Nightingale Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Patients confirmed that their physical and mental health needs were assessed and treated in consultation with them. Care plans indicated that patients were involved in making decisions about their care and support. Staff assessed and monitored physical health needs arising from patients’ eating disorders, such as a fast heart rate, and urinary symptoms. They carried out blood tests and checked patients’ vital signs on a regular basis. They also provided support with wider physical health needs such as diabetes. Records showed that staff assessed patients for the risk of refeeding syndrome, which can include heart, lung and neurological symptoms. When required they carried out appropriate monitoring and treatment. As required at the previous inspection, staff undertook assessments of tissue viability to reduce the risk of patients with low weights developing pressure ulcers. We found that care plans for day patients did not always take into account their new circumstances (after discharge from the ward). However, patients said that staff had prepared them for the transition to day patient status with appropriate support. Following the inspection, managers provided an example of an updated day care plan taking account of relevant risks. Most patients knew who their named nurse was, but they said that they could not always see them if they were on leave. Staff provided patients with psychological interventions, a meal planning group and a nutrition group each week, as well as supporting wellbeing activities such as mediation, yoga, groups on body image, and self compassion. The service had access to a full range of specialists to meet the needs of patients on the ward. As recommended at the previous inspection staff had access to the results of recent audits, managers assessed staff competencies in areas including mealtime supervision, and patient engagement. Some patients felt that there could be an improvement in communication between therapy and nursing staff.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

All patients we spoke with confirmed their care and treatment needs were assessed and reviewed with them. Most carers spoke positively about staff’s understanding of the needs of their relatives. Patients and carers confirmed physical and mental health needs were assessed and treated in consultation with them. Patients we spoke with confirmed that their care plans were individualised to their specific needs.

Staff completed a comprehensive assessment of each patient either on admission or soon after. Staff developed a comprehensive care plan for each patient that met their mental and physical health needs. Staff said that they regularly reviewed and updated care plans when patients' needs changed, and attempted to make these personalised, holistic and recovery orientated.

Care plans indicated that patients were involved in making decisions about their care and support and were written from their perspective. The service ensured communication needs were met and used a translation service. Managers ensured staff had systems, processes, and tools in place to assess patients care and treatment needs. Staff assessed the physical and mental health of patients on admission to the ward. They developed individual care plans for inpatients, which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff assessed and monitored physical health needs arising from patients’ eating disorders, such as a fast heart rate, and urinary symptoms. They carried out blood tests and checked patients’ vital signs on a regular basis. They also provided support with wider physical health needs such as diabetes. Records showed that staff assessed patients for the risk of refeeding syndrome, which can include heart, lung and neurological symptoms. When required they carried out appropriate monitoring and treatment. For example, prescribing appropriate meal plans and thiamine, taking regular blood tests, and keeping the patient in a warm and restful environment. Staff regularly reviewed and updated inpatients’ care plans when their needs changed. Day patients we spoke with said that staff had prepared them for the transition to day patient status and provided appropriate support. Following the inspection, managers provided an example of an updated day care plan which took account of risks patients’ views and wishes and how these were taken into account when patients were not at the service. Care plans were personalised. They included details of patients’ views and wishes and how these were taken into account.

Patients indicated they received care and treatment in accordance with best practice. Patients spoke about accessing a wide range of psychological interventions. They referred to group and individual activities they attended to support them with their recovery. Some patients referred to goals that they had set to work towards discharge. At the previous inspection in June 2022, we recommended that patients should be aware of who their named nurse was, have regular one-to-one sessions with their named nurse, and that these sessions are recorded. Most patients knew who their named nurse was, but they said that they could not always see them if they were on leave. However, they did say that they could speak to other members of staff instead.

The service had access to a full range of specialists to meet the needs of the patients on the ward. Patients received care, treatment and support that was evidence-based and in line with good practice standards. Patients had access to a full multi-disciplinary team including doctors, nurses, dietitians, therapists, and psychologists. Staff delivered care in line with best practice and national guidance. They were aware of national guidance for the treatment of adults with an eating disorder. For example, the National Institute for Health and Care Excellence (NICE) recommended treatments, such as individual eating disorder focussed cognitive behavioural therapy and access to psychoeducation groups about a specific diagnosis. The service offered these, as well as a family forum, and a range of therapies including family therapy, art therapy, mentalisation, cognitive remediation therapy, and mindfulness. Staff had access to NICE and other guidance such as guidelines about Medical Emergencies in Eating Disorders on the provider’s intranet. Staff had regular reflective practice sessions to understand the culture on the ward. Staff made sure patients had access to physical health care, including specialists as required and met patients’ dietary needs. We met with a dietitian working at the service, who noted that in response to patient feedback they attempted to include additional alternatives on the menu. This was prepared 1 week in advance, with new admissions to the unit planned on Monday to Thursdays. Staff used recognised rating scales to assess and record the severity of patients’ conditions and care and treatment outcomes. Staff helped patients live healthier lives by supporting them to take part in programmes or giving advice. Patients could access smoking cessation support if they wished. Staff could refer patients to see specialists for example for an autism assessment or eye movement desensitisation reprogramming therapy for trauma.

Staff worked together as a multidisciplinary team. The ward doctor carried out a physical examination of patients on admission and ensured that refeeding was monitored by regular blood tests, in collaboration with the dietitian’s assessment. Staff carried out regular physical health checks on patients including blood pressure, pulse, temperature and oxygen saturation. Physical health was monitored using an appropriate tool (NEWS2 charts). The dietitian assessed patients’ nutritional status, prescribed individualised eating plans, and supported behaviour changes around food. On admission, the dietitian met with the patient for an individual assessment which could include a family member if the patient wished. The service offered three stages of mealtime support, which meant they could meet the needs of a range of patients. The occupational therapist offered group work and supported patients in eating out, creative groups and goal setting. There was a kitchen they could use with patients to support the preparation of meals, as part of treatment. All patients were assessed by a psychologist before attending groups to ensure their suitability. Nursing staff used documented guidelines written by the dietitian that outlined the exact portions of food to prepare at breakfast and snack times. This included details of how much food supplement should be provided if a patient was unable to finish elements of their meal. There was a weekly timetable available to both day and inpatients which included individual and group therapy and psychoeducation groups. The therapy team met once a month to review the timetable and make any changes to meet the needs of the patient group at the time. Oral refeeding was the preferred method on the ward. There was a policy in place for the use of nasogastric feeding (by tube). As recommended at the previous inspection in June 2022, staff had access to the results of audits on the ward, and checked staff competencies in key areas.

Patients and carers generally felt that staff worked well with them to support their needs and care for them. Patients spoke particularly positively about some members of staff in the permanent team, who they felt had made a huge difference to them some indicating that their interventions had been lifesaving. Some patients and carers felt that there could be an improvement in communication between therapy staff and nursing staff, to avoid misunderstandings about dietary plan changes or agreed activities and improve consistency on the ward. Following the inspection, the hospital provided examples of improved recording of handovers between nursing and therapy staff and weekly catch-up meetings between the ward manager and the lead therapist.

Staff felt that they worked well together to meet patients’ needs. Some staff acknowledged that there could be an improvement in communication between nursing staff and therapy staff including the dietitian so that patients received consistent support. Following the inspection managers provided examples of improved recording of handovers between the teams, and weekly catch-up meetings between the ward manager and the lead therapist. Staff gave examples of how they worked together as a multi-disciplinary team to support patients with transitioning towards discharge or attending as a day patient. They said that reflective practice sessions had been increased to twice monthly provision for all staff on the ward, facilitated by a psychologist. They also noted that the full multidisciplinary team was involved in providing training for staff covering refeeding syndrome, dangers of eating disorders, bloods and monitoring, portion sizes, and family dynamics. They said that they attended peer support sessions on a weekly basis, which they found helpful. Staff described lots of support provided with the new electronic records system that they were using. Overall staff were very positive about teamwork and support on the ward.

We observed onsite staff interactions and working practices, and reviewed care records. These demonstrated effective working across teams and services to support people. We saw evidence of discharge planning and preparation to ensure effective transitions were in place. Handover meetings took place twice a day between nursing shifts. We attended an evening staff handover meeting, in which each patient’s needs were discussed in detail. Staff kept up-to-date and detailed records of patient needs and could refer to these notes throughout their shift.

Managers ensured that staff worked well together. There were systems and processes in place to ensure continuity of care for patients with treatment needs or transitioning plans. These were communicated effectively and coordinated well between services or teams. The ward team had access to the full range of specialists required to meet the needs of patients on the ward including 3 consultant psychiatrists, an occupational therapist, dietitian, psychologists and therapists. Managers made sure they had staff with the range of skills needed to provide high quality care. They provided an induction programme for staff new to the ward including bank or agency staff this included a document titled ‘the minimum you should know.’ They supported staff with appraisals, supervision and opportunities to update and further develop their skills including competency training in all relevant areas of care, and in working with patients with autism. Nursing staff confirmed that they received clinical and management supervision monthly and felt supported. This was confirmed by records of supervision sessions indicating 94% compliance with monthly supervision sessions for staff, and 83% compliance with annual appraisals. We looked at three staff members’ records of supervision on the ward, which indicated that a range of topics were routinely discussed including lessons learned from recent incidents or complaints. Student nurses confirmed that they received regular supervision and support. Therapy staff received regular supervision from senior staff of the same discipline, in line with professional requirements. Junior doctors received supervision from a hospital consultant and worked closely with the ward consultant psychiatrist to gain expertise in eating disorders. Managers made sure staff attended regular team meetings. The meetings dealt with a range of issues relevant to the ward including learning from recent complaints or incidents in the hospital.

Patients told us that the programme of groups at the service, encouraged them to look at healthy choices in diet and lifestyle. They were encouraged to make choices within the dietary plans agreed, and consider healthier lifestyles upon discharge from the service.

Whilst patients were able to smoke or vape outside the hospital, and there was a smoking area inside the main hospital, managers said that they were working towards becoming a smoke free hospital. Staff were able to refer patients to smoking cessation support, with doctors prescribing nicotine replacement options. Staff provided patients with a meal planning group and a nutrition group each week, as well as supporting wellbeing activities such as mediation, yoga, groups on body image, psychoeducation, and self-compassion.

The hospital's processes supported people to manage their health and wellbeing so they could maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

Patients told us that they were asked for their views about the service, at regular ward rounds, and in weekly community meetings, as well as through a survey they completed at the end of treatment.

Staff rotated between working day and night shifts. Registered and non-registered nurses said that they usually carried out audits at night and had been provided with training in undertaking the audits. These included audits of medicines, the environment, patient rights, and patient care and treatment records. Staff said that the results of audits were discussed in handover meetings, and other staff meetings, with plans put in place to improve performance.

The provider undertook weekly audits on the ward, including patient records and clinical notes, patient Mental Health Act and other rights, medicines stocks, first aid provisions, and the environment. They had recently highlighted an area for improvement in recording weekly one to one key working sessions with patients and were working to improve staff performance in this area. Minutes of staff meetings included lessons learned from incidents, audits, complaints and feedback. For example, the need to have spillage kits available, correct recording of assembly of the sharps bin, recording patients’ consent to have photographs taken, and reports of staff raising their voices with patients. Audits were undertaken of staff inductions, training, and competencies. Managers advised that they relayed any individual areas for improvement to the staff team, to ensure that they were addressed. Results of audits were discussed at clinical governance meeting, and the clinical improvement meeting (led by the therapy team) each month, as well as at other staff meetings.

Patients were aware of and understood their rights around consent and the care and treatment they received. Carers were consulted with and invited to best interest meetings, where appropriate. Patients had easy access to information about independent mental health advocacy and patients who lacked capacity were referred to the service. Informal patients could leave at will and told us that they knew this. The ward displayed signs explaining the rights of informal patients.

Staff demonstrated an understanding and commitment to ensuring patients were aware of and understood their rights. They said that consent was sought from them prior to care and treatment decisions so that patients could make informed choices. Staff were aware of the need to request an opinion from a Second Opinion Appointed Doctor (SOAD) in particular circumstances. At the time of the inspection no patients were detained under the Mental Health Act 1983. However, staff had experience of working with detained patients, and had systems in place to store copies of patients’ detention papers and associated records appropriately so that they could be accessed when needed. Staff received and kept up to date with training on the Mental Health Act and the Mental Capacity Act and said that they could access support and advice on implementing these legal frameworks from within the hospital. When staff assessed patients as not having capacity, they made decisions in the best interest of patients and considered the patient’s wishes, feelings, culture, and history. They said that they attempted to support patients to make specific decisions for themselves before deciding a patient did not have the capacity to do so. Staff assessed and recorded capacity to consent each time a patient needed to make an important decision.

Our observations of staff and patient interactions indicated that consent was sought from patients prior to any care intervention or treatment. Care records demonstrated patients were being informed of their rights, people’s capacity, and ability to consent were taken in to account, carers, families and advocates were consulted with, and capacity assessments and best interest meetings were held, where appropriate.

The service had clear, accessible, relevant, and up-to-date policies and procedures that reflected the Mental Capacity Act, Mental Health Act, and the Mental Health Act Code of Practice. On admission, staff assessed patients’ capacity to consent to treatment, either for the general care provided or for specific interventions, such as nasogastric feeding. Staff re-assessed capacity for new decisions or if there was a change in the patient’s situation and gave patients all possible support to make specific decisions for themselves before deciding a patient did not have the capacity to do so. When staff assessed patients as not having capacity, they made best interest decisions considering the patient’s wishes, feelings, culture and history. The provider had systems and processes in place to ensure that people understood the care and treatment being offered and made informed decisions. Staff conducted audits of Mental Health Act rights being read to patients. Care records demonstrated evidence of patients being informed of their rights and capacity assessments being conducted and reviewed. Managers made sure that staff could explain patients’ rights to them. At the time of the inspection there were no patients on the ward detained under the Mental Health Act, or a Deprivation of Liberty Safeguard. Patients had easy access to information about independent mental health advocacy and patients who lacked capacity were automatically referred to the service. Staff made sure patients could take section 17 leave (permission to leave the hospital) when this was agreed with the Responsible Clinician. Informal patients knew that they could leave the ward freely and the service displayed posters to tell them this. Managers and staff completed audits of Mental Health Act and Mental Capacity Act compliance. All eligible staff were up to date with Mental Health Act training and 86% of staff were up to date with training in the Mental Capacity Act.