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

Safe systems and pathways were not always in place for patients using the local community mental health teams. We found a breach in regulation under safe care and treatment. We have asked the trust for an action plan to improve access to services for patients from all parts of the community. Patients felt challenges when accessing specialist services due to long waiting lists. Staff felt they were unable to meet patient needs due to these long waiting lists and were frustrated by not being able to meet the patient's needs. Partners told us certain patients found it difficult to access local mental health teams due to the requirements of an address and GP referral when accessing the service. We found effective processes for safe transfers were not in place and patients requiring specialist services did not have access to them in a timely manner. We found a breach in regulation under good governance. We have asked the trust for an action plan to improve waiting lists patients, to ensure patients have access to specialist treatment in a timely manner. There was no clinical strategy in place for teams to support patients who were unable to access these specialist services which left both patients and staff at risk. We found a breach in regulation under good governance. We have asked to trust to implement an effective clinical strategy to ensure services provided meet patients needs. We found the environment in the City North hub was not suitable for wheelchair access and did not offer patients basic facilities of drinking water and there was inadequate space with the waiting area. We found a breach in regulation under safe environments. We have asked the trust to ensure all hubs are accessible for patients using a wheelchair.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

Patients told us that the support they get from the teams was good. They told us how the team checked up with them regularly. When referring patients to other services patients told us this was not always good. A patient said they faced challenges getting support from a specialist service. The team had correctly referred the patient to the service. However, this referral was not accepted, and the patient told us “I was made to feel like I was helpless”. The patient was not aware of why and this had occurred before, this left the patient at risk.

Staff understood their responsibilities in how and when they should refer patients to other services. They told us they were frustrated about delays in transfers due to long waiting lists to those services. They felt frustrated when patients were not accepted without clear clinical reasons and with no support on how they proceed with the patient. Staff told us that they felt they were not always able to support their patients fully due to this. They had correctly identified what patients needed but couldn’t provide it due to these limitations.

Partners told us staff teams worked hard to reach hard to reach communities and patients by having posts within different locations including substance misuse services and hostels. However, local mental health teams were difficult to access for some community members, including patients that were homeless. The service required a GP referral, an address where they could send confirmation of a referral, and a phone number where they could make calls to those on a waiting list to complete safe and well checks. This was something that not all patients requiring the service would have access to. The service had attempted to address this through having community psychiatric nurses attend appointments at hostels. However, these community nurses did not always work with the hostel staff around providing advice on supporting patients and just came to see the patients at the location. Partners found as Nottinghamshire Healthcare NHS Foundation Trust was such a large organisation, staff often failed to identify services that were external to them and that they could refer out to. Partners recognised that the trust were trialling new initiatives with the voluntary sector as this is something they have recognised as an area they can improve on.

Processes in place for safe transfers of care were not always effective. Patients had experienced delays in transfer to specialist services due to either waiting lists or not meeting the criteria for the service. We reviewed the waiting list for the step 4 programme for psychology and the waiting time for an assessment at the time of the CQC onsite assessment was on average 10 weeks and for treatment on the programme on average the waiting time was 33 weeks. We found staff were referring appropriately to services but were frustrated at the amount of time patients had to wait to access the service. There was no clear clinical strategy in place for the teams to support patients who were unable to access these specialist services which left both patients and staff at risk. We observed a phone call with the service and a family member who had concerns about their loved one. Before the call the qualified staff member reviewed the patients care notes and saw that the patient had been referred to the service in April 2024 and had not received their assessment. The assessment was booked in for September 2024 due to availability of medical staff. During the phone call it was apparent that the patient was at high risk of harm. Action was taken immediately for an assessment to happen that day. Leaders told us the long wait time was a mistake and appointments were available within 4 weeks. It was not clear why this had happened on that occasion.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Patients told us that the environment at Lavender house made them feel welcome. Patients told us the access to Lavender house was fine and accessible. Patients had told staff there was no water at the City North hub and went to sessions desperate for a drink due to side effects from their medicine.

Staff told us there was no water facilities available for patients waiting at City North. We were told side effects of some medication that patients were on would be a dry mouth and the patients had no way to relieve this side effect whilst waiting and would attend sessions already in distress due to this. Staff told us they had brought this to the attention of leaders, but no action was taken. Staff told us the reception area at City North was too small and ‘very poor’. Patients would have to wait outside if there was no room inside, there was covering available if there was bad weather. Staff told us they had had to pick up a patient’s wheelchair so they could get over the threshold at City North as the door entrance was not adhering to regulations to allow wheelchair access.

The reception area at City North was small, it had only 4 chairs for patients to sit in that allowed no space between people. A chair was used to keep the door to reception open. No water facilities were available for patients. We observed a nurse ask for a plastic cup as a patient was distressed in reception and needed water. The reception areas of the other services we visited had accessible areas, open spaces with plenty of seating areas, and drinking water available. The waiting area for City Central had different types of chairs to suit patient needs. The area had a sound cancelling ceiling which helped reduce noise. Two out the 4 services had a quiet space in their waiting area for patients who were autistic or required a quiet area.

Three out of the 4 services visited had adequate safe environments, they were spacious, user friendly and posed no risks for patients. However, City North service was not accessible for patient using a wheelchair and included an outside door that opened outwards presenting difficulties for patients in wheelchairs. The City North hub consisted of 2 buildings and the ramp and entrance to the other service building again was not accessible for patients using wheelchairs.

Patients told us that they had no concerns over staffing and appointments happened without cancellations. Patients told us staff were “Really knowledgeable and helped me to understand what I’m going through”.

Staff told us that staffing was tight and a struggle with the number of staff available. They told us how many of their colleagues were leaving and the impact this had on them. They told us they were not clear if the roles becoming vacant were going to be filled. Leaders told us that recruitment was underway and vacancies were trying to be filled. Staff told us they felt stressed and under pressure with the risk they held due to patients who needed specialist treatment not being able to access it. They told us they felt frustrated with the impact on patients and about how this had impacted on their practice.

We observed a daily meeting where it was explained that due to lack of staffing any triage appointments couldn’t happen. There were 3 patients that were booked in, which would have to wait longer. They had had their referral read but were waiting for the next step in their support. Staff and leaders told us that this does happen.

Risks and priorities were discussed at daily meetings. Staff were allocated prior to the meetings and the meeting looked at staffing issues and if appointments needed to be moved or cancelled. The services had effective systems and oversight on caseloads and how they were shared in teams. We saw how staff skill-mix and experience were considered to match the right person to patients. However, we were told by staff that when someone left, their caseloads increased. Staff told us caseloads were manageable, however only due to their passion in wanting to care and support patients.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.