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

Patients felt safe on the wards and there were enough staff on the wards to keep them safe. Patients told us they attended ward rounds to discuss their care and treatment. However, we found not all care and treatment plans were written in the patients’ voice. We found a patient had not accessed section 17 leave since January 2024 and there was not clear clinical reason logged for this within the patients care and treatment plan. We saw a lack of person-centred information to guide staff on which medicine to give when people were prescribed more than one “as required” medicine. Physical health monitoring was not always carried out in line with care plans. This put patients at risk of deterioration of underlying physical health conditions. We found a breach in regulation under safe care and treatment and good governance. Staff did not always follow national guidance for using ‘as required medicines’ and did not always monitor physical health in line with patients care plans. We found staff did not always have access to consistent information regarding environmental and ligature risk assessments for each ward. The seclusion room on Thurland ward was not fit for purpose and did not meet the requirements within the Mental Health Act Code of Practice. We have asked to trust to improve these areas of concern within an action plan.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients told us that incidents were discussed with them with their named staff and at ward rounds. A patient told us “Staff are around to discuss next steps and goals”. Another patient told us they felt staff would assess the most appropriate time to explain any changes, and said “if there’s aggression, staff will wait for patients to calm down”.

Staff told us after incidents they received debriefs, which was welcomed by staff. They had reflective practice sessions ran by psychology. They told us after incidents they looked at what happened and what could be learnt.

Staff could utilise reflective practice led by psychology teams and debriefs after each incident. Incidents were recorded and leaders had access to these records. A process was in place to ensure an incident could not be closed until it had leader sign off, ensuring each incident was reviewed.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

During the assessment a patient discussed how they felt during their section 17 leave. They felt confident they were listened to and understood by staff. Patients told us any issues were spoken about during their ward rounds, but they could also speak to staff if they needed to.

Staff told us that they understood safeguarding; and had all received up to date training on it. However, a staff member at Wathwood told us that not all incidents are raised, which meant that leaders did not always have all the correct information to keep patients and staff safe. Staff told us an example where a patient was moved wards due to a safeguarding issue with another patient which meant both were made safe.

We observed how staff worked as a team on each ward. We observed how the teams communicated with each other on how the shift was being run. Staff checked in on each other, handed information over about the whereabouts of patients on the wards and continually briefed each other on risks. We saw that any issues were recorded in patient’s daily notes.

We reviewed patients care plans, which showed examples of how safeguarding was documented for the well-being of the patients and risks associated with them. There were safeguarding leads on each ward.

Patients told us that they were involved in writing their risk assessments. We found the patient voice was not always recorded within care and treatment plans. We found one patient had not left the ward area since admission and there was no clear clinical reason of discussion on why this had occurred.

Staff told us they received debriefs when any incident happened. They told us that sometimes patients were discharged onto other wards at Wathwood hospital without being fit for that discharge. This meant the patient would then come back to the ward later.

We reviewed patients care plans on each ward. There was an inconsistency on how these were completed and how often they were reviewed. We found risk assessments were carried out and input from the multidisciplinary team was present. However, active patient’s voices were inconsistently recorded in risk assessments. We reviewed a patient’s restrictive practice plan and found that since their admission into Wathwood hospital they had not had their section 17 leave approved, which meant the patient could not leave the ward. We found no clinical reason for this apart from an entry made by the multidisciplinary team on the 24 May 2024 stating that they will be approved “When you are ready”. This patient was admitted onto the ward on 31 January 2024.

Patients told us that they felt safe on the ward. A patient told us “I feel quite safe on the ward”. Patients told us that the environment was ok, a patient told us “The environment is not perfect, but it will do”. However, a patient with physical disabilities did not feel safe due to a lack of support rails required in their ensuite, they told us that they were afraid of slipping as the floor is slippery after use. The multi-disciplinary team had put in place the correct equipment in the patient’s room but had not installed rails. The patient was not aware why this hadn’t been done.

Staff told us they knew how to raise maintenance issues. If the issues were urgent they would be actioned, but they were frustrated on how long some things took to be mended and how they had wait for funding approval from the trust. Staff told us they felt they operated safe wards with how they used the security measures in place. We saw each area had curved mirrors to eliminate blind spots and closed-circuit television (CCTV) in place in communal areas. However, the seclusion room on Thurland ward was not fit for purpose. This had been highlighted at a recent Mental Health Act Review visit and it was found not meeting the code of practice. We found ligature points and no natural light. The leaders had said that the seclusion room was not in use on the ward but remained open. This left the potential of use in a not fit for purpose seclusion room available for patients, putting them at risk of harm. Leaders at Wells Road told us the seclusion rooms at the location had been assessed and a plan was in place to address issues found.

The wards in both Wells Road and Wathwood were tired and worn. We found seating for patients to have rips in the fabric and obvious wear and tear. We found flooring in communal areas taped down when lifting. Stained carpets due to high flow areas. Whilst at Wathwood we found concrete slabs that were loose in the outside space where patients, patients are then at risk of trips and falls. Most of all the patient areas at both locations had weeds present. Leaders at Wells Road told us that work was to start soon in replacing chairs on the wards.

We found environmental risk assessments which included separate ligature risk assessments on each ward we visited. However, we found inconsistences in the accessibility of these documents whilst at Wathwood. On the rehabilitation ward at Wathwood the staff copy of the ligature audit was dated 5 August 2020 meaning it was out of date. Leaders told us the recent copy was online. This was not clear whilst on the ward and would be confusing for new or temporary members or of staff. We found that 2 of the 3 wards had images for staff to indicate where ligature points were found in patient’s bedrooms. However, these images were not available on the assessment ward which was where the most at risk patients were located. This was raised to leaders at the time of the assessment and was being actioned.

Patients told us that “staff are always around to keep an eye on you”. They told us that sometimes it felt like the shifts were short staffed and patients knew that bank staff were utilised. A patient told us that “Care, managing our needs and risks are of a high quality- staff keep us safe”.

We reviewed staff training figures for each location and found that staff were compliant with their mandatory training. Staff told us that staffing levels were tight. They worked to make sure patients were safe and needs were met. However, it was a struggle, and breaks were often missed to make sure needs were met. Staff told us that morale was low due to staffing numbers. When reviewing staffing numbers they showed no gaps. However, staff expressed that often activities were cancelled including section 17 leave due to making sure there were enough staff on the ward to keep it safe.

We saw that shifts were covered at the time of assessment. Observations were covered and patient needs were being met. Patients were being supported to go on leave and to attend activities. However, this was always dependant on staffing numbers. We were made aware that although section 17 leave was happening some patients were not always able to go due to staffing.

We reviewed recent staff rotas and saw that when gaps were identified leaders would reach out to regular bank staff. When reviewing staff rota, we saw times where bank staff were not available, and ward management had stepped in to support shifts to minimise impact of the shortfall. We reviewed the use of agency staff and saw that no agency staff were utilised on both locations. We saw the use of agency staff had ceased. The services used regular bank staff known to the service and to the patients. Daily demand meetings occurred where leaders were made aware of ward safety issues and could also make changes to allow for shifts to have efficient numbers to run safely.

Patients told us the cleaners did a great job, and supported room cleans as well. However, a patient on the rehabilitation ward at Wathwood told us that it was frustrating that there was only one washing machine available on the ward.

Staff told us domestic staff were on the wards during the week. Domestic staff worked reduced hours during the weekends, therefore, some cleaning tasks were completed by ward staff over the weekend. They told us if any maintenance issues are found they could log them.

The wards we visited were clean but worn and tired. We saw cleaning staff on each ward. We checked fridges used for storing patients’ food, temperature checks were being completed but we did find gaps in some charts. When checking the fridge in the assessment ward at Wathwood the fridge read at a high temperature due to the fridge door not being able to close properly. We found that no one had realised this, this was however actioned immediately when raised with staff. There was only one washing machine available for the rehabilitation ward at Wathwood which meant staff were having to take patients dirty washing through the hospital to another ward to be washed. Staff said that was reported in April 2024 and still hadn’t been actioned. We found in the long-term segregation area on Lister ward at Wells Road that staff had put the patient’s underwear on the floor of the observation area. Staff didn’t see this as an issue. This was actioned and was placed in a washing basket. The staff were unsure if the underwear was clean or dirty.

We found there were inconsistencies in documentation of environmental checks on the wards at Wathwood. Each ward had its own way of recording environmental checks which meant there was no consistent approach.

Staff did not follow national guidance when using ‘when required’ (PRN) medicines to manage distress and or agitation. We were not assured from patients’ records that medicines used to manage distress and or agitation were used for the right reason. For example, records stated that patients were calm and polite however they had been given PRN medicines. 17 out of 25 PRN dose records that we looked at did not state the reason why PRN medicines were given or the outcome, which was not in line with trust policy. We saw a lack of person-centred information to guide staff on which medicine to give when people were prescribed more than one PRN medicine to manage distress and or agitation. Physical health monitoring was not always carried out in line with care plans. This, put patients at risk of deterioration of underlying physical health conditions. For example, blood pressure monitoring had not been completed for one patient despite the GP making an entry about this in the patient’s records. We highlighted this to a member of staff.

Staff said that they felt supported by senior leaders within the Trust. The service had systems to ensure staff knew about safety alerts and incidents. Staff were supported by the Physical Health Care Team and had access to people’s blood results so that decisions around treatment could be made in a timely manner. Staff told us that electronic systems for prescribing and auditing had helped to reduce incidents involving medicines. Staff were able to access the patient information leaflets from the intranet to support and provide specific advice to patients about their medicines.

We saw staff treating patients in a kind, dignified and respectful manner. However, we saw confidential documents were left lying around unattended in the treatment room area, when patients were being given medicines.

Staff did not always follow systems and processes when safely prescribing, administering and recording medicines. The trust had an electronic prescribing and medicines administration (EPMA) system in place. We found that staff did not always accurately record what medicine they had administered to patients. For example, we saw an intramuscular injection recorded on the EPMA system, but the pateint had received oral medicines. EPMA allows patients on High Dose Antipsychotic Therapy (HDAT) to be flagged but despite this, patients were not always monitored as per guidance. A recent HDAT audit from March 2024 highlighted trust wide 48% of patients HDAT monitoring had not been completed. We saw appropriate arrangements were in place for high-risk medicines like clozapine, lithium and valproate with monitoring care plans and risk assessment in place. However, we did see refusals of critical medicine were not always followed up in line with guidance which may result in adverse effects from medicines or medicines not working effectively. Mental Health Act documentation was available, and medicines had been legally prescribed and administered.