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

Ward areas were clean, spacious and patients had access to their own en-suite bathroom. There were plentiful and varied activities on the ward and patients were very complimentary of the support by the activity coordinators. However, not all patients felt safe on the wards. During this assessment we found breaches in regulation under safe care and treatment and good governance. Staff did not always follow trust policy regarding safe administration of medicines, staff did not complete comprehensive risk assessments for patients, staff did not always record safeguarding concerns in the patient record, staff did not always include sufficient details within incident forms to allow learning to take place and managers did not have sufficient oversight of medicine administration practice. We have asked to trust to address these areas of concern within an action plan.

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.

Patients felt dedicated one to one time with their named nurse was very valuable. They were used to having lots of items confiscated on previous admissions to other hospitals. Three patients told us they had self-harmed on restricted items that were kept in a locker.

Managers told us they were able to release staff for training and the team on Beech ward were involved in a pilot of the use of positive behaviour support plans. Staff could access specific specialist training such as bite size psychology and personality disorder sessions. Leaders told us they would like to develop a specialised female patient induction programme that focussed on specific areas of the patient group.

We were told that the trust was moving towards a “block” system whereby mandatory training would be delivered over a week. Managers said this would make it easier to manage the staffing rotas. We saw managers held monthly quality governance meetings, the items covered in the meeting included, reviews of the quality dashboard, clinical audits, staff and information management and triangulation of learning and key themes.

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.

Patients we spoke with gave mixed views of their experiences. Two patients said they did not feel safe at all however 4 said staff were good at managing risks, and they listened to them. One patient said staff genuinely cared and they did positive risk taking which they said was good for them.

All staff we spoke with were able to demonstrate how they would identify and raise a safeguarding issue. There was a safeguarding lead at the trust that staff could contact for advice.

We saw one example where staff had made a safeguarding referral following an incident involving 2 patients. Staff had taken appropriate actions to safeguard both patients. However, we found staff had not included reported safeguarding concerns regarding parental access to children in the patient’s risk assessment.

The trust had a safeguarding policy in place, we saw a notice board which was dedicated to safeguarding. However, staff did not always follow this policy when updating patient records regarding safeguarding risks.

One patient we spoke with told us they had found it refreshing that staff trusted them if they said they felt safe. Patients they said there were plentiful and varied activities on the ward which kept them busy and reduced the likelihood of risky behaviour. They were very complimentary of the support by the activity coordinators. However, 2 patients said they did not feel safe on the ward, and one found the ward scary. They were used to having lots of items confiscated on previous admissions to other hospitals. Three patients told us they had self-harmed on restricted items that are kept in a locker.

Staff we spoke with said that having time allocated to spend one to one named nurse time with patients was very beneficial. There were posters on display on the ward area showing what items were restricted on the ward areas. Staff told us patient ‘risk items’ (items that were restricted on the ward area) were stored in patient lockers, however, we found there was no item list for each locker in place so that staff would know what stored in them. Staff told us they put ‘all things’ in these lockers as patients couldn’t have risk items in their room due to other patients entering their rooms and taking things. This was a decision to reduce risk on the ward. Staff explained they did not have separate lockers for personal belongings and ‘risk items’ and patients used to have personal lockers available on the ward but these had been damaged and replacements had arrived but had not been placed on the ward yet.

We reviewed 8 patient care and treatment records. We saw the patient voice had only been recorded in 3 patients risk assessments. We saw comprehensive risk assessments were not in place when patients had access to restricted items that could be used to self-harm. At the time of the onsite assessment although there was a poster showing what items were restricted on the wards, there was no specific policy in place around how these were managed. We reviewed patient incident records. We found staff did not always record the item used when patients were involved in incidents of self-harm. Therefore, staff were not able to determine whether incidents were related to items restricted on the ward. This meant staff were unable to learn lessons effectively and put appropriate support in place for patients.

Patients we spoke with told us the wards were very clean and spacious. They appreciated having their own en-suite bathroom and the garden areas were particularly pleasant. They told us that the choice of rooms was good and said they could access them whenever they needed to. Two patients told us they regularly visited the hospital café with their families which was enjoyable.

Staff we spoke with told us Fir and Beech wards were a homely, safe and a good environment to work in.

Both Fir and Beech wards were bright, airy and appropriately furnished. The Control of Substances Hazardous to Health (COSHH) were appropriately stored. The spaces available to patients included: a quiet room, a TV lounge, a relaxation room, de-escalation area, a large living and dining room.

We saw audits of the ward environment and ligatures had been undertaken monthly.

Patients we spoke with told us there were enough staff to meet their needs. However, on Fir ward patients told us there were “too many agency staff that did not know them” and not all staff wore name badges, and this made communication challenging at times.

Managers on Fir ward told us they had vacancies for registered nurses, and this would be further depleted in October. Senior managers told us there were plans in place to support the ward staffing issues.

We saw staffing levels met the requirement of 6 on early and late shifts and 5 on night shift.

We looked at staffing rotas for the last three months, whilst the minimum staffing numbers were met, we saw the requirement for at least 2 registered members of staff was not achieved. We saw impact of this on patients, particularly when having to wait for medication.

Patients told us staff worked hard to ensure the environment was clean and homely.

Staff described how they managed infection prevention control on their respective wards. They had appropriate amounts of protective equipment and could access support from infection, prevention and control experts within the trust.

We saw not all staff were bare below the elbows according to trust policy.

Cleaning schedules were completed, and audits of cleanliness were undertaken, the results of which were displayed on the ward noticeboards for staff and patients to see.

One patient told us they had to ask several times before they were given pain relief, another said it took staff 30 minutes to find their inhaler. One patient said the ward did not have her medication for 2 days following admission and this had caused her distress and led to incidents of self-harm.

Staff told us the ward was in the process of transferring to an electronic prescribing system, but this had yet to be completed. We were told that wards had pharmacist or technician input five days a week.

We saw all medicines were stored appropriately. Staff completed temperature checks of the clinic room and the medicines fridge. We saw managers had completed an incident report where staff had administered double the amount of an as required sedative medication on several occasions, the manager informed us that an investigation into the errors was underway.

The trust had an up-to-date medicines administration policy, which staff had access to.