Nightingale Hospital

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Patients said that staff supported them with their physical, mental, emotional, and social needs. They were clear that they were asked about their needs and preferences and able to contribute to their risk assessments and care plans. Patients and their carers/relatives (when patients agreed) were involved in planning and making shared decisions about their care and treatment. The service made reasonable adjustments where necessary to meet people’s needs such as mobility issues or language barriers. Meals reflected individual dietary, cultural and religious needs. The ward’s weekly timetable was available for patients to see on the ward including mealtimes and a range of group therapies and educational sessions from Monday to Friday, and some weekend sessions. Groups included goal setting, self-compassion, body image, nutrition, creative writing, arts and crafts, and meal planning. Patients also had sessions in compassion-focussed therapy, dramatherapy, art therapy, cognitive behavioural therapy, dialectical behavioural therapy, meditation, yoga, and gentle stretching. At the time of the inspection, management had limited the total number of patients (inpatients and day patients) to 15, to ensure that the unit was able to provide safe and appropriate support to all. There was some flexibility in exclusion criteria for the ward, the lead psychiatrist said that they conducted a holistic assessment and would carefully consider whether it was appropriate to admit patients with a chronic physical illness or psychiatric risk. At the time of the inspection patients and carers felt that the hospital looked into their complaints and made changes accordingly. However, prior to the inspection, a small number of patients and carers were not happy with how responsive the service was to their concerns.

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.

Patients said that staff supported them with their physical, mental, emotional, and social needs. They were clear that they were asked about their needs and preferences and able to contribute to their risk assessments and care plans. Patients and their carers/relatives (when patients agreed) were involved in planning and making shared decisions about their care and treatment at ward rounds and other meetings. Patients understood their conditions, and care and treatment options (including associated risks and benefits) and any advice provided. Whilst they did not always agree with the medicines they were prescribed, their concerns were discussed and recorded, alongside the reason for the treatment, and this was reviewed regularly. The service made reasonable adjustments where necessary to meet people’s needs such as mobility issues or language barriers. Meals reflected individual dietary, cultural and religious needs. Breakfast was no longer part of the day programme at the time of the inspection, however staff advised that there could be flexibility if particular patients were struggling to manage an independent breakfast. The ward’s weekly timetable was available for patients to see on the ward including mealtimes and a range of group therapies and educational sessions from Monday to Friday, and some weekend sessions. Groups included goal setting, self-compassion, body image, nutrition, creative writing, arts and crafts, and meal planning. Patients also had sessions in compassion-focussed therapy, dramatherapy, art therapy, cognitive behavioural therapy, dialectical behavioural therapy, meditation, yoga, and gentle stretching.

Staff said that they were able to provide safe, effective, and person-centred care and management were working to provide the support and resources they needed. They received regular supervision, training, and support, and could refer patients to physical health professionals outside of the hospital as needed. They provided examples of how they supported patients according to their individual preferences, including patients who identified as of a different gender from their birth gender, patients with ongoing physical health conditions, and those who needed reassurance in particular situations. For example, some patients needed extra support after using leave outside of the hospital, as this was a particularly high-risk time for them.

We observed staff treating patients as individuals and supporting them according to their wishes. Staff demonstrated that they knew patients well and were able to engage with them in positive ways reducing distress and anxiety. Some patients had opportunities to go on leave for activities outside of the hospital, including shopping, visiting cafes and home visits.

Staff supported patients with activities outside the service, such as work, education and family relationships. Staff supported patients who were in education and work. Day patients told us that they were able to continue with their university courses, and employment, with the support of the service. Staff encouraged patients to develop and maintain relationships with people that mattered to them, both within the service and the wider community. The occupational therapist ran a social program for eligible patients using a graded approach. This started in the ward dining room, then moved to the main part of the hospital, and then to going out into the local community. This included shop and cook sessions broken down into tasks from writing a shopping list, to cooking and portion control, followed by a reflective session. Patients’ care plans reflected their physical, mental, emotional, and social needs, including those related to protected characteristics under the Equality Act. Patients were involved in planning and making shared decisions about their care and treatment, so these were centred around them and their needs. They had the option of having their own copy of their care plan. Patients were given information about their conditions, care and treatment options and the service made reasonable adjustments for patients where necessary.

Most patients told us that the service had provided them with care and support at a time in their lives when they had been in great need. They described the support as being flexible despite the restrictions and rules necessary in such a service. They valued the opportunity to step down to day care rather than be discharged fully at the end of their inpatient stay and said that staff prepared them for the transitions. Carers also described flexible support provided to themselves and their relatives, with an educational and supportive carers’ group available to them.

During the inspection, patients were working towards full discharge or stepping down to attend the ward as day patients. Staff were aware of individual patients’ support needs in working towards discharge, and fully involved patients in identifying goals and monitoring achievements towards discharge planning as recommended at the previous inspection. As required at the previous inspection they worked with patients to ensure that they were ready for transitions. Care plans did not always indicate the changes for patients stepping down to day care. However, following the inspection, managers provided examples of an updated day care plan that did reflect this change in status, which was to be rolled out for all day patients. Staff considered the needs of the patient at each referral. If it was clear a patient required more intensive care or long-term care than the ward could provide, the reason for not accepting the referral was explained to the patient and/or the referrer. When it became clear a patient required more intensive care during their stay, staff liaised with external services to arrange a transfer. From the start of treatment, staff said there was a clear discussion and agreement with patients about their goals for treatment, including, when appropriate, any weight restoration.

The advocate who visited the service regularly was satisfied that patients were encouraged to work towards discharge, and to access the local community as far as possible.

The ward had capacity for 9 inpatients, and at the time of the inspection there were several vacancies on the ward. Patients could be admitted as inpatients or day patients, depending on their level of need. Day patients attended the service between 10am and 7pm each day and took part in all meals, therapeutic groups and sessions. At the time of the inspection, management had limited the total number of patients (inpatients and day patients) to 15, to ensure that the unit was able to provide safe and appropriate support to all. There was some flexibility in exclusion criteria for the ward, the lead psychiatrist said that they conducted a holistic assessment and would carefully consider whether it was appropriate to admit patients with a chronic physical illness or psychiatric risk. Managers and staff worked to make sure they did not discharge patients before they were ready. When patients went on leave there was always a bed available when they returned. Patients were moved between wards only when there were clear clinical reasons, or it was in the best interest of the patient. Staff did not move or discharge patients at night or very early in the morning. Management delivering services considered the needs and preferences of different people, including those with protected characteristics under the Equality Act and those at most risk of a poorer experience of care.

Patients told us that staff gave them current information and advice in a way that they could understand. Most carers were also satisfied with the information provided to them about supporting a relative with an eating disorder, although some carers felt this could sometimes be provided more sensitively. Patients knew that they could have a copy of their care plans and could request access to their health and care records. They were able to decide which personal information could be shared with other people, including their family and care staff.

Staff said that they tried to give patients information and advice in their preferred way. They noted that they only shared information with carers with the permission of the patient. Staff were aware of the language needs, and any other accessibility needs of patients at the service in terms of understanding information. They were aware of how to request an interpreter when needed. Staff said that they offered patients a copy of their care plans.

There were systems in place to book interpreters and obtain translations when needed. Information about people that was collected and shared met data protection legislation requirements. There were posters with information about the ward, and useful information about help and support for managing eating disorders posted in communal areas in the ward.

Patients knew how to give feedback about their experiences of care and support at the hospital. They were aware of the complaints process, and how to express informal concerns to staff at the hospital, including speaking with the ward manager, who they described as very approachable and responsive. At the time of the inspection patients and carers felt that the hospital looked into their complaints and made changes accordingly. However, prior to the inspection, a small number of patients and carers were not happy with how responsive the service was to their concerns.

Staff were aware of the service’s complaints procedure, and said they received feedback following complaint investigations. They felt that their own concerns and suggestions about the hospital were taken seriously. Staff addressed and recorded verbal complaints raised by patients. If patients were unhappy with the response, staff encouraged them to make a formal complaint. Staff said that they would protect patients who raised concerns or complaints from discrimination and harassment. They said that feedback from complaints across the hospital was shared with staff in lessons learned bulletins and at staff meetings. The service also used compliments to learn, celebrate success and improve the quality of care. Managers said that they kept people informed about how their feedback was acted on. Where improvements were required as a result, they tried to involve patients in shaping the solutions. Staff said that learning from complaints and concerns was seen as an opportunity for improvement and staff could give examples of how they incorporated learning into daily practice. For example, they had taken action to address complaints about some staff interactions, with further training, and reflective practice sessions put in place to improve staff communication with patients.

We looked at records of complaints received by the hospital within the last 12 months and found that these were generally addressed within expected timescales, and people were informed if there was any delay. Between April 2023 to April 2024, 7 Complaints (which included 75 concerns) had been received. Of these 12 had been upheld, 6 partially upheld, and 57 were not upheld. The main themes were staff conduct, treatment and care, patient service team communication, and hospital protocol. Checks of the service’s maintenance logging indicated that issues were addressed promptly, usually by the next day.

The service clearly displayed information about how to raise a concern in patient areas. The service’s complaints policy and procedure were up to date and allowed 3 working days for people to receive an acknowledgement, and 20 working days for people to receive an outcome. Managers investigated complaints and identified themes. There was no current patient representative from the ward for patient forums, although this role had been in place previously. Weekly community meetings were held for patients on the ward. They provided an opportunity for patients to feedback on what was working well, and any concerns or requests they had. Changes made because of these meetings included improving information about snacks available, staff behaviours at mealtimes, and additional therapy groups provided. Feedback from complaints across the hospital was shared with staff directly and in staff meetings. The service also used compliments to learn, celebrate success and improve the quality of care.

Patients told us that they received care and treatment in a way that met their accessibility needs and ensured that they were treated without fear of discrimination. They said that they usually received treatment and support when they needed it, and that their rights were protected as far as possible. This included making the premises as accessible as possible, and reasonable adjustments for disabled people. Most carers were satisfied with the support provided to their relatives, but some indicated that they were not satisfied with the service's approach to monitoring their relative's progress.

Staff spoke of planned work to upgrade the lift in the ward, to ensure that patients could access all areas they needed in a way that worked for them. Managers and staff were aware of their responsibilities to prevent discrimination and inequality and provide treatment and support in an equitable way to all patients. Staff said that the provider prioritised, and allocated resources to tackle inequalities and achieve equity of access for all.

We observed and the advocate confirmed that the ward was accessible to patients with mobility issues and all rooms had en suite facilities. Male patients had rooms allocated in a particular area. When needed a male or female only lounge was made available.

Within the limitations of the hospital building, patients had access to accessible care, treatment, and support in line with best practice, quality standards and legal requirements. Reasonable adjustments were made for disabled people, addressing communication barriers, and having accessible premises. Patients under the age of 18 were no longer admitted to the service. Managers said they used people’s feedback and other evidence to actively seek to improve access for people more likely to experience barriers or delays in accessing their care. The provider complied with legal equality and human rights requirements, including avoiding discrimination, considering the needs of people with different protected characteristics, and making reasonable adjustments. Criteria for admission included a confirmed diagnosis of an eating disorder such as anorexia nervosa, bulimia nervosa, binge eating disorder, or other specified feeding and eating disorders, medical stability, and a body mass index of 12 or above (or in the range 10-12 after careful assessment of medical risk). The service was accessible for patients with mobility needs or those with very low weight who used a wheelchair. There was an assisted toilet next to the nursing office and a lift that staff and patients could use to reach all floors of the ward. If the service could not support a patient with a particular disability, they would explain to the referrer why this was the case. Air pump mattresses were available for patients at risk of pressure ulcers.

Patients told us that they felt able to give their views and understood their rights, including their rights to equality and their human rights. They said that if they experienced discrimination or inequality, staff listened to them, and where possible, made changes to improve their care.

Managers and staff were aware of possible discrimination and inequality that could disadvantage different groups of people using their services. Staff were aware of the need to respect patients’ pronouns, religious needs, and beliefs. Staff members recorded and addressed patients using the name and title they preferred and offered patients a staff member of the same gender or chaperone for physical examinations. Staff gave examples of supporting patients who were LGBT+ including patients who identified as transgender, in line with their identified gender. Managers proactively looked at ways to address barriers to improve people’s experience, act on information about people's experiences and outcomes and allocate resources and opportunities to achieve equity.

The provider complied with legal equality and human rights requirements, including avoiding discrimination, having regard to the needs of people with different protected characteristics and making reasonable adjustments to support equity in experience and outcomes. They had appropriate equality, diversity and human rights policies in place. The service met the needs of all patients, including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support. The service could support and make adjustments for disabled people and those with communication needs or other specific needs. Staff could access interpreters where necessary. Staff made sure patients could access information on treatment, local services, their rights and how to complain. The service provided a variety of food to meet the dietary and cultural needs of individual patients. The ward ran a weekly group for patients to confirm and clarify any questions about the following week’s meal plans. Patients had access to spiritual, religious and cultural support. Staff could support patients with religious needs, by facilitating access to places of worship and religious officials.

Patients told us that they were supported to make informed choices about their care and plan their future care. Patients said that their decisions and priorities were recorded in personalised care plans that were only shared with others if they agreed to this. Patients said that staff encouraged them to work towards discharge and supported them in their plans for moving on from the service.

Staff told us that they tried to work with patients collaboratively to make decisions about their care and treatment and prioritise what was important to them. They planned for patients’ discharge, supporting patients to gain independence before leaving completely. This included going out for meals and snacks, and discussing how this went, prior to discharge.

When appropriate, patients were offered the option of day care as a step down from inpatient care prior to discharge. Staff supported patients when they were referred or transferred between services. Where patients needed longer term care in another facility, staff liaised with external organisations, including NHS hospitals, to transfer patients. Patient care records included some brief information about discharge plans, but these did not focus on each patient’s strengths, and there was a lack of detail about longer term plans for care after discharge. However, patients we spoke with said that staff had helped them to prepare for discharge effectively. At the start of an admission, staff and patients discussed the length of stay and therapeutic package to be delivered. This was usually influenced by funding arrangements and patients were made aware of any limitations. At the time of the inspection managers had instigated a cap of 15 patients for the ward (a mix of inpatients and day patients). Patients’ future plans were recorded in personalised care plans. On discharge patients were provided with crisis plans jointly devised by patients and staff, and contact numbers for local MH crisis services and a charity supporting people with eating disorders.