Care Quality Commission tells Nottinghamshire Healthcare NHS Foundation Trust improvements are needed to keep people safe on mental health wards
Two NHS mental health services have been rated ‘inadequate’ after staff were found to have falsified records and assaulted people.
The Care Quality Commission (CQC) found that improvements need to be made by Nottinghamshire Healthcare NHS Foundation Trust following inspections carried out between October and December last year.
Unannounced focused inspections were carried out at the trust’s acute wards for adults of working age and psychiatric intensive care units (PICU) and wards for older people with mental health problems. These were done after concerns were raised about the safety and quality of these services.
Following the inspections, the ratings for both services were dropped by the CQC.
Greg Rielly, CQC deputy director of operations in the Midlands, said: “When we inspected acute wards for adults of working age and psychiatric intensive care units (PICU), as well as wards for older people with mental health problems, it was concerning to find a lack of oversight from leaders across the services. We also found staff weren’t always being kind and respectful to the people they were caring for.
“When we visited Cherry ward (at Highbury Hospital, Nottingham) for older people, there was a significant impact on staffing due to a serious incident which took place last November. That incident resulted in a number of staff being suspended, which heavily impacted on the standard of care people were receiving due to staffing levels.
“A trust investigation of close circuit television (CCTV) found that these staff had falsified care records to show that observations had been done when they hadn’t. Our inspectors also reviewed CCTV footage in the acute wards for adults of working age and PICU and found staff had assaulted people causing physical harm. There had been four occasions where two people had been physically assaulted on Elm ward (at Sherwood Oaks hospital, Mansfield). The staff involved had been suspended and the trust have investigated the incidents.
“This is totally unacceptable behaviour and must be addressed by the trust as a priority. Leaders must take urgent action to have better oversight of issues, to ensure people are safe and receiving the care they deserve.
“Since the inspection, we have told the trust where we need to see rapid and widespread improvements and have issued requirement notices, so they know where they need to focus their attention. We will continue to monitor the trust closely whilst these improvements are being made to keep people safe. If we’re not assured improvements have been made and embedded, we will not hesitate to use further enforcement powers to keep people safe.”
The overall rating for acute wards for adults of working age and PICU has dropped from requires improvement to inadequate. The ‘safe and well-led’ aspect was again rated inadequate, while being ‘effective, caring and responsive’ was not included in this inspection and remains rated requires improvement.
Following this inspection, CQC told the trust it must make improvements to the service to mitigate urgent risks. The trust responded with an action plan to mitigate the risks which gave CQC assurance.
Wards for older people with mental health problems’ overall rating has declined from requires improvement to inadequate (as has its rating for being safe and well-led). The score for ‘being effective’ was again re-rated as requires improvement. The ‘responsive’ aspect was not included in this inspection and remains rated as requires improvement. ‘Caring’ was not included and remains rated an aspect rated as good.
At acute wards for adults of working age and PICU inspectors found there were inconsistent approaches to recording patients’ details when they accessed leave from their wards and on which documentation to use when recording seclusion observations, ligature risks which had not been identified or acted on to reduce the risk of harm to people, a high use of agency staff due to staff vacancies, staff did not always share key information to keep people safe when handing over their care to others, and did not always raise concerns and report incidents and near misses in line with trust policy.
They also found the service did not always learn from incidents.
The CQC reported detailed feedback from people who use the service, who described the night staff as “shocking”. They said they felt unsafe at night due to the use of agency staff not knowing how to support them and they struggled to get answers from those staff.
However, the wards were clean, well equipped and well furnished, cleaning records were up-to-date, staff completed and kept up to date with their mandatory training, and patient notes were comprehensive, and all staff could access them easily.
At wards for older people with mental health problems, inspectors found there were missing signatures on the administration of people’s medicines, examples where sedative medication had been administered against the prescribed dose and against medical advice, inconsistent approaches on which documentation to use when recording people’s risks and the completion of charts that were being completed by staff.
There were also wards that did not have single ensuite rooms – with dormitories still in place on three out of the four wards visited – no assurance that people’s dietary intake was being effectively completed by staff and no assurance that management had timely oversight over data collected by staff regarding people’s risk.
Service users told inspectors that sometimes they don’t have their own clothes and have someone else’s, they were confused which room they could sit in, and the ward was noisy due to building work.
However the CQC noted that activities were taking place on two out of four wards visited, staff were receiving supervisions from their managers and felt supported, and clinic rooms were stocked, organised and clean. Service users also told the CQC that staff were kind and caring.
Ifti Majid, chief executive of Nottinghamshire Healthcare said: “The safety and wellbeing of our patients is always our priority. We welcome inspections as they are an important way for us to understand how we are doing, identify any areas for improvement and the opportunity to make things better.
“I absolutely accept that these inspections found care that was not of the standard or quality that it should have been and I apologise unreservedly that we have let down patients who have not received the level of care they deserve. I recognise that we have to do better, to make changes in the way we deliver care so we can help those who need us and reassure the public of Nottingham and Nottinghamshire that it is a good thing to seek care and support from us.
“We have responded quickly to start that improvement journey.”
He said examples of the changes we have made so far since the inspections took place include:
• Increased support and oversight of clinical practice – including a group with responsibility for overseeing improvements and listening to and acting on patients’ feedback.
• Additional senior nurse capacity and support into adult services and older people's services, consolidating the role of the service manager and matron to reduce the numbers of wards each is responsible for, which means they will have greater oversight.
• Increased medicines management training and improved medicine administration.
• A review of all observations with a specific focus on listening to patients’ experiences, revised and enhanced training packages for substantive and bank staff so they are all fully aware of how to carry out therapeutic observations to keep patients safe.
• Strengthened the patient safety team with additional senior nurses to further support the implementation of the national Patient Safety Incident Response Framework (PSIRF) to ensure we learn from incidents and take action as a result.
• Established a ward managers development programme.
• Active recruitment campaign to reduce the need for agency staff.
• Enhanced daily checks on records of patients’ leave to ensure risk assessments and safety measures are in place.
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