Nottinghamshire Healthcare NHS Foundation Trust

On this page

• 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 were comfortable with staff and felt they could approach staff. Patients felt safe on the wards. Medications were stored, administered and managed well. The environment was safe, and appropriate environmental risk assessments were in place. However, not all areas of the wards were clean and there were insufficient showering facilities on Blake ward, with only 2 showers for up to 16 patients (at the time of the onsite assessment there were 12 patients on this ward). Wards were often working under optimal staffing levels. We found processes in place to manage and monitor staffing did not always record the intricate details of how staffing changed over a shift, meaning management did not have oversight of the true staffing levels on wards over a single shift. We found a breach in regulations under safe care and treatment. Staff did not always manage risks well. We found staff did not always complete and record appropriate checks when monitoring side effects of medications. We have asked the trust for an action plan to improve completing and recording appropriate checks when monitoring side effects of medications.

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.

All patients we spoke with, told us they were fully involved to develop their care plan and discussed any risks. They said they could talk to an advocate or a social worker if they need too.

Staff on the men’s wards felt they learnt from lessons and work towards this as a team. They told us that they shared knowledge between each other and implemented changes. The teams spoke about ‘relational security’ and how this was very important in supporting patients. Incidents and reflections post incidents were important to maintain the supportive relationships they had with patients. However, staff we spoke with on Newmarket and Aintree wards said they no longer received the lessons learnt bulletin. Managers said it was available to staff on the trust intranet however it was not easy to find. We were told that specialist nurses had developed a monthly poster to display in staff restrooms to increase staff knowledge of learning disability and autism, including, diagnostic overshadowing.

Ward community meeting minutes had a set agenda which covered frequent reviews of restrictive practices, feedback from wider patient forums and issues directly affecting patients for example the impact of staff shortages.

On the wards for patients with a learning disability 2 patients we spoke with said the ward teams had worked with others to identify placements for them in the community and discharge plans were ongoing. When speaking to patients on Carlisle ward they told us that staff supported them to do things for themselves and prepared them for moving on. They told us that they had access to multi-disciplinary teams that also supported this process. A recently admitted patient told us they were very unsettled and didn’t trust anyone when they arrived on the ward, but staff had helped them settle in and supported them without judgement.

We saw staff from other specialities were regular attendees on the ward, for example, speech and language therapists and social workers. Leaders told us how they worked with other agencies to facilitate smooth entry and discharge from the service, including making visits to introduce themselves to potential patients. Patients were able to access education sessions and staff told us these were having a positive impact on patients. We were given an example of a patient whose first language wasn’t English but was receiving support to learn how to read and write English. Staff also told us how they used interpreters to also support this patient.

We saw examples of partnership working, for example with acute hospitals, community and other secure providers and adult social services. We saw how staff and leaders coordinated the movement of patients when leaving their wards to other areas of the hospital. There was a clear process regarding admissions into the wards we visited. This approach was managed by senior leaders and involved ward teams in making sure transfers happened safely and smoothly for all involved.

All patients we spoke with, told us they felt very safe on the ward and were fully involved to develop their care plan and discussed any risks. They told us ‘Staff make us safe; I can talk to them’. A patient told us they were in distress ‘I know I can talk to psychology; I have an appointment but that’s for next week. I can speak to staff in between, they understand’. They said they could talk to an advocate or a social worker if they need too.

Staff we spoke with were able to demonstrate how they would identify and raise a safeguarding issue. We were told there was a safeguarding lead at the hospital who they could contact for advice. They also told us how they would support a patient throughout the safeguarding process. Staff told us they had completed the required training. We found patients from Carlise and Erskine ward accessed fresh air together. Staff told us they managed patient dynamics and risk following a no mix patient list to prevent incidents when patients accessed fresh air.

We saw evidence in ward community meeting minutes of safeguarding being a regular agenda item along with patient safety, anti-bullying and equality and diversity. We observed how a patient who was in distress was supported by staff, speaking calmly to them and mentioning to other staff about what was happening. This was then in turn recorded on daily notes.

The trust had a safeguarding policy in place, we saw a notice board which was dedicated to safeguarding. Safeguarding training was to up to date with staff teams across the wards visited.

On Newmarket and Aintree wards the patients we spoke with said there were plentiful and varied meaningful activities both on and off the ward which kept them busy and reduced the likelihood of risky behaviour. They said nursing and psychology staff helped them to share their feelings openly and to recognise when they were feeling unsafe and develop strategies to help them manage them. Patients we spoke with on the men’s wards told us that they knew they could talk to staff if they needed to. ‘I can speak to advocacy as well but haven’t seen one yet’. Patients told us why they went to seclusion ‘I went in as my behaviour wasn’t good, seclusion calmed me down and then I came back on the ward’. Whilst walking in a corridor of a ward a patient was able to tell a member of staff how they felt. They told us ‘I walk as it helps me to cope with the voices’ they were comfortable in explaining to staff what was happening to them.

Staff we spoke with said patients were nursed in the least restrictive way possible. Staff told us about the daily check-in where staff and patients met every morning to discuss the day ahead and to ask how everyone was feeling. Photos of staff on duty and daily activities such as use of the phone and laundry were displayed. Each patient chose which member of staff would be primarily looking after them for the day and what activity they would like to do. This was then displayed on the noticeboard, so any visitors to the ward could easily identify the patient’s nurse for that day. Staff spoke about patients with knowledge and understanding and were able to discuss risks and how they manage them. A staff member told us ‘I understand that when I lock a patient in their bedspace, I’m taking their liberty away’. This showed awareness of their role and responsibility. They showed compassion with how they supported patients.

The care records we reviewed across the 2 wards for patients with a learning disability, were comprehensive and had updated risk assessments in place. The records showed patient involvement and the patients voice was evident throughout. However, whilst reviewing care plans on the men’s wards we found that patients who were on Clozapine (medication used to treat schizophrenia and has side effects including constipation, irregular heart beat or pulse and confusion) were not having the prescribed routine checks for side effects from the medication. On Erskine ward the forms were in place but were not being completed consistently. There was no clear rationale for staff to explain the purpose of these checks and actions to take place if issues were found. Nursing staff were able to tell us the implications of the side effects and why they had to record them but were unclear how often they should be completed. Leaders assured us this was going to be actioned immediately. No impact had occurred to the patients involved due to inconsistent recording. Staff knew that this was to be looked at and changes would be made.

All patients we spoke with told us they felt safe on the ward. They had access to their own bedrooms whenever they liked. They said the staff helped them personalise their rooms and supported them to keep their space clean. We were told there was plenty of space both inside and outside for them to participate in activities with staff on Aintree and Newmarket wards. However, patients on Erskine ward told us they were very hot as there was no fresh air coming through onto the ward. They told us ‘Don’t know why we can’t open the windows more’. They told us that they get fresh air but only two times a day and with other patients.

Staff we spoke with said they said they worked with patients to be as least restrictive as possible. For example, patients had their own key to their bedroom following appropriate risk assessments taking place. However, staff told us how frustrated they were for the patients to experience such hot environments on Erskine ward. They told us that they understood why the windows in the main area couldn’t be opened fully as these areas were not always supervised by staff, but they didn’t understand why the windows in the other communal areas could hardly open as they were always staffed well. Staff on Carlise ward were frustrated at the space for patients to use for therapy and one to one time as they were too small. Staff told us that space on the ward for storage was a struggle as there was hardly any for the staff to use. Staff showed us how a disabled toilet was being used as a storage area for cleaning equipment as there was no suitable storage space available.

We saw both Aintree and Newmarket wards were bright, airy and appropriately furnished. Erskine, Carlise and Blake wards were on the older part of the hospital. The wards on the mental health pathway were on 3 different levels. Erskine and Carlisle wards were both on the first floor and Blake ward was on the ground floor. Erskine was very hot during the onsite assessment. The windows in corridors were only allowed to open a very small amount due patient risk.

Full environmental and ligature risk assessments were in place on all wards we assessed. We were told that patients accessed fresh air on Erskine and Carlisle by joining up with another ward so that they could share staff. The process was that patients were escorted down stairwells onto an area of dedicated green space.

Patients on Erskine, Carlise and Blake told us that there was staff around if they needed them. Patients told us that they get fresh air a few times a day ‘if there is staff to do it’. They told us that ‘Staff are nice and good’. We spoke with 8 patients on Aintree and Newmarket wards, they all said the wards were often short of staff. Two patients said they had worked very hard to attain “singleton status” this meant they had 1 staff member to support them to walk around the hospital grounds. They said this gave them a great sense of achievement and they were very disappointed when their sessions were cancelled, and this affected their mental health. One patient had had a very recent bereavement, a staff member had spent a significant amount of time supporting the patient and had agreed to continue this with the patient the following day. The staff member was moved to another ward at short notice and consequently the session could not take place. The patient was very upset and disappointed.

On the men’s wards staff told us on each ward that staffing is very tight, and they felt they are working on a level that is safe but there is no flexibility if circumstances change. They told us ‘they work together to make sure things happen’. They explained how they had to plan the shifts closely to make sure things were completed but this meant that patients had to wait for fresh air or activities as staff maybe required to do a task at that time. Staff told us that often the gender mix wasn’t correct on the ward. Whilst on Carlise ward we were informed that other members of the multidisciplinary team would come and volunteer their support so that breaks would be covered due to the lack of flexibility of the staffing numbers. Staff on Aintree and Newmarket wards told us they did not have sufficient staff to care for patients adequately. We were told Aintree ward had 14 staff on duty which was their agreed level, however, staff told us 4 staff were finishing their shift at 15:30 which meant they would not be at required staffing after this. We were told the central staffing team endeavoured to find staff to cover, but this was rarely fulfilled. They also told us that all patients required mandatory care and treatment reviews which needed a staff member to attend for the whole day, this was not factored into staffing numbers. We were also told that staff who were employed as supernumerary were often deployed into ward numbers. Newmarket ward did not have the required number or gender of staff on the day of the onsite assessment. The agreed ward required staffing level was 7, staff told us 2 male staff had been moved to another ward meaning there were insufficient male staff to undertake timely personal care. Staff told us they were moved frequently and often and found it hard to catch up with changes that had occurred whilst they were not on the ward. They found this to be anxiety provoking especially if patients were on different diets for medical conditions.

We saw how staff were supporting patients, managing observations and communicating changes and risks. We saw how staff moved and change positions if a staff member was leaving observation areas, making sure patients were observed and safe. Whilst on Carlise ward we observed there were only 2 males on shift leaving them to do all the searches and any tasks needed that only males could do, due to the ward being male only. This put pressure on the male staff, and they expressed the difficulty to us.

We looked at staff rotas, each ward had safe staffing levels and required/ optimal staffing levels. We found within a 4-week period Aintree ward had not met safe staffing levels on 3 out of 56 day shifts and had not met required/ optimal staffing levels 52 of the 56-day shifts. On the day of the onsite assessment Newmarket ward did not have the gender mix of staff required to meet patient needs. We found processes in place to manage and monitor staffing did not always record the impact of the intricate details of how staffing changed over a shift, meaning management did not have oversight of the true impact of the staffing levels on wards over a single shift. For example, the rota recorded if a shift was fully covered by the correct number of staff, but the times when the numbers fell below safe staffing due to staff breaks, if a staff member was escorting patient or left the ward to get a prescription was not recorded. The rotas did not show if there was always the correct gender mix on the wards throughout the shifts post redeployment. Therefore, senior leaders would not have oversight of staffing as this was not recorded fully. As a result, staff felt the pressure on the shift and felt ‘short staffed’.

Patients we spoke with said staff worked hard to ensure the environment was clean and encouraged and supported them with good hygiene practice such as washing hands before meals and keeping their rooms clean. A patient told us that their shower had been altered as the water pressure wasn’t ok. They told us, ‘Its ok now, it comes out hot and with pressure’.

Staff we spoke with described how they managed infection prevention control. We saw 1 bedroom on Aintree ward was closed as it required a full refurbishment following prolonged episodes of urine contamination which had permeated the structure of the floor. Staff we spoke to told us that cleaners are on the ward each day and some duties are given to staff when cleaners aren’t available. We were shown sluice rooms on each ward. However, due to lack of storage spaces on Carlise ward the sluice room, albeit tidy was full of items. Leaders told us this was due to not having enough space on the ward. Staff on Carlise ward also told us how the ward had been re painted recently. However, due to the re decoration, stains were on the floor, we were told that these would be cleaned after the painting had finished.

We saw cleaning staff on each ward. They were using appropriate equipment for the jobs they were completing and using warning signs when the floor was wet. We found a recently emptied room on Blake ward which was dirty. There was evidence of dirt on the floor and the toilet and sink was stained. We were informed that there had been no deep clean of the room, but it was going to happen. On Blake ward we found there was no communal bath as it was out of use, and no one knew when it would be available again. Patients on this ward did not have access to ensuite showers and had only two showers between them all. The showers were clinical in their appearance and different form the ones found in ensuite facilities that other patients had access to. Staff told us that Blake ward was decommissioned for several months and the patients were on another ward before. The patients felt like they had stepped backwards due to the standard of ward facilities.

Cleaning schedules were completed, and audits of cleanliness undertaken, the results of which were displayed on the ward noticeboards for staff and patients to see. All staff were aware of the responsibilities in terms of cleanliness on the ward and knew and understood what happens during the times when cleaning staff were not on the wards.

Patients we spoke with told us they were able to talk to staff about any concerns regarding their medications and were told information on what they are taking and why. They said staff were always available to dispense as required medication.

Staff told us the wards were in the process of transferring to an electronic prescribing system, but this had yet to be completed. Staff told us that they had systems in place for monitoring the processes of administrating medication. They told us how medication was ordered and how this came from the main pharmacy of the hospital. The staff felt they had all the equipment including emergency equipment at hand and this was in good working order on each ward.

We saw all medication was stored appropriately. Staff completed temperature checks of the clinic room and the medication fridge. We saw consent to treatment under the Mental Health Act were appropriately stored with the patient medication charts. We saw staff completed High Dose Antipsychotic Treatment (HDAT) monitoring forms for patients prescribed medication that exceeded the recommended maximum dose. We saw how within the clinics processes were embedded on the discarding of sharps and unused medications. All patient medication charts were in order. We observed a patient ask for discretionary medication and staff supported him to have it without having a wait a long time. However, on the men’s wards we observed during medication administration time, patients were asked to return to their rooms which were then ‘top locked’ this meant that staff were semi confining them to their rooms. But patients knew that they could come out by unlocking from the inside if they needed to. Patients told us ‘We go to our rooms, so it helps staff’. Leaders informed us that this practice was recorded as a blanket restriction and had been authorised. However, this practice was not recorded in patient daily notes records. After the onsite assessment, leaders told us, although this was not documented in the patients notes it was discussed and reviewed within community meetings with patients on the ward and overseen via the Care Unit Restrictive practice group.

There was a medication administration policy in place and processes were in place to support administration of medication. We found the correct equipment in place in clinics we visited. Policies were in place and available for staff. We saw how staff were using whiteboards to communicate information, this was done confidentially and supported them to be able to support patients to take their medication safely. However, staff were unsure around the physical health monitoring requirements for patients on Clozapine.