Nottinghamshire Healthcare NHS Foundation Trust

Updated 1 March 2024

We carried out this unannounced inspection of Nottinghamshire Healthcare NHS Foundation Trust of the mental health and community health services provided by this trust the services hadn’t been inspected since for over three years and they had an overall rating of requires improvement.

At this inspection, we visited the three mental health services which had been rated as good in 2014 and four community health services, one of which had been rated as requires improvement in 2018. This inspection was carried out as part of our programme of ongoing checks on the safety and quality of healthcare services.

We also inspected the well-led key question for the trust overall.

At this inspection, the overall rating for the three mental health services we inspected went down to requires improvement. The ratings of the four community health services we inspected remained the same as good for three services and rated one as requires improvement.

At this inspection the overall ratings for mental health services stayed the same in safe and responsive, which we rated as requires improvement. Caring stayed the same, rated as good. The ratings for effective and responsive went down. We rated these as requires improvement.

The rating for well-led in mental health services, remained the same as requires improvement.

At this inspection the overall well-led provider rating improved stayed the same as requires improvement.

We inspected two mental health inpatient services, and one community based mental health service. The two mental health inpatient service inspections were unannounced. The community based mental health service was announced 24 hours before the inspection began.

• Long stay rehabilitation mental health wards for working age adults.
• Wards for Older People with Mental Health problems.
• Community-based mental health services for older people.

We inspected all key lines of enquiry in all domains (safe, effective, caring, responsive and well-led) in these services.

We inspected four community health services. The community health inpatient service was inspected because of the ratings from the previous inspection. The other three community health services were inspected as they hadn’t been inspected since 2014. The community health inpatient services inspection was unannounced and the remaining three community health based services were announced 24 hours before the inspection began.

• Community Health – Inpatients.
• Community Health – End of Life Care.
• Community health services – children, young people and families.
• Community Health – Adults.

We inspected all key lines of enquiry in all domains (safe, effective, caring, responsive and well-led) in these services.

We also assessed if the organisation is well-led and looked at areas of governance, culture, leadership capability and improvement. Our inspection approach allows us to make a judgement on how the trust’s senior leadership leads the organisation and the provider level well-led rating is separate from the ratings of the services we inspected.

Prior to this well led review of Nottinghamshire Healthcare NHS Foundation Trust we also carried out two focussed inspections of forensic inpatient or secure wards and acute wards for adults of working age that had been rated as inadequate in 2019. To check if these services now met legal requirements. These inspections were unannounced.

We did not inspect the following core services previously rated as requires improvement:

• high secure hospital.

We did not inspect the following core services previously rated as good:

• child and adolescent mental health wards
• wards for people with a learning disability or autism
• community based metal health services for adults of working age
• mental health crisis services and health-based places of safety
• specialist community mental health services for children and young people.
• community based mental health services for people with a learning disability or autism.

We are monitoring the progress of improvements to these services and will re-inspect them as appropriate.

In rating the trust overall, we took into account the current ratings of the seven services we did not inspect this time and the two focussed inspections.

Our overall rating of this trust stayed the same. We rated them as requires improvement because:

• The trust had not responded in a timely way to eliminate shared sleeping arrangements (dormitories). At the last inspection in 2019 we told the trust that they should have an action plan to eradicate dormitories at Bassetlaw and Millbrook Mental Health Unit. We were pleased to see that this plan was in place with set deadlines for this work to be completed. However, we were concerned that the timelines within the plan had slipped due to the significant additional remedial works and refurbishment of a newly purchased hospital site. The impact of these delays meant that a total of 80 patients, on nine wards across the trust were required to share sleeping accommodation. Whilst the bed areas were separated by curtains the bedroom areas did not promote privacy or dignity of the service users admitted into these areas.
• Whilst the trust had a robust appointment process for all board directors, they did not ensure that that the senior leaders personal files met General Data Protection Regulations (GDPR) and the fit and proper persons checks had not been reviewed as they should have been.
• We found that the trust equality impact assessments required improvement and had not fully delivered on reducing inequalities that they were designed to deliver. The trust agreed with this. Although, we were assured that the equality impact assessments were always completed and approved by the board.
• In two of the community health core services and one mental health core service inspected we found that were issues with medicines management. This included, the ineffective audit system processes, omissions in recording when a patient had self-administered critical medication, incorrect storage, and ineffective monitoring, use, and correct disposal of prescription pads.
• Patients at Thorneywood Mount did not have up to date crisis or contingency plans. The absence of these plans meant that if a patient’s mental health deteriorated either on the units or when in the community, their carers, or staff would not know what action should be taken to ensure their safety. Whilst the provider addressed this issue within two weeks of our inspection, we did not feel the processes for updating these plans had sufficient time to become embedded into practice.
• In two mental health core services and one community health core services staff were not up to date with mandatory training. The compliance rates fell below the expected 75% compliance rate for specific training. It was acknowledged that the pandemic and COVID-19 outbreaks on wards and community teams had impacted on staff training.
• Governance systems and processes, and the strategy of the organisation had been extensively reviewed since our last inspection but was not fully embedded into services. It was not clear how the divisional teams used governance processes and measures to make positive, sustainable changes. Many of the leaders within mental health and community health core services did not use the trust governance process and reports effectively within their roles.
• Not all governance processes operated effectively at team level. Some of the mental health and community heath core services were still waiting for the roll out of the governance dashboards. It was planned within the next 10 months they would all be in place. Governance processes including clinical and pharmacist audits and recording of meeting decisions were not embedded into practice and therefore the service might not be aware of findings that would improve practice. In addition, governance structures were not robust, and this meant that there were gaps in training and supervision.
• The trust had a digital strategy in place. The use of digital technology was evident in some areas throughout the trust. However, divisions across the trust did not have designated digital leads. In addition, we were not clear how the board were using information and communication technology (ICT) as a key enabler to service change and transformation. We found there were delays with some digital produces such as Electronic Prescribing and Medicines Administration (EPMA).
• Whilst managers ensured staff had access to regular, constructive clinical supervision of their work, clinical supervision compliance rates in four of the inspected core services did not meet the trusts target rate of 80%. We could not ascertain if this was because staff had not accessed supervision or recorded that supervision had taken place.
• There were not always additional alarms for staff working in the wards for older people if staffing numbers increased. This meant staff could not get help quickly if there was an emergency.
• Within two mental health core services and one community health core services inspected we found that staffing numbers did not always provide enough suitably qualified staff on duty to meet patient needs.
• In long stay rehabilitation mental health wards for working age adults, the environment had not been well maintained and maintenance teams had not undertaken repairs in a timely way. At Thorneywood Mount showers had not worked properly for nearly two years; managers had reported the showers for repair on at least six occasions. On all occasions a temporary fix was made but the issue remained.

However:

• The executive board members were proactive, accomplished, open and responsive to feedback and passionate about improving the organisation. The trust demonstrated succession planning at board level. Since the last well led review there had been changes to the executive team; this had been strategically planned to ensure that the changes were implemented effectively with minimal impact on the running of the trust.
• Non-executive and executive directors were clear about their areas of responsibility. The trust used the organisational risk register and its board assurance framework to support good governance. Individual directorates were held to account by the board on financial, performance and quality.
• The board recognised that they needed more work to ensure the diversity of the board reflected the diversity of the communities it served.
• The trust had a Quality Mental Health legislation committee which chaired by a non-executive and lead by an executive. They provided leadership and held mental health operational groups, across the three divisions within the trust. The trust had reviewed their responsibilities and requirements under the Mental Health Act. This led to an organisational change in the structure of the mental health act teams.
• The trust had a clear vision and a set of values with quality and sustainability as the top priority. The trust worked inclusively when developing its strategy for 2022-2026. The strategy was launched in April 2022 and was the culmination of 18 months of engagement with a wide range of stakeholders. The strategy clearly demonstrated the trusts ambition over the next five years. It detailed the way in which they planned to improve the delivery and quality of care, support the workforce and embed a culture of continuous improvement across the organisation.
• The strategy was aligned with the local health economy and took into account the needs of the developing Integrated Care System (ICS). It outlined the need for collaboration and building strong clinical and non-clinical alliances between the health and care services to reduce barriers and improve patient care. The trust had responded proactively to the Integrated Care Board (ICB) development, and specifically the development of provider collaboratives.
• The trust had identified that they needed to further develop the culture to allow people to perform at their best and where everyone was able to be themselves, with a zero tolerance for inequality, harassment, discrimination and bullying. The trust promoted inclusivity and celebrating diversity in daily work and provided opportunities for staff development and career progression.
• The Black and minority ethnic network was one of the longest and best established staff groups in the trust with 285 members. We heard from some of the staff in this network. The network reported that their ideas and suggestions for change had been listened and heard by the trust, but they had not been followed through to bring about change.
• The trust continued to provide an extensive range of health and wellbeing offers to staff. Leaders of the trust viewed staff wellbeing as a high priority. The trust worked closely with their staff health and wellbeing leads to ensure that they supported colleagues in line with the staff feedback from the staff survey. The trust had a strong emphasis on safety and wellbeing of all staff and promoted a culture of having the right support in place for all staff.
• The trust was committed to patient involvement and experience and working with volunteers. The trust had an active volunteer network within excess of 185 volunteers.
• The trust had a people and culture committee which coordinated and supported implementation and development of the trust equality and diversity action plan with associated equality and diversity initiatives. At an executive level the trust had a good understanding of the equality, diversity and inclusion challenges and how the trust was meeting these challenges.
• Since the last inspection the trust corporate governance structure had been reviewed, redeveloped and improved. The structure was effective at board level with clear process and systems of accountability to support the delivery of the trusts strategy.
• The board recognised that that risk management was an essential and integral part of good management practice. The trust had a risk process in place to manage current and future performance. The trusts risk register report was comprehensive and identified risk to the organisation. The Board had developed a well-documented Board Assurance Framework and Risk Register. Most actions for assurance were clearly set out and were specific, measurable, achievable, and timely.
• During our inspection it was evident that clinical staff took part in clinical audits, benchmarking and quality improvement initiatives. Senior leaders supported improvement and innovation work and there was a strong programme of staff training.
• Quality improvement was high on the agenda of the trust. We were pleased to hear and see how quality improvement was in action. The trust had a quality improvement lead and has participated in Quality, Service Improvement and Redesign programme since 2020.

How we carried out the inspection

During the inspection, our inspection teams carried out the following activities across 10 wards and 11 community mental health teams, 4 community health services inpatient services and two community health teams:

• reviewed 97 care records
• reviewed 60 medication records
• interviewed 153 staff and 20 managers
• held 13 focus groups
• interviewed 43 patients
• spoke with 35 family members or carers of patients
• observed 20 episodes of care, multidisciplinary meetings.

During our well-led inspection, we spoke with 33 senior leaders of the organisation and looked at a range of policies, procedures and other governance documents relating to the running of the trust.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke with nine patients receiving care from the Community-based mental health services for older people. Their feedback was continually positive about the way staff treated them. Patients told us there was a strong focus on person centred care. One patient said the service had sign posted them to a Parkinson nurse to support them. Another patient said the doctor had visited her at home about mobility problems and provided options and advice. A third patient told us they had knowledge about their medicines as staff always provided full explanations which gave them a better understanding of their condition. A fourth patient told us staff had spent time explaining their diagnosis and answering their questions.

Other patient feedback received, “The service had transformed our lives. “Staff were very patient and took time to explain, you never felt rushed” “All matters were discussed openly.” Patients told us the service was wonderful, staff were kind, will go out of their way to help and support you, the service had been a lifesaver, enjoyed visits from the team. Patients consistently told us staff were motivated went over and above their duties.

We spoke with six patients and five carers on Wards for Older People with Mental Health problems. Feedback was generally positive. They said staff were compassionate and caring and that staff always made time for them. Patients also said they saw their consultant regularly.

Some patients in multiple occupancy dormitories said they would prefer to have their own bedroom.

Patients spoke positively about the food including the range of options, although one patient said they wanted more healthy choices including fruit and vegetables.

Patients said they were encouraged to take part in activities and to exercise.

Carers described the challenges of COVID-19 and not being able to go on to the ward but said that they had been able to visit patients outside of the ward.

Carers mostly said staff kept them informed of care and treatment decisions, including explaining the purpose and side effects of medication to them. One carer said they had not received a call back from the consultant in a timely manner.

We spoke with five people using the service and four carers within Long stay rehabilitation mental health wards for working age adults. Patients we spoke with were all positive about how the service was helping them to move on and treated them as responsible adults. They all agreed that the staff were great and even when busy they could make time to listen to patients.

Patients felt that lock down had been a difficult time particularly as many of them had only recently started to get more freedom to access community activities and home visits but the lock down rules had prevented them from doing these things. Patients told us that during lock down staff had gone out of their way to ensure they still did meaningful activities and explained how those activities would support their mental health recovery.

However, all patients we spoke with commented that the showers at both 106 and 145 Thorneywood Mount were awful and had not worked for a long time. Two patients said they did not like the bedrooms as they did not have their own shower and toilet and the building (145) was very old fashioned. Though another patient described the same building as homely. Patients from 106 told us there was very little space on that ward and no therapy space and they had to come to 145 for group therapy and craft type activities.

Carers we spoke with said communication with the wards was good and all four carers knew who their relatives named nurse was and knew they could ring them if they had queries. Three carers said they had copies of their relative’s care plans but only after permission had been gained another carer said their relative did not want them to have a copy of the care plan.

Two carers commented on how good the doctors were and how they had time to explain things to them clearly and without rushing.

All carers said they could see improvement in their relative’s mental health and wellbeing. One carer said staff try to create a community on the ward, give patients responsibility for themselves as much as possible and help people to become friends. Another carer said, “her son was much happier since moving to this service, he got into a lot less trouble with other patients and for the first time in many years said he felt safe on the ward”.

We spoke with 13 patients across the Community Health – Adults service, and three carers. Every patient and carer we spoke with told us how caring and respectful the staff were. Every patient and carer we spoke with talked highly of the service and of the staff.

All patients and carers said that staff used gloves, aprons and masks which made them feel safe with COVID-19. Patients and carers were aware that visiting staff had been regularly tested for the virus.

All patients and carers had a contact number so that they could contact the service if needed. Most patients had used this.

One patient explained that they were awaiting some new dressings from her GP. A visiting nurse had managed to locate a few while they were awaiting the delivery.

One patient described the nursing service as “very efficient” and said that they “help me emotionally”.

One patient confirmed that the nurses had got to them very quickly when they experienced a blocked catheter.

Two patients said that they had experienced a cancelled visit but had been visited the following day. Staff had called them individually and had explained to them why and offered an apology.

We spoke to 12 family members and three patients within the Community Health – Inpatients service. All three patients spoke positively about their experiences on the ward. One family member was not positive about the care of her family member or the way staff had communicated with them and three other families told us that they thought communication from staff on the ward could be improved. Not all families knew how to make a complaint, but they did say that they would ask staff if they wanted to raise a concern and some families said they would like to know more about activities on the ward.

However overall families reported that patients were well cared for on the ward and that patients were well-nourished and hydrated. They told us staff were kind and caring and that the ward environments were very clean. They did not report any issues in respect of patient safety and said that medication was well managed, including pain relief. Three families referred to the wards being short of staff some of the time.

We reviewed 23 complements across the Community health services – children, young people and families service that recognised the team’s individual clinicians, including health visitors, school nurses, orthotics, speech and language therapists, and nurse family practitioners. The following are examples of the comments we reviewed; “we could not express more gratitude to the Home Talk scheme,” “so dedicated and passionate and truly enabled my daughter to feel proud of the progress and “the nurse helped with sorting out problems with GP.”

We spoke with nine parents; they were overwhelmingly positive about both the care and the staff. Three parents said that the staff were outstanding and had gone the extra mile to ensure children and young people’s voices were heard and their needs considered.

They said staff were caring, respectful and supportive and they felt very valued and involved in their child's care and treatment.

Updated 26 June 2024

The service was last rated good (published May 2019). The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our on-site assessment on 09 July 2024. This was an unannounced assessment, which means the provider was not told an assessment was going to be starting beforehand. During this assessment we looked at 3 quality statements across 5 key questions: Safe systems, pathways, and transitions, Safe staffing, Safe environments, Assessing needs and Person-centred care. As we assessed some but not all quality statements at this visit it means we use the ratings from the previous inspection to rate all the key questions safe, effective, caring, responsive and well-led. The service is based across 11 locations across Nottinghamshire. At this assessment we carried out an on-site assessment of the Nottingham City provision of this service. This included 4 hubs across Nottingham city. During this assessment we found breaches in regulation under safe care and treatment, good governance and safe environments. Not all patients could access services easily, access to specialist services consisted of long waiting lists, there was no clinical strategy in place showing the services met patients needs and not all environments were wheelchair accessible. The service is made up of various clinicians, who worked alongside other partners.

Updated 26 June 2024

Rampton is a high secure hospital with services run by Nottinghamshire Healthcare NHS Foundation Trust. Rampton was last rated inadequate (published March 2024). The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our on-site assessment on 30 July 2024. This was an unannounced assessment, which means the provider was not told an assessment was going to be starting beforehand. During this assessment we looked at all the quality statements across the key question effective and one quality statement of safe and effective staffing under the key question of safe. As we assessed all the quality statements across the key question, effective, this has been re rated as part of this assessment. As we did not look at enough key question quality statements at this visit it means we use the ratings from the previous inspection to rate the key questions safe, caring, responsive and well-led. During this assessment we visited the 3 dedicated women’s wards.

Updated 26 June 2024

The Lookout is an inpatient facility open to children and young people aged 13 - 18 years old run by Nottinghamshire Healthcare NHS Foundation Trust. It supports those who are experiencing mental health difficulties that can no longer be managed in the community. The unit consists of 3 wards: Phoenix Ward (a 12-bed general adolescent unit), Hercules Ward (an 8-bed psychiatric intensive care unit) and Pegasus Ward (a 12-bed specialist eating disorder service). The children and adolescent inpatient service was last rated as Good (Published May 2019). The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our on-site assessment on 16 July 2024. This was an unannounced assessment, which means the provider was not told an assessment was going to be starting beforehand. During this assessment we looked at 3 quality statements across 3 key questions; Safe and effective staffing; Responding to people’s immediate needs; Planning for the Future. As we assessed some but not all quality statements at this visit it means we use the ratings from the previous inspection to rate the key questions safe, effective, caring, responsive and well-led. At this assessment we assessed 2 of the 3 wards: Pheonix ward and Hercules ward. There were 4 young people on Phoenix ward at the time of the assessment and 5 young people admitted on Hercules ward at the time of the assessment. We found there were sufficient staff on the wards to meet young peoples needs and facilitate activities. Patients and families were involved in the development and regular reviews of care and treatment plans and planning for the future.

Updated 21 May 2024

Nottinghamshire Healthcare NHS Foundation Trust specialist perinatal services consist of an 8-bedded inpatient unit and a community service. The Margaret Oates Mother and Baby Unit is an 8-bed specialist inpatient perinatal unit based at Hopewood Hospital and is for mothers from 32 weeks of pregnancy and their babies up to one year after birth. They are a regional unit for the East Midlands, however, as a national resource they accept admissions from other areas of England if needed. Community Perinatal services cover the whole of Nottinghamshire, the base is located at Hopewood Hospital, however the team see patients across the county in a variety of locations including in the patient’s home, GP practices. The service was last rated good (published). The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our on-site assessment on 18 June 2024. This was an unannounced assessment, which means the provider was not told an assessment was going to be starting beforehand. During this assessment we looked at all quality statements across 1 key question; 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. As we assessed all the quality statements for the key question of Safe, the rating for this key question reflects the findings of this assessment. However, as we did not assess quality statements from the key questions; Effective, Responsive, Caring and Well led, which means we use the ratings from the previous inspection to rate these key questions. At the time of the assessment the service was supporting 3 mothers and their babies on the unit.

Updated 10 June 2024

The Nottingham Eating Disorder Service run by Nottinghamshire Healthcare NHS Foundation Trust is a multidisciplinary community service which provides treatment and support for those aged 18 and over with an eating disorder. The service was last rated good (published July 2014). The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our on-site assessment on 18 June 2024. This was an unannounced assessment, which means the provider was not told an assessment was going to be starting beforehand. During this assessment we looked at 5 quality statements across 5 key questions; Safe and effective staffing; Assessing needs, Treating people as individuals; Care provision, integration, and continuity; Governance, management, and sustainability. As we assessed some but not all quality statements at this visit it means we use the ratings from the previous inspection to rate all the key questions safe, effective, caring, responsive and well-led. The service is based in a main office in Nottingham offering telephone and face to face or video conferencing appointments, this is based around individual need. The service is made up of various clinicians and worked alongside other partners. The service is made up of various clinicians and they worked alongside other partners. At the time of the assessment the service was supporting 115 people in the Nottingham eating disorder service.

Updated 10 June 2024

The Orion Unit is part of Nottinghamshire Healthcare NHS foundation trust and is an 8 bedded mixed gender inpatient unit providing assessment and treatment for patients with learning disabilities, behaviours that challenge and mental health issues. The unit provided accommodation for adults over the age of 18 who are treated informally or under the Mental Health Act. The service was last rated good (published August 2018). The report was published following the CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our on-site assessment on 24 June 2024. This was an unannounced assessment, which means the provider was not told an assessment was going to be starting beforehand. During this assessment we looked at 4 quality statements across 2 key questions; Involving people to manage risks, Safe environments, Learning culture and Independence choice and control. During this assessment we found a breach in regulation under safe care and treatment. Staff were not effectively assessing risk after patient incidents. As we assessed some but not all quality statements at this visit it means we use the ratings from the previous inspection to rate all the key questions safe, effective, caring, responsive and well-led. The service is based at Highbury Hospital. The service is made up of various clinicians and they worked alongside other partners. At the time of the onsite assessment the unit was supporting 8 patients.

Updated 25 November 2022

Updated 25 November 2022

Updated 25 November 2022

Updated 25 November 2022

Updated 23 December 2015

Specialist community mental health services for children and young people:

• young people and their families felt listened to, respected and treated with dignity

• young people and their carers told us staff involved them in planning, reviewing and updating their care

• the service provided access to advocacy and plenty of age appropriate leaflets and posters in the waiting area

• the service involved young people in the recruitment process for new staff

• there were enough rooms for young people to meet with professionals

• rooms were clean, bright and created a relaxed, therapeutic environment

• staff told young people if things went wrong

• people with disabilities, including wheelchair users, could access the unit

• the multi-disciplinary team consisted of a good range of disciplines, who were happy working in the team.

• the service had systems to ensure staff received mandatory training, appraisal and supervision

• staff received specialist training in recognised and recommended psychological interventions

• staff had a working knowledge of the Mental Health Act and Mental Capacity Act

• staff received safeguarding training and had a clear understanding of their responsibilities in relation to this

• risk assessments were comprehensive and up to date

• staff used clinical outcome measures to monitor young people’s progress

• the service had a process for dealing with complaints and made sure staff learned lessons from them

• staff could describe the duty of candour and the importance of it

• staff informed us they felt confident raising concerns without fear of victimisation

• staffing levels were adequate, and at the levels commissioned. Vacancies were actively being recruited to

• staff knew who the senior managers were within the organisation

• managers were supportive and visible

• staff understood and followed the procedures on lone working.

However:

• Four out of seven care records we reviewed did not contain a current plan of care.

• Six out of seven records were incomplete and inconsistent with limited up to date information and, in some cases, gaps of up to two years in the notes

• care plans were not recorded electronically, which made it difficult to access all information

• staff recorded notes on an electronic system so each young person had two sets of notes making it difficult to access all the information. The different types of notes put young people and staff at risk because vital information could be missed

• there were no records of face to face contacts, assessments or therapy sessions.

Updated 24 May 2019

Our rating of this service stayed the same. We rated it as good because:

• The service provided safe care. The number of patients on the caseload of the teams, and of individual members of staff, was not too high. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Teams included, or had access to, the full range of specialists required to meet the needs of patients in the community. Managers ensured that staff received training and supervision. Staff worked well together as a multi-disciplinary team and with relevant services outside the organisation.
• Staff understood and performed their roles and responsibilities under the Mental Health Act and the Mental Capacity Act.
• Staff treated patients with compassion and kindness and understood the individual needs of patients. Staff involved patients and families and carers in care decisions.
• The service was easy to access and staff and managers managed access and caseloads well. The service did not exclude people who would have benefitted from care. Staff assessed and initiated care for people who required urgent care promptly and those who did not require urgent care did not wait too long to receive help and start treatment.

However:

• The trust reported that it had received no complaints from patients under the care of the intellectual and developmental disabilities services. However, staff working in this service did not routinely provide patients and carers with information about how to raise a concern or complaint. Staff were aware of the availability of complaints leaflets, but they were not clear about how patients and carers would access them without asking.
• Some teams within the service had appraisal rates for non-medical staff that were significantly below the trust’s target.
• Omissions were present in care planning practices. Records did not always demonstrate that staff always developed care plans to address the identified needs of patients. Additionally, records did not clearly demonstrate when staff had offered or shared care plans with patients.
• Clinical audit practices were not always robust. Outcomes of audits were not always consistent with practices seen during the inspection and staff were not clear how the trust audited the application of the Mental Capacity Act.

Updated 25 November 2022

Updated 24 May 2019

Our rating of this service stayed the same . We rated it as good because:

• Clinical premises where staff saw patients were safe and clean. The number of patients on the caseload of the mental health crisis teams and of individual members of staff, was not too high. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff had provided a range of treatments suitable to the needs of the patients and staff engaged in clinical audit to evaluate the quality of care they provided.
• The mental health crisis teams included or had access to the full range of specialists required to meet the needs of patients. Managers ensured staff received training. Staff worked well together as a multi-disciplinary team and with relevant services outside the organisation.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients, families and carers in care decisions.
• The mental health crisis service and the health-based places of safety were easy to access. Staff assessed people promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude people who would have benefitted from care.

However:

• Staff working for the mental health crisis team at Millbrook Mental Health Unit had not always developed holistic, recovery-oriented care plans and staff at Millbrook Mental Health Unit and Bassetlaw Hospital had not offered all patients a copy of their care plan.
• Managers had not ensured that staff received supervision and appraisal in line with their policy.
• Staff did not always follow trust guidelines in relation to medicines management. Highbury Hospital staff did not safely deliver medication to patients as they did not secure the medicine in a safe way to transport it to a patient’s home or get patients to sign they had received it.
• In the section 136 Cassidy suite the locks and bolts on the suite doors were not suitable and therefore did not provide a safe environment for patients or staff.
• Although the environment at the Cassidy suite met the requirements of the Mental Health Act Code of Practice the Jasmine suite did not because there was no clock visible to patients when they were detained in the suite.
• Staffing levels in the section 136 suites did not meet safe staffing levels when there were emergencies.

Updated 20 May 2022

This report relates to Nottinghamshire Healthcare NHS Trusts’ Forensic and secure inpatient service. People in these services have often been in contact with the criminal justice system. These services may be low, medium or high secure, reflecting the different levels of risk that people may present. This service has 268 beds, on 17 male or female wards, across three hospital locations known as Wathwood Hospital Rotherham, Arnold Lodge Leicester, and Wells Road Nottingham.

We carried out this unannounced focused inspection between 08 and 18 February 2022. At this inspection we looked at the specific issues raised in the requirement and warning notices and sampled evidence across 13 of the possible 17 wards. We covered all the key lines of enquiry.

We wanted to see how the trust had met the requirement notices from our comprehensive inspection in May 2019 and the warning notices from our focussed inspection in February 2021.

After our comprehensive inspection in May 2019, we rated this core service as requires improvement overall. In response to concerns raised in late 2020 early 2021 we carried out a further responsive focussed inspection in February 2021. We re-rated this core service as Inadequate overall and issued warning notices.

To get a representative sample of evidence across the service we visited the Assessment and ICU ward, Continuing care ward, Rehabilitation ward and the Lodges at Wathwood Hospital; Ridgeway, Cannock, Foxton, Coniston and Thornton wards at Arnold Lodge; Porchester, Lister, Thurland and Seacole wards at Wells Road. We reviewed a range of data, reports, policies and procedures sent to us by the trust covering all wards in the service.

Our rating of this core service improved. We rated them as good because:

• Managers addressed all warning notices from 2021 at Wells Road. We reviewed their action plans, and it was evident they had addressed all the previous concerns. The action plan clearly demonstrated what was complete and work that was still in progress. It was evident on the wards we visited that there had been significant and positive changes in practice. We were assured that the trust had complied with the warning notice.
• We were pleased to see that managers across the service had addressed the requirement notices issued in May 2019.
• We were assured that managers had learnt lessons from the Warning Notices served at Wells Road. Managers used what they learnt to review service delivery and quality at Wathwood Hospital and Arnold Lodge. This resulted in changes to some of the practices and procedures at Wathwood Hospital and Arnold Lodge as well as Wells Road, as detailed below.
• The service had enough nursing and medical staff, who knew the patients and received basic training to keep people safe from avoidable harm.
• Staff assessed and managed risks to patients and themselves well. They achieved the right balance between maintaining safety and providing the least restrictive environment possible to support patients’ recovery.
• Staff provided a range of treatment and care for patients based on national guidance and best practice. They ensured that patients had good access to physical healthcare and supported them to live healthier lives.
• There was strong and visible leadership in the service, staff morale was good and robust governance systems and processes enabled managers to ensure that they delivered a safe and good quality service for patients.

However:

• On Thornton ward there were 20 male bedrooms each with en suite toilets but shared shower rooms or bathrooms. There were three shower rooms and one bathroom to service the 20 bedrooms, but one shower room had been out of action for over two months. This was not adequate provision for 20 patients. who told us they often waited a long time to use the bathroom. This was a different issue to those raised at previous inspections.
• At Wathwood Hospital across all wards, we found brown staining below the water line in some toilets. This was due to stained limescale build up rather than lack of cleaning. While risk of infection from this was low the limescale staining could harbour germs. We advised the manager of this issue. After the inspection we were advised that the facilities department were going to change their limescale remover for a more effective product. This was a different issue to those found at our previous inspections.
• At Wathwood Hospital closed-circuit television had not yet been installed in courtyard areas of the wards. Managers told us that following the Mental Health Act Review visit the absence of closed-circuit television in the courtyard was escalated to the trust’s blanket restrictions review meeting for ongoing review. In mitigation we saw that the trust was now considering this as part of their site improvement plans, and as soon as funds become available closed-circuit television will be installed in the courtyards. Individual risk assessments were in place for patients. The issue was discussed with patients in community meetings.
• We found opened, unlabelled food items in patient fridges on Thurland and Lister wards at Wells Road. This included an opened packet of ham on Thurland ward and opened jars of chutneys. This could prove to be hazardous to health.
• At Arnold Lodge there was not always enough staff to monitor the twin seclusion rooms. On four occasions they only had one staff member to monitor both rooms. While on Porchester ward at Wells Road, there was poor line of sight into the seclusion rooms, though the installation of closed-circuit television in these rooms would eliminate the issue.

How we carried out the inspection

During our inspection visit we:

• visited 13 wards and 10 clinic rooms across the service and looked at the accommodation and communal areas of the wards, we looked at the quality of the environment and saw how staff were caring for people
• spoke with 35 people who were using the service
• spoke with 10 relatives, who had family members using the service
• spoke with 10 senior managers
• spoke with 10 ward managers
• spoke with 38 other staff members including doctors, nurses, therapists, and healthcare support workers
• observed four multidisciplinary team care and treatment and handover meetings
• observed seven staff and patients’ interactions
• reviewed 24 care and treatment records of people using the service
• reviewed 42 prescription charts of people using the service
• reviewed prescribing practice and medicines management across the service
• looked at a range of policies, procedures, records and other documents relating to the running of the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Patients told us they were “not worried about violence or anything, it is friendly”. “They feel safe during the day and at night”.

A patient told us “I have met the advocate face to face, and she is friendly and understanding. I can have 1:1 session whenever you want”. Another patient told us “I know my named nurse and am happy with the care I receive. I attend psychologist appointments on a weekly basis. I work in the coffee bar once a week and do shop management work on a computer twice a week”.

Another patient told us he was following a fish diet; he said, “kitchen staff are particularly good and try and give you what you want to eat. I have a different meal for lunch and dinner. The pudding is okay and there is a choice of different foods for other patients”.

Patients were positive about the activities available on the ward saying, “there is a pool table and a games console”. “We have ward timetables showing what activities we can join such as cooking, going to the gym, visiting the coffee bar, television and video players. The timetables are updated on a weekly basis”. “Each of us has an individual timetable to help us get well again”. Another patient confirmed “we can have televisions and gaming in our rooms if our risk allows this”.

At Wathwood Hospital patients told us “We have access to gardening at the allotment, farm visits, and escorted leave to Christmas markets and restaurants”. Other patients said, they had “access to education courses through the onsite recovery college, voluntary dog walking at a nearby animal sanctuary and a new wellbeing therapy group had started on the ward one evening a week”.

Carers said they were mostly happy with the care and treatment provided by the service. Staff seemed very approachable and listened to any concerns. They tried to sort out problems before they become an issue.

Six out of ten carers said they knew about the carers forums and how to give feedback to the service.

However:

Patients told us that occasionally short staffing meant they “have to wait longer for things, for example, if you want to go into the kitchen or hospital shop”.

Other patients said that COVID-19 had made family visits difficult particularly when there was COVID-19 on the ward. While a carer said they were not allowed to see their relative for six weeks during a COVID-19 outbreak and because their relative did not like using the telephone or video calls they felt very cut off.

Updated 25 November 2022

Updated 1 March 2024

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services.

We have rated safe, effective and well led following this inspection. The rating at the previous inspection of March 2022 was requires improvement, this inspection shows that the rating has gone down.

We inspected the Wards for older people with mental health problems as part of this inspection. The trust has 5 wards across 2 locations, Highbury Hospital in Nottingham and Millbrook Hospital in Mansfield. We visited the following wards:

• Highbury Hospital - Silverbirch ward for older people with mental health problems. This ward was for patients living with dementia. 18 beds (male and female)
• Highbury Hospital - Cherry ward for older people with mental health problems. 16 beds (male and female)
• Millbrook Hospital – Kingsley ward for older people with mental health problems. 20 beds (male and female)
• Millbrook Hospital – Orchid ward for older people with mental health problems. 11 beds (female)

Our rating of services went down. We rated them as inadequate because:

• We found missing signatures on the administration of patient's medicines.
• We found examples where a patient's sedative medication had been administered against the prescribed dose and against medical advice.
• We observed examples of moving and handling that put patients at risk of harm.
• The ward for patients living with dementia did not follow national guidance in its environment.
• We were not assured that falls risks were routinely identified effectively, and mitigation or plans how to manage the risk.
• There was an inconsistent approach on which documentation to use when recording patients risks.
• There was an inconsistent approach in the completion of charts that were being completed by staff.
• We found inconsistencies on the provisions of informing informal patients of their rights under the Mental Health Act.
• There were still wards in the service that did not have single ensuite rooms and dormitories were still in place on 3 out of the 4 wards visited.
• There were documents for staff to complete on each ward we visited. We were not assured that data collection was used for specific reasons, such as stool charts or self-care charts when patients did not present risks in these areas.
• We were not assured that dietary intake of patients was being effectively completed by staff.
• We were not assured that management had timely oversight over data collected by staff regarding patient risk.

However:

• We found activities taking place on 2 out of 4 wards visited.
• Staff were receiving supervisions from there managers and felt supported
• Clinic rooms were stocked, organised and clean.

How we carried out the inspection

During the inspection we:

• spoke with 12 patients
• interviewed 11 staff members
• reviewed 18 patient care plans
• Looked at 4 clinic rooms
• Reviewed 48 patient medical cards
• visited 4 wards
• reviewed handover documents
• Reviewed patient records on food and fluid and self-care
• Observed staff interacting with patients
• reviewed section 17 leave documentation on all wards
• looked at environmental risk assessments.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

A patient told us that they don’t like sharing a room.

People told us that the ward is noisy with the building work, and they didn’t know what was being built.

People told us they were confused which room they could sit in.

People told us that sometimes they don’t have their own clothes and have someone else’s.

People told us that staff were kind and caring.

People told us that there are some activities.

Updated 1 March 2024

We carried out this unannounced focused inspection because we received information that gave us concerns about the safety and quality of the services.

We have rated safe and well led following this inspection. The rating at the previous inspection of March 2022 was requires improvement, this inspection shows that the rating has gone down.

We inspected the Acute wards for adults of working age and psychiatric intensive care units as part of this inspection. The trust has 9 wards across 2 locations, Highbury Hospital and Sherwood Oaks. We visited the following wards:

• Highbury Hospital- Redwood 1: acute wards for adults of working age (male) 16 beds.
• Highbury Hospital - Redwood 2: acute wards for working are (female) 16 beds.
• Sherwood Oaks hospital - Elm ward: acute ward for adults of working age (male) 18 beds.
• Sherwood Oaks hospital - Cedar ward: acute ward for adults of working age (male) 18 beds.

Following this inspection, we told the trust they must make improvement to mitigate urgent risks. The trust responded with an action plan to mitigate the risks and we were assured by their response.

Our rating of acute wards for adults of working age and psychiatric intensive care units went down. We rated them as inadequate because:

• There was an inconsistent approach to recording patients details when they accessed their leave from wards.
• There was an inconsistent approach on which documentation to use when recording seclusion observations.
• Observation records completed by staff had been falsified.
• We found incidents of assaults on patients by staff members.
• There were ligature risks which had not been identified but not acted on to reduce the risk of harm to patients.
• There was a high use of agency staff due to staff vacancies.
• Staff did not always share key information to keep patients safe when handing over their care to others.
• Staff did not always raise concerns and report incidents and near misses in line with trust policy.
• The service did not always learn from incidents.
• Management processes did not operate effectively at team level.

However:

• We found all wards were clean well equipped, well furnished.
• Staff made sure cleaning records were up-to-date and the premises were clean.
• Staff completed and kept up to date with their mandatory training.
• Patient notes were comprehensive, and all staff could access them easily.

How we carried out the inspection

During the inspection we:

• spoke with 14 patients
• interviewed 15 staff members
• reviewed 7 patient care plans
• reviewed 5 incidents on CCTV
• reviewed 4 seclusion records
• visited 4 wards
• reviewed handover documents
• reviewed section 17 leave documentation on all wards
• looked at environmental risk assessments.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

People told us that they felt unsafe at night due to the use of agency staff not knowing how to support them.

People told us that they struggled to get answers from staff when they ask questions or wanted something.

People told us that they liked the food.

A patient told us that they felt the night staff was shocking.

People told us that they feel that their observations are not completed properly.

A patient told us that staff do not wear names badges and sometimes they do not tell patients their name.

People told us that they felt their beds were comfortable.