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CQC report: Nottinghamshire mental trust health staff falsified documents and assaulted patients

The Care Quality Commission (CQC) reported incidents of staff falsifying records and assaulting patients at Nottinghamshire Healthcare NHS Foundation Trust after its inspection in 2023.

The trust’s acute adult and older people wards were visited by inspectors last year.


Inspection reports published on Friday 1 March noted the failings across theservices, resulting in both to having overall ratings dropped to Inadequate.

The CQC visited acute adult mental health wards at Highbury Hospital in Nottingham, and Sherwood Oaks in Mansfield, as part of the inspection.

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The report on these visits highlights a number of concerns, including an inconsistent approach to recording patient’s details when they accessed leave at both hospitals and incidents of assaults on patients by staff members at Sherwood Oaks.

It also details occasions where staff were found to have falsified records at Highbury Hospital – two of which were uncovered before the CQC’s inspection following the deaths of two patients and after the police became involved.

The CQC also observed an example of staff falsifying records while visiting Redwood 2 – a ward at Highbury Hospital.

A patient who had been assessed as needing regular 10-minute observations due to the risk of harm to themselves was found in their bathroom with a ligature.

Observations were noted on the electronic patient record but the CQC found there were two occasions when the patient was not checked, however staff recorded that they had been checked.

Greig Rielly, the CQC’s deputy director of operations in the midlands.

“A trust investigation of CCTV found that these staff had falsified care records to show that observations had been done when by hadn’t,”

“Our inspectors also reviewed CCTV footage in the acute wards for adults of working age and psychiatric intensive care units and found staff had assaulted people causing physical harm.

“There had been four occasions where two people had been physically assaulted on Elm ward. 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.”

Inspectorsfound shortcomings when they visited the trust’s wards for older people at Highbury Hospital and Millbrook Mental Health Unit in Mansfield.

Among failings were that a patient’s sedative medication had been given against the prescribed dose and against medical advice, as well as missing signatures on some of the patient cards.

The report also notes that there was no clear signage on the wards to support people living with dementia and that the signs that were in place “did not comply with best practice”.

The inspections of the two services took place on dates in October, November and December last year.

The CQC noted that the acute adult wards were clean and patient records were comprehensive, while staff working on the wards for older people felt supported.

Mr Rielly said:

“Since the inspection, we have told the trust where we need to see rapid and widespread improvements and we 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.”

In response Ifti Majid, Chief Executive of the trust said:

‘Today, the Care Quality Commission (CQC) is publishing its reports following inspection of our services in acute wards for adults and psychiatric intensive care units (PICU) and wards for older people with mental health problems. The inspections took place in October, November and December 2023.

‘The CQC found a number of areas that needed to be improved and we have therefore been rated as inadequate overall for both the services we provide to inpatient adults and older adults. These are decreased ratings from our previous inspections.

‘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. Some 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 are happening, 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.

‘We will continue to work closely with the CQC, our colleagues, and importantly those who use our services and their families, so that the experience for all those who use our services is vastly improved.’

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