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

Staff were always responsive and kind to patients. Patients were involved when assessing risks. Pathways and transitions between services were generally smooth but staff felt there was a lack of support for patients with issues regarding drug and alcohol abuse. We found patient care and treatment records were not always updated before the patients’ risk level had been downgraded. We saw high vacancy rates of registered staff within the clinical access team. During this assessment we found breaches in regulation under safe care and treatment, safe staffing and good governance. Staff did not always review risk levels effectively and document changes in line with this. The trust had not been able to ensure that a registered clinical practitioner was on duty to support the unregistered call handlers leaving patients at risk of not having access to appropriate support. Staff had not completed all required mandatory training. Managers did not have oversight of the training undertaken by staff working on the crisis access line which was the first point of contact for people in crisis as at the time of the assessment this service was being commissioned out to another provider. Following the assessment, we asked the trust to submit an action plan to address these areas.

This service scored 53 (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.

We reviewed 11 examples of feedback from patients who had used the service. One patient said "support from the team had been invaluable" and they "had a positive experience with everyone they met". We saw an example where feedback described “fabulous support, responsiveness & communication has been from your team”. We spoke with 3 patients being cared for within the 2 health-based places of safety (136 suites). Two were waiting for beds on the trust acute inpatient wards and whilst they said staff were "very kind" they were "bored and hoped a bed would be found soon".

Staff we spoke with told us pathways and transitions were generally smooth. However, several staff and leaders highlighted the lack of support for patients with issues regarding drug and alcohol abuse. We were told the local substance misuse teams who worked exclusively on the inpatient wards did not work within the emergency departments. This meant that liaison staff had to make multiple visits to assess whether the patient was fit to undertake their assessment. Staff told us within the Crisis Resolution Home Treatment (CRHT) they encountered challenges in securing information from substance misuse services whereby the service cited patient confidentially as the reason to withhold the information. They found this frustrating. Managers told us the introduction of the crisis access line service had been problematic. The trust had not been able to ensure that a registered clinical practitioner was on duty to support the unregistered call handlers and were unable to assure themselves that these staff had received adequate and relevant training required for the role. We received an update from the trust following the on-site assessment that all calls were now being diverted to a registered clinician, and this had been an oversight on their part.

We saw examples of partnership working with the acute hospital, police, local safeguarding team, and adult social services. The trust liaison teams had achieved the Psychiatric Liaison Accreditation Network (PLAN) standards. PLAN aimed to provide a clear and comprehensive description of best practice in liaison psychiatry services.

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

We reviewed patient feedback where a patient extended their gratitude to the team for working with them and supporting them and keeping them out of hospital. One patient also said, "the team have all been brilliant and it has been great to open up to people”.

Staff we spoke with said they involved the patient and families in assessing risk whenever possible and recorded this in the clinical patient care and treatment record progress notes.

We reviewed 20 patient care and treatment records for patients receiving care within the community crisis teams. We found in 7 records the risks assessments were not updated before the patients’ risk level had been downgraded.

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

The patient feedback we reviewed did not raise any concerns around staffing issues. We saw very positive feedback regarding the care patients received. The 3 patients we spoke with within the Health Based Places of Safety told us there was always enough staff on duty to support them.

Staff we spoke with across the clinical pathway told us that teams were often short staffed, and this was leading to staff burnout. They told us non mandatory training was often cancelled, and they did not feel valued by the very senior management team.

We saw work was planned to address issues with demand on the service, and capacity of staff, as referrals had risen significantly, and patients were presenting with increased complex needs. Managers did not have plans in place to address staffing issues in the Crisis Access Line. We saw examples where there was not a registered clinician on duty, which meant crisis calls were triaged by unregistered staff. This left patients at risk of not receiving appropriate treatment at the right time.

Following the on-site assessment, we received assurance from the senior leadership team regarding an improvement workstream across the crisis service, this included a review of the implementation of the crisis line, improving access, the delivery of clinical care and patient experience. We saw high vacancy rates of registered staff within the clinical access team, whilst the trust had an active and ongoing recruitment process in place managers had found these posts difficult to recruit to. Managers did not have oversight of the training undertaken by staff working on the crisis access line which was the first point of contact for people in crisis in the Nottingham County South and Mid CRHTs as these staff were employed by another company. After the onsite assessment the trust had taken the decision to suspend the contract in place with this provider. All staff did not have appropriate mandatory training in place including breakaway training and basic life support training. Breakaway training compliance was at 59% for staff at the County South Crisis Resolution Home Treatment team (CRHT). Basic life support training compliance was at 51% for the Mid and North Crisis Resolution Home Treatment team (CRHT) Team and 63% compliance for the City CRHT team. Staff in the Mid and North Notts CRHT did not complete Basic Life Support training but were required to complete Hospital Life Support as they had access to an emergency grab bag in their clinic room. At the time of the assessment Mid and North Notts CRHT team’s Hospital Life Support training compliance was 44%. After the assessment the trust assured the CQC that they had planned to ensure all staff had completed all mandatory training by the end of February 2025.

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.