodge) were outstanding. However, we have rated services as ‘good’ in safety and responsiveness because there were blanket rules in place for the shop, and improvements were needed in the out-of-hours medical reviews of seclusion. This is the supervised confinement of a patient in a room, which may be locked. Its aim is to contain disturbed behaviour which is likely to cause harm to others (Code of Practice, 15.43).

Care at both sites was person-centred and was assessed, planned and delivered on an individual basis. People also had the opportunity to comment on the services, as well as have changes made. The care was recovery focused, and therapy and education were available to support this.

Staff morale was very high and the multidisciplinary teams worked well together. Staff were proud of the care they delivered. They also felt supportive of, and supported by, their colleagues, management and the trust.

The facilities were very good and were well-maintained, safe and secure.

The services were safe and effective. There were clear reporting procedures and systems in place, which enabled staff to learn from incidents

Low secure and forensic community services

Although we heard mixed views about the standard of care at Wells Road during our inspection, overall people thought it was good.

The majority of people and staff said they felt safe, and people told us about the different ways in which they were encouraged to be involved in their care. However, some said that at times there were not enough staff, and that their care and treatment were affected as a result.

Staff told us that they attended a mandatory induction programme when they started working for the trust. The majority of staff also felt that they received a good level of professional development and that training was actively encouraged.

The Rapid Response Liaison Psychiatry team is based in the Queen’s Medical Centre at Nottingham University Hospital. The team assess people who walk in to the service for help and those that are referred by the community crisis resolution services.

We found that team members were compassionate and skilful when assessing people experiencing mental health problems. They worked closely with hospital staff and were proactive in dealing with referrals, prioritising them on a need and risk basis. The team also had good risk management strategies in place to make sure people were safe.  

People’s wellbeing and safety was central to making decisions about care. The team worked closely with staff in the emergency department (ED) to manage any delays. When there were delays in transferring people to inpatient beds, facilities were used resourcefully as they are not purpose built. This was jointly managed by the team and ED staff, as they remain responsible for people while waiting on hospital premises.

Staff understood the trust’s policies and procedures for safeguarding adults and children, but had difficulty using the trust’s recording systems as both paper and electronic records were used. This made finding information about previous risks, as well as more up-to-date information, difficult and could cause delays for people being referred to the team.

We found that there was not much feedback from people using the service. This was because of the nature of the teams’ work, which was often a one-time contact when people were experiencing high levels of emotional and psychological distress. The team was working with an external organisation to address this, as they were keen to develop the service according to local need and discuss areas for improvement.

Staff told us that they enjoyed working in the service and that they felt well supported by their manager. Information including wider trust issues, as well as visions for the organisation, was regularly shared with staff in team meetings and via email.

The psychiatric intensive care units (PICUs) and health based place of safety are based on two hospital sites at Millbrook Mental Health Unit and Highbury Hospital. They provide inpatient mental health services for adults aged 18 to 65.

We found the intensive care units and place of safety service provided by Nottinghamshire Healthcare Trust provided people with a safe place to have their mental health needs assessed. There were also good systems for transferring people to the right areas for care. Staff were skilled to work with the service users and were trained to keep people safe during disturbances. The trust also ensured that they worked within the Mental Health Act Code of Practice. There were good systems in place to monitor care provided, but seclusion facilities did not protect people from the risk of infections.

People’s physical health was regularly assessed; however, we saw examples where their privacy and dignity was not always protected.

The different services involved in the place of safety, including Crisis Resolution Home Treatment teams, worked well together. Services were planned and delivered to meet the needs of vulnerable people and risk assessments were completed.

Staff understood how to follow the local multi-agency operational policy for safeguarding adults and children. This governed the use of the place of safety and the transfer of patients.

Staff told us they were well supported by their managers and regularly received supervision and appraisals.

Perinatal services provided by Nottinghamshire Healthcare Trust were delivered in a safe and caring environment. People told us that staff were kind and interacted well with them and their families. Referrals to community teams were sometimes delayed, but the team did provide a good service.

Although some of the records were not up-to-date, staff understood the risks to people’s health and welfare. Managers also had a good understanding of the service and the areas that needed more improvement.

We found that staff understood how to follow the local multi-agency policies and procedures for protecting adults and children. They worked well with other teams and agencies, both within the trust and with external organisations, such as primary and secondary healthcare. However, not all the teams were multidisciplinary. Some groups had established good links with, for example, midwives and health visitors, but there was little involvement from occupational therapy services and there were no social workers in the teams. There was little input from clinical psychologists across the inpatient and community services, and staff told us that inpatients found it difficult to access to GPs.

People on the ward and in the community were able to provide feedback on the service, and people said that they felt involved. Staff told us that they enjoyed working in the service and felt supported by their managers. However, we heard that there had been many changes in the management structure above the ward manager level and that this had been unsettling. Most staff we spoke to, however, felt that this was improving.

Nottinghamshire Healthcare Trust provides a specialist Child and Adolescent Mental Health Service (CAMHS). The service consists of community and inpatient care for young people with mental health needs. There is a 12-bedded ward for inpatient treatment, but only 10 beds were being used on the day of our inspection. The inpatient service was commissioned through NHS England.

We found that the CAMHS services were delivered in a safe and caring environment. However, the trust needs to make improvements to ensure that risks to people using the service are fully reviewed, understood and managed.

The trust provides an effective service. We saw some good examples of care, and teams working together, both in the inpatient unit and community services.

The services provided were caring. We saw good examples of individualised and person-centred care in the inpatient unit and within community services.

The services provided by the trust were responsive. We found that individual needs and wishes were met when assessing, planning and delivering care and treatment, and there was an emphasis on avoiding admission wherever possible.

These services were well-led by the trust. Most staff we spoke with felt well supported by their immediate line manager and were aware of the senior leaders within the trust. They also felt that communication from ‘board to ward and community’ was effective.

Overall, people received a good service from the adult admission wards. The service had a clear vision and staff were positive about working towards this. The quality of the service delivered was also monitored on an ongoing basis, where areas for development were identified, clear action plans were put in place and progress was monitored. Staff were generally supported in their roles and were supervised regularly. In addition, patients told us, and we observed, that staff were caring and compassionate.

There were some particular areas of good practice across the wards:

The skills of staff were being developed to meet the needs of patients. Across the wards staff were allocated link roles in specialty areas in order to support people appropriately.

The supervision structure. This helped staff to feel well supported and enabled lessons learnt to be shared.

Clear working practices across acute admission wards, and clear learning from incidents across the trust and within the adult admission service as a result.

There were good links with community care coordinators from the point of a people’s admission. Staff described working to the least restrictive practice with patients and confirmed a low use of restraint was used as a result. Sometimes this was in order to prevent people harming themselves or when treatment was being provided. This way of working underpinned the adult mental health service line’s recovery focus model. De-escalation techniques were used first with restraint used as a last resort. This practice was echoed throughout all of the adult inpatient services we visited.

However, we found that there were some areas where the service could make some improvements, including:

There were noted staffing level pressures on Redwood 1 and Redwood 2. For example on Redwood 2 there was one qualified member of staff on at night. Staff had reported challenges with this and it was felt that the cost improvement had a direct impact on these staffing pressures. We were told there had been increased staff sickness and patient complaints and a lot of pressures to complete ward related tasks on time. On Redwood 1 some staff we spoke with expressed feeling stressed on shift and felt that due to staffing level pressures on the ward this could impact on quality of time they spent with patients, and whether their leave was accommodated. We found that leave was usually accommodated however. Staff informed us that it was not always easy to fill the day shift and that a lot of ringing around was involved to get someone at short notice.

Across the adult admission wards staff confirmed that access to occupational therapy and psychology had been reduced. 

There was an air of anxiety about the potential closures of A42 and A43 wards at the Queen’s Medical Centre. The service director for these wards told us that this had not yet been confirmed, and that staff had been told about developments so far. Plans for moving services to a virtual ward in the community had been considered, but staff remained unclear where this left them in the trust.

The dispensing of medicines on Orchid Ward, Millbrook Mental Health Unit was not always carried out in line with the trust’s medicines policy.

We found there was an area where the service must make some improvements. The trust had not adhered to national guidance on gender separation at Bassetlaw hospital (B2 ward) and Millbrook Mental Health Unit (Orchid ward).        

Nottinghamshire Healthcare Mental Health services for older people provide both inpatient and community services for people over 65 with functional mental illness, and people of all ages with organic mental health illness.

These services for older people were good. They had a clear vision and staff where positive about working towards this. The quality of the service delivered was monitored on an ongoing basis using a range of measures. Where areas for development were identified, clear action plans were in place and progress monitored. Staff were supported in their roles and received regular supervision. People using the service and their carers and relatives told us, and we observed, that most staff were very caring.

We found that there were a number of areas where the service should make improvements. The medical staff felt they were not empowered and did not always have enough time for direct clinical care with people using the service. The communication between the community and inpatient teams was not always working effectively to ensure that information was shared at all times. Do not attempt resuscitation documentation was not consistent.

The Health Partnerships Division of the trust works closely with primary care services to provide community health services for Nottinghamshire and Bassetlaw. The division is a partnership model, with services in Nottinghamshire provided by County Health Partnerships, and services in Bassetlaw provided by Bassetlaw Health Partnerships. The trust delivers community services to people with long-term conditions. This included the integrated community teams, falls prevention clinics and continence clinics.

The service covers Nottingham City and Nottinghamshire with an estimated population of over 1 million people. There are a number of areas with lower than average levels of deprivation; Nottingham City is ranked 20th out of 326 local authorities.  Additionally, 24 out of 32 health indicators are significantly worse than the England average.  Services are delivered in people’s homes and from over 80 clinics across the city and county. As you would expect from a service of this size and complexity, we found some levels of inconsistency in the provision of care.

There were systems and procedures in place to safeguard vulnerable patients and to identify, assess and manage risks. However, there was no consistent system to give staff feedback or learn from safeguarding investigations. There were systems and procedures in place to safeguard vulnerable patients and to identify, assess and manage risks. However, We found some inconsistencies in the level of feedback given to staff.

There were arrangements for comprehensive assessment of patients on referral, communication among members of the multi-disciplinary team was effective and supported the planning and delivery of care. The trust was moving to a “paper light” records system, we found there could be potential risks whilst records are held in written format and electronically. Some teams reported inconsistent access to equipment.

We saw many examples of care, compassion and kindness. Patients were involved in making decisions about care and treatment, privacy and dignity was maintained although the physical layout of some clinics made this challenging. Patients were offered emotional support to enhance their care.

Services were planned and delivered around local need.  Staff were responsive and the introduction of integrated care pathways was working well. There were systems in place to receive feedback from patients. However patients were not always told how to complain if they were unhappy with the care they received.

Services were well-led. Staff were well informed, felt supported by their managers, and were engaged.