Special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust

Staffing levels

In our 2022/23 State of Care report we raised our concerns about longstanding issues with staffing at all 3 of England’s high secure hospitals. We reported that at each inspection, all 3 high secure hospitals had a significant shortage of staff, particularly registered nurses.

Consistent staffing is fundamental to therapeutic relationships, so a high turnover of staff can have negative impacts on patient recovery and lead to longer stays in hospital. A lack of staff can also affect services’ ability to provide therapeutic care.

Following our inspection in June 2023, we raised our specific concerns around staffing levels at Rampton Hospital. While the data suggests that staffing levels have improved since our last inspection, they were still variable and not yet sustainable.

Safe staffing levels at Rampton Hospital were classed as 80% or above in relation to staff on duty. The actual number of staff on duty changed daily, as well as throughout the day depending on patient needs. Actual numbers of staff needed would regularly be in the high 100s or low 200s on shift at any one time.

In June 2023, the average staffing level was 62% against safe staffing levels of 80%. To put this into context, on 22 June 2023 there should have been 205 staff on shift. Safe staffing levels would have been a minimum of 164 staff based on the figures used by the trust. On this particular day, there were only 126 staff on duty, meaning that the staffing level was at 61.5% of staff rostered on, or 79 staff below planned staffing levels. This meant that staffing levels were significantly below what was planned, and also what was classed as safe.

From July to October 2023 actual staffing levels against planned staffing varied with an average of 68% of staff on shift. Staffing levels did exceed the minimum safe staffing levels in November 2023 with a rate of 84%, maintained in December 2023 at 96% and then in January 2024 at 94%.

Since early July 2023, Rampton Hospital has been able to fill all weekday early shifts by at least 80%, but struggled to achieve the 80% target for late shifts and at weekends and bank holidays. The average fill rate for night shifts at Rampton Hospital between 20 July 2023 and 7 February 2024 was 80.7%.

All staff we spoke with mentioned ‘Z’ levels of staffing. The ‘Z’ level is the minimum number of staff needed to safely manage the ward; this number includes one patient being cared for on enhanced observations. When we reviewed the ‘Z’ levels of staffing it became clear that these numbers were significantly lower than the numbers of staff required to manage the acuity of some wards, meet patient needs and improve the perceived safety for staff.

For example, on one of our out of hours visits, the nurse in charge told us that they should have 14 staff on duty for the day, but there were only 11 staff on duty. The nurse in charge was allocated a morning shift but had stayed at work until 7.30pm. We heard how this shortage of staff had affected the care delivered, with one patient not allowed out of long-term segregation for the whole day, and other patients not given all of their planned time out of long-term segregation. As well as the negative impact on patient care, as highlighted in our 2022/23 Mental Health Act annual report, the July 2023 report from the Public Accounts Committee (PAC), has warned how increasing workloads are leading to burnout for staff.

We also heard concerns about the culture of relying on therapy and education staff to cover nursing gaps. While the staff we spoke with told us the amount of time they were asked to cover observations was less, we heard that this practice is still happening.

As highlighted in our section on therapeutic activities, therapy staff told us they had been placed on wards with inadequate training to make up staff numbers, which had led to therapies, such as exercise, being cancelled. A former member of staff made clear the effects of having to cancel activities, such as exercise, on patients’ wellbeing, claiming they became more aggressive, and staff were more likely to be attacked. This is supported by the findings from our 2022/23 Mental Health Act annual report where we reported that patients told us how a lack of therapeutic activities leads to boredom and could, in turn, lead to patient-on-staff violence, patient-on-patient aggression or self-harm.

Staff who are asked to cover nursing gaps also told us that when they were on the wards they were not made to feel part of the team, did not get a full handover of the patients' needs or risks and were not asked if they needed food or drink. They reported feeling undervalued, stressed and not suitably trained, competent or confident.

Leaders at the trust recognise that further improvements are needed in relation to staffing. Communication around the staffing levels and how staffing numbers are set needs to be escalated to ensure understanding.

Confinement

Night-time confinement is a practice used at the 3 high secure hospitals where patients are locked in their rooms overnight. The High Security Psychiatric Services (Arrangements for Safety and Security) Directions 2019 state that each high secure hospital, in line with guidance from the Secretary of State, may only lock a patient’s room at night if:

1. the room has toilet and washing facilities and a staff call system; or
2. the patient is subject to continuous observation by a member of staff.

In line with guidance, the policy for night-time confinement at Rampton Hospital is from 8.30pm to 8am. However, we previously raised our concerns about the inappropriate use of confinement at the hospital. For example, between April 2023 and June 2023, there were 127 episodes of confinement outside of these hours. At the inspections in June and July 2023, we found that staff across the hospital routinely used confinement as the ‘go to’ measure to deal with most matters. We also found that confinement was being planned several weeks in advance of known staff shortages, rather than less restrictive measures being considered.

Confinement had unfortunately become part of the culture at the hospital and staff did not recognise when it was being used inappropriately. For example, during our July 2023 inspection, whistleblowers reported to us that some new members of staff were being instructed to ‘lock up the patients at the first chance they get, otherwise the patients will eat them’. We are clear that it is unacceptable to lock patients in their room outside of the High security psychiatric services directions: Security and Safety.

Leaders at both hospital and trust level did not have appropriate oversight of confinement in Rampton Hospital other than knowing it was happening. It had not been recognised by leaders that confinement was being use inappropriately, nor had any alternative measures been put in place to minimise its use.

In July 2023, based on findings from our inspection in June 2023, we wrote to the Independent Chair of the National Oversight Group for High Secure Psychiatric Services raising our concerns about staffing shortages and the use of daytime confinement and extended night-time confinement at Rampton Hospital, including restricting patients’ access to communal ward areas during parts of the day. We escalated these concerns to the Independent Chair to help lever improvements at the hospital quickly.

Since our last inspection, the trust has redesigned its processes for requesting the use of daytime confinement. This means that the leadership team are now immediately aware when it is being used, and could move staff across the hospital safely to end confinement. In addition, the trust no longer uses confinement as an option for contingency planning when staffing levels are low.

As a result of the changes, the use of confinement has decreased. From July 2023 to the end of December 2023, there were 28 episodes of daytime confinement. This is supported by feedback from patients and staff who told us that the use of daytime confinement had either stopped or reduced significantly. While the use of daytime confinement was arguably still too high, it was an improvement and patients told us they were pleased with this change.

Although the majority of staff were also pleased with confinement being used less, some felt that that not having the option of day confinement placed them at risk when staffing levels were low. We are concerned that some staff feel this way when there is evidence that staffing levels were improving.

Training and clinical supervision

Over the last 5 years, we have consistently raised concerns about training for staff at Rampton Hospital. While there have been some improvements, we remain concerned about the numbers of staff completing mandatory training and clinical supervision.

On previous inspections, we have raised particular concerns about low levels of staff trained in hospital life support. We were not assured that in an emergency there would be enough trained and competent staff to provide life support to patients until medical or emergency services arrived. At the June and July 2023 inspections, this had improved, with 87% of all staff recorded as having received this training. However, we are concerned that as at December 2023 this had dropped back down to 81%. The trust have provided evidence of planned training for staff, which will mean that by the end of March 2024 all staff (100%) will have received the training.

Since 1 July 2022, all registered health and social care providers are required to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people who have a learning disability. Between July 2023 and February 2024, we carried out 20 Mental Health Act (MHA) reviewer visits to Rampton Hospital. Through these reviews, staff on Evans Ward told MHA reviewers they had not completed training in autism and learning disability. Not only is this a legal requirement, but it means that people may not receive person-centred care that meets their needs.

As part our review, the trust updated us that e-learning for learning disability and autism training became available to staff in January and, to date, 43% of staff had completed the training.

However, as highlighted in our section on communication at Rampton Hospital, we were concerned that staff were not confident in caring for patients with a learning disability. For example, one person with a learning disability who was in long-term segregation said they felt lonely. We reported this to the matron who said that staff do not always know how to speak with them or what about. The inspector noted the patient had stickers or animals and their football team on the wall. They found using these as prompts helped the conversation to flow. Therefore, we questioned whether communication was difficult. Regardless of the reason, the patient’s communication needs were not being supported, which needs to be addressed.

It was noted that 94% of staff had completed training in the Mental Capacity Act (MCA) and 97% had completed Mental Health Act (MHA) training. This had improved since the September 2022 inspection, when 80% had completed MCA training and 84% had completed MHA training.

However, we are concerned that clinical supervision and support for staff has decreased. Since our last inspection, the trust has revised down its requirements for clinical supervision from once a month to once every 3 months. While the figures suggest the performance rates for supervision taking place have improved, the actual number of clinical supervisions taking place have reduced. We are concerned that reducing attendance at supervision to every 3 months will have a detrimental effect on both staff and ultimately patients within the hospital. In addition it is concerning that the requirements have been reduced rather than improvements made to meet the original target.