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

The wards and hospitals used different tools and initiatives to share learning and risks. Patients attended regular community meetings where they could share their views. However, risk was not managed well. Patient risk assessments were not updated after incidents of risk, and they did not include all safeguarding incidents. Staff had an inconsistent approach to reporting incidents involving risk items being found, carrying out patient searches after Section 17 leave and the definition of what covered grounds leave. Leaving patients at risk. There was no consistent process in place for recording when patients had access to their personal risk items and when these had been returned. This meant staff were unaware when there were additional potential risks on the ward. Not all staff had access to regular managerial supervision, where they could raise concerns and seek support from their managers. We found ripped furniture which could not be cleaned effectively and posed a potential infection control risk on ward areas, that had not been identified on the environmental audits. Therefore, we found breaches in regulation under safe care and treatment, safe staffing and premises and equipment. We have asked the trust to submit an action plan outlining how they are going to meet these areas of concern.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients we spoke with told us that they could attend community meetings, this was a place where any learning would be shared.

Staff we spoke with told us they received updates from the trust via emails weekly. They told us that information is shared through handovers, daily huddles and staff meetings. However, staff told us that sometimes they don’t have time to read trust emails.

We found the wards and hospitals used different tools and initiatives to share learning and risks.

Senior leaders from Sherwood Oaks told us due to the repeated incidents, of patients absconding and learning from a recent incident a new initiative was brought in making staff more aware of how to document a patient when accessing their section 17 leave. This was focused on Beech ward and not found on the other wards we visited.

We observed a daily huddle whilst on Redwood 2. It was thorough and covered each patient's risks and any incidents from the past 24 hours. The structure of the meeting was clear and allowed time for discussion. Leaders of the ward expressed that they identified that structure was missing from the way of working on the ward and one element that they had changed was the structure of daily huddles to share information to the team more effectively.

At Highbury Hospital, we observed that the wards were using a document called ‘Safety Cross’ which displayed the number of incidents during each day and the level of incident. It was a visual tool which then expanded into a detailed document to explain the incident. We did not see this document at our visit at Sherwood Oaks. It was a useful document for staff to visualise potential hot spots of incidents.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Staff did not always include an active patient voice in care planning and risk assessments.

Staff did not always have access to appropriate information around managing patient risk. Patient care plans, and risk assessments were not always updated after incidents or changes in patient presentation. We found risks and incidents around ligating identified in the patient’s daily notes, but these were not reflected in the patient's care plan or risk assessments. This patient’s care plans and risk assessments had not been updated since December 2024 and did not always include safeguarding incidents.

We conducted a review of incidents where patients had absconded. Staff at Sherwood Oaks were inconsistent around the definition of what covered ‘ground leave’. Some staff thought it covered access reception area to the car park, whereas other did not. We were not assured staff would be confident in knowing where patients were if the failed to return after leave, leaving patients at risk.

The management of risk items and searches after section 17 leave was inconsistent. During environmental searches between October 2024 and January 2025, 87 risk items were found on ward areas. Items included screwdriver, lighters, and drug injection equipment amongst other restricted items. Incident records were inconsistent when risk items were found. A ward manager told us they did not always record every time staff found a risk item. This meant staff would not be aware if patients were at risk of secreting items onto the ward which could cause them harm.

Patients had access to lockers to store personal risk items. However, there was no clear process in place to log when these items had been given to patients and when they had been collected and stored back into their lockers. This increased the risk of harm to patients. Management of patient risk was an area of improvement identified at the previous assessment in September 2024. We found managers had not addressed this effectively.

Patients at Highbury Hospital we spoke with told us “Ward environment is uncomfortable”, “Environment is busy and small’. At Sherwood Oaks patients we told us “No issues with the facilities”, “Facilities are brilliant and spacious”. Patients had access to a nurse call system. However, we found 1 patient’s call bell was not working. When we asked staff to review this, it was found the system had been disabled and no one knew how or for how long this had been disabled for as it could only have been done using a specific access key. The patient was pleased that it had been addressed and working again. Patients at both locations had access to outside spaces that were accessible from their wards.

Staff at Sherwood Oaks knew how to report maintenance issues. However, staff at Highbury Hospital told us that due to the building not being owned by the trust, they had to wait for repairs to be made. On Willow ward we saw ripped and damaged chairs in the communal lounge. This issue had not been identified, which could have been an infection control risk due to the chair not being able to be cleaned effectively. The ward manager assured us this would be looked at.

Ward layouts at both locations allowed staff to observe all parts of the ward and there was CCTV in place, which was regularly reviewed. However, on Beech ward at Sherwood Oaks, the ward managers office had paper placed in the window of the door meaning staff could not see the ward, leaving patients at risk.

Wards had an environmental coordinator who oversaw an environmental audit and risk assessment schedule. However, there was no formal guidance in place for this role and there was no cover in place when the coordinators were off work. There was a process in place to check patient’s bedrooms at both locations, but the documentation used to record this was inconsistent. Leaders told us they were working on ways to ensure there was a consistent approach in place across wards.

People told us they felt “staff are too busy, they sit in the office or using their phones” another patient told us “I don’t feel safe on the ward, too many agency staff”. A patient on the Willow ward told us staff “didn’t listen” when they spoke to staff about being in pain and they had to result in harming themselves to be heard “I burst the abscess in my mouth to be taken seriously”. Another patient told us how they felt the ward can be understaffed and that “sometimes we can’t get fresh air in the courtyard due to needing 2 staff”. However, patients did tell us that they felt staff can be “supportive” and “caring and brilliant”.

On each ward we visited there was enough staff to respond to patients' needs. The shifts were filled with a mix of permanent and agency or bank staff. Leaders told us that vacancies levels were low, but they still required to back fill gaps. They told us that they only use familiar agency staff from a reliable agency firm to allow consistent care for the patient. Safe recruitment practices were not always in place to ensure that agency staff were suitably experienced, competent and able to carry out their role.

Agency staff on Cedar Ward told us they received a local induction and were familiar with the ward. However, on Beech Ward, agency staff did not know the process for gaining consent to search patients returning from planned leave.

We reviewed supervision rates for staff at both locations. The compliance rates were over 80% on each ward apart from Redwood 2 whose compliance rates for clinical and managerial supervision were below 60%. This means that just over 40% of staff did not receive supervision in the month of December. Staff may have not had the formal opportunity to discuss issues or receive 1:1 time with their line managers. Staff who we spoke with told us they used supervision to bring up issues and to learn from incidents, also to give and receive feedback.

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

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