Nightingale Hospital

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

Patients we spoke with felt safe at the service. Most relatives of people using the service were positive about staff care and treatment and approach in keeping their relatives safe. However, some raised concerns about incidents that had occurred on or off the hospital premises particularly between November 2023 and February 2024 and had been in contact with the hospital management to discuss their concerns. Managers investigated incidents thoroughly, and staff could give examples of learning from incidents. Staff confirmed that managers debriefed and supported them after any serious incident. Incidents were discussed at staff meetings, handovers, and the quality performance management group. Staff we spoke with knew the needs and risks for patients and were able to provide examples of how they had supported patients with their needs and risks. Managers had conducted their own gap analysis of the service and had identified areas for improvement in the physical environment, and further recruitment of staff. Minutes of team and multidisciplinary meetings showed that safeguarding incidents were discussed, with onward referrals to the local authority and protection plans put in place. Patients said that staff helped them to prepare for stepping down to being day patients with appropriate advice and consideration of risks they would face. Patients and staff completed risk assessments on a daily basis and discussed any differences in scoring at weekly ward rounds. The service no longer admitted patients under the age of 18. As required at the previous inspection staff conducted a risk assessment for patients in terms of their skin integrity and took appropriate actions, and a more appropriate chair was available for nasogastric feeding. A nasogastric feeding policy was in place but this did not include guidance for nasogastric feeding under restraint. The environment was clean, and well maintained, with appropriate medicines and health and safety systems in place.

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 we spoke with felt safe at the service, and that staff took them seriously about any concerns they had about their safety. Most relatives of people using the service were positive about staff care and treatment and approach in keeping their relatives safe. However, some raised concerns about incidents that had occurred on or off the hospital premises particularly between November 2023 and February 2024. They had been in contact with the hospital management to discuss ways in which systems could be improved.

Staff could give examples of incidents reported and learning from incidents. For example, staff told us about learning from an incident when a patient had left the unit without authorised leave. Learning from the incident included reviewing observations procedures, stopping use of the staff door to the unit which did not have an airlock feature. Staff received monthly bulletins about lessons learned from incidents and complaints across the hospital. Staff reported serious incidents clearly and in line with the provider’s policy including safeguarding alerts. Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Staff had access to a duty of candour policy on the intranet, to ensure transparency about any errors in patients’ treatment. Staff we spoke with were aware of their duties in this area. Staff confirmed that managers debriefed and supported them after any serious incident. Staff and managers confirmed that there had been a period of time on the unit between November 2023 and February 2024 when patient acuity was very high and the ward had been unsettled, and staff had struggled to manage some patients' needs. Extra management support had been put in place at this time, and the frequency of reflective practice sessions for staff had been increased to improve understanding of the culture on the ward.

Managers investigated incidents thoroughly. Patients and their families were involved in these investigations. Staff received feedback from investigation of incidents, both internal and external to the service. Incidents were discussed at staff meetings, handovers, and the quality performance management group. Staff discussed the feedback and looked at improvements to patient care.

Patients on the ward felt that they were kept safe at the service, and that staff knew their needs well. Most relatives/carers were satisfied with the safety systems on the ward. One relative noted that processes for visitors to sign into the unit were not consistent, so that not all visitors signed in on entering the unit. Another relative raised concerns about the consistency of weighing on the unit. However, we did not find current concerns with systems for weighing patients at the time of the inspection.

Staff had easy access to clinical information about patients and maintained accurate clinical records both paper-based and electronic. All information needed to deliver patient care was available to relevant staff including agency staff when they needed it and was in an accessible form. This included when patients transferred to another ward. Records were stored securely. Doctors and managers were clear that they would not take on any referral unless the team felt confident, they could meet their needs safely. Staff we spoke with knew the needs and risks of patients and were able to provide examples of how they had supported patients with their needs and risks. Staff spoke about how patients were supported on admission and during transition to another service. Managers told us they would review CCTV following any incidents to ensure the safety of the service.

The advocate we spoke with confirmed that staff had safe systems in place for patient care and would address any concerns expressed by patients with regard to making improvements on the ward.

Managers had conducted their own gap analysis of the service and had identified areas for improvement. They were planning further improvements to the physical environment, and further recruitment of staff. They had undertaken a closed culture review with an action plan in place to ensure that a closed culture did not develop at the service, with staff moving to work in other wards to ensure that there were some changes to the staffing team. We observed a staff handover meeting at the end of an evening shift. We found safety and continuity of care was focused on, there was an awareness and review of risks with a plan on how to support people with these. Patient care records we reviewed evidenced multi-disciplinary collaborative working and patient views. Risk assessments and treatment plans were updated and reflected current risks and needs and goals patients were working towards. There were detailed weighing protocols in place for the unit and patients were provided information about this during their admission. Patients had their weights measured in a designated treatment room using a seated weighing scale that was calibrated annually. Since 2017 only one patient had been weighed in their bedroom due to physical health needs. If patients insisted on using a standing scale, this was available, but staff would then continue to weigh them consistently using this scale to ensure consistency and accuracy.

Patients we spoke with said they felt safe at the service. Most carers felt that the service was run safely but one carer expressed concerns about items being brought into the unit. Other carers were positive that staff knew the needs of their relative well and spoke positively about staff behaviour and approach.

All the staff we spoke with showed a commitment to taking immediate action to keeping people safe from abuse and neglect and felt comfortable and safe to do so. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Managers gave examples of recent safeguarding concerns considered including making a safeguarding referral following the contents of a complaint and ensuring that all staff were familiar with the hospitals policy on gifts to staff.

During the ward visits we observed that the ward felt safe, and staff were visible and engaging with patients. Our observations showed positive staff interactions with patients of a relaxed, inclusive, facilitative, and warm nature. Observation of care records showed that safeguarding concerns were taken seriously and discussed within the multidisciplinary team, with a plan put in place to safeguard individuals where necessary.

The provider’s processes promoted people living in safety, free from abuse, neglect, and avoidable harm. We saw evidence that there were effective systems, processes, and practices to make sure people were protected from abuse and neglect. The service had a comprehensive safeguarding policy and procedure which included good working relationships with other agencies, including the local authority. Minutes of team and multidisciplinary meetings showed that safeguarding incidents were discussed, and managed with onward referrals to the local authority and protection plans put in place. Staff received training on how to recognise and report abuse, appropriate for their role and kept up to date with their safeguarding training. Overall, the providers compliance with safeguarding level 2 training for staff was 85% for safeguarding adults, and 87% for safeguarding children. As part of the assessment, we reviewed the hospital safeguarding log which was up to date and included details of the safeguarding incident, the incident date, and if concerns were reported to the local authority or being investigated by them with a record of the outcome.

All the patients we spoke with during our inspection visits said they felt safe at the service. They said that they were involved in producing their care plans and could have a copy of these. Patients told us that staff helped them to prepare for stepping down to being day patients with appropriate advice and consideration of risks that they would face. Patients told us that they understood why they had regular staff observations and that observations were generally carried out in a respectful way. Some patients and carers described some inappropriate interventions from bank or agency staff who did not know their needs well. They had reported their concerns to managers, who were looking at ways to improve the consistency of bank and agency staff interactions. We reviewed recent community meeting minutes at the time of our inspection visits, and found that people using the service were able to raise their concerns about restrictions. Staff reviewed these, explaining why some restrictions had to remain in place, but making changes where possible, for example in the range of snacks offered.

Staff were able to provide examples of risks posed by some people using the service and could describe how they acted to prevent or reduce risks for them. All staff said that the team undertook a risk assessment for each patient on admission and updated these regularly and after incidents. Staff demonstrated a good understanding of the management of risk and reducing restrictive interventions. Staff told us that restraint was only ever used as a last resort and only when a patient was causing harm to themselves or others. Staff were aware of the particular risks (including physical health risks) faced by patients with eating disorders and monitored patient’s physical health appropriately.

Staff completed risk assessments for each patient on admission, and reviewed this regularly, including after any incident. In addition, both staff and patients completed daily risk assessments and discussed any differences in scoring. Risks were also reviewed at weekly ward rounds, including feedback from both patients and staff. We reviewed minutes from clinical governance meetings, and other multi-disciplinary team meetings. Safety and risks were reviewed in detail at these meetings, including learning from incidents and complaints and reducing restrictive practice. Care plans we reviewed were person centred with details for staff on how best to support patients in line with their preferences. Staff regularly reviewed care plans and risk plans with people and updated these with new information when required. Risk management plans included meal plans, body maps, and specific support to be provided in the event of particular incidents. Patients’ level of observation was reviewed as needed when their risks increased or decreased in line with the service’s observation and engagement policy. Rooms that were not in use were kept locked. If the top floor of the ward was in use, a staff member remained there to ensure patients’ safety in this area. Staff followed hospital policies when they needed to search patients to keep them safe from harm. Care plans did not always fully reflect the changing circumstances of patients who had stepped down from being an inpatient to a day patient (only detailing support provided when they were on the premises) but patients confirmed that they were given appropriate preparation for stepping down. The service no longer admitted patients under the age of 18. As required at the previous inspection in June 2022, staff conducted a risk assessment for patients in terms of their skin integrity using an assessment tool and took appropriate action accordingly such as use of pressure relieving mattresses.

Patients we spoke with told us that the environment was clean, well maintained, with the facilities and equipment to meet their needs. Carers were satisfied with the environment when visiting the service. Although there had been limited space for visitors to meet with relatives during the Covid-19 pandemic, patients were now able to meet friends and relatives in their own rooms, so this was no longer a concern. Patients did not express any concerns about the sound of the closing of bedroom doors as mentioned at the previous inspection.

Staff and leaders spoke about how they maintained facilities and equipment to be able to deliver safe care to patients. Staff told us that they regularly completed daily security and environmental checks to ensure the environment was safe for patients. Staff we spoke with were aware of a ligature map of the service which highlighted ligature risk points within the service. This enabled staff to be aware of ligature risks so that they could keep people using the service safe. Staff were aware of blind spots within the service and knew how to mitigate against these. The service had fitted mirrors and closed-circuit television (externally monitored) in communal areas and used enhanced observations to support patients with additional risks. Managers spoke about the use of CCTV to review any incidents of harm so that this could be learned from and prevented.

We carried out a tour of the environment at the service. The service was clean, comfortable, decorated and furnished well. The ward was situated over three floors and its layout made it difficult for staff to observe all areas due to blind spots. These risks were mitigated by convex mirrors, and individual risk assessments and observations. Observations ranged between constant one-to-one observations and hourly observations. The ward was in a separate building from the rest of the hospital with a separate entrance. We observed records showing that staff completed and regularly updated thorough risk assessments of all wards areas and removed or reduced any risks they identified. Our observations did not indicate that patients were using towels over the tops of doors to quieten the doors closing (compromising fire safety) as found at the previous inspection. All bedrooms had ensuite bathroom facilities and at the time of the inspection there was no mixed sex accommodation. However, male patients could be accommodated on the second floor of the unit, and when this was the case there were separate male and female lounge areas available. As recommended at the previous inspection, there was clear signage in the unit to inform staff and visitors that CCTV was in operation in communal areas. We observed ligature points which staff were aware of. The service had a ligature audit and map identifying and mitigating these. We saw that staff used alarms and patients had easy access to nurse call systems in their bedrooms. All bathroom doors and taps had been refitted to ensure they were anti-ligature. The clinic room was clean, fully equipped, with accessible resuscitation equipment and emergency drugs.

The provider managed the environment well to ensure it was safe for people using services. The provider completed regular and up to date environmental, health and safety risk assessments and ligature audits. Managers ensured risk assessments for fire safety, water monitoring, gas and electrical installation and calibration of equipment were up to date. All actions resulting from assessments and audits were monitored and completed. Managers ensured maintenance issues were reported and addressed within reasonable timeframes and that cleaning checks and handwashing and infection control audits were regularly completed. As required at the previous inspection, a suitable room and high back chair had been provided for nasogastric feeding. Staff completed and regularly updated risk assessments of all ward areas and removed or reduced any risks they identified.

Patients and carers we spoke with did not raise any concerns with the numbers of staff available at the service. Patients generally said staff were readily available, supporting them with kindness, and knew how to meet their needs. However, patients raised concerns about the number of bank or agency staff that worked with them, who did not always support them sensitively. Patients were aware of actions being taken by the ward manager to address their concerns about bank and agency staff, providing them with improved inductions and training. Following the inspection management confirmed that meal supervision training was scheduled for regular bank and locum agency staff in September 2024. Some patients we spoke with said there were not enough activities at weekends, but others were satisfied with the weekend programme.

All of the staff we spoke with said that there were appropriate staffing levels to make sure patients received consistently safe, good quality care that met their needs. Managers reported current nursing staffing vacancies for 2 registered mental health nurses. However, staff indicated that there were times when they had worked with a significant proportion of bank or agency staff members, particularly towards the end of 2023 and beginning of 2024. There were 2 registered nurses on long term absence at the time of the inspection. In the last 12 months the only nursing staff turnover was for 2 registered nurses at the service. Managers noted that staffing was adjusted depending on the number of patients admitted to and receiving day care at the service. For 3 patients nursing staffing consisted of 2 registered nurses during the day and 2 registered nurses at night. Staffing was increased when patients required one to one observation and as numbers increased on the ward. Staff reported receiving reflective practice, regular supervision, and appraisals. They said that they had received mandatory and specialist training to enable them to have the knowledge and skills to meet patients' needs. Newer staff said that they had received an induction when they commenced employment at the service.

Our observations of staff and patient interactions on the ward indicated that there were sufficient staff available to meet patients’ needs.

At the previous inspection in June 2022 we recommended that the provider should continue recruitment of staff for the ward to ensure continuity of care for patients. At the time of the inspection, recruitment was ongoing with vacancies for 2 registered nurses. The ward manager could adjust staffing levels according to the needs of patients. We reviewed nursing rotas and spoke with staff and managers about staffing levels at the service. Whilst there were sufficient staff available on each shift, there remained significant use of bank and agency staff on the ward. Managers said that they limited their use of bank and agency staff and requested staff familiar with the service whenever possible. There was a consultant psychiatrist, and ward doctor available on the ward (as well as two other psychiatrists who could admit patients to the ward. There was also a dietitian, and a wide range of therapists providing support to patients on the ward. Managers ensured staff received mandatory and specialist training. Mandatory training rates for staff were 86%. Managers made sure all bank and agency staff had a full induction and understood the service before starting their shift. They reported staff supervision rates at 94% and appraisal rates at 83%. We looked at the recruitment records for 3 staff working in different roles on the ward, and found that these included all appropriate checks including two references, and disclosure and baring checks. The hospital carried out a range of checks to ensure that each doctor was fit to carry out their role including General Medical Council registration, and revalidation, and the completion of a signed agreement with the hospital. The training for nursing staff included adult and child safeguarding, basic life support, immediate life support, managing violence and aggression and nasogastric tube feeding training. Bank staff were also able to access all of this training.

Patients told us that the ward was kept clean and hygienic, and any repairs were undertaken swiftly.

Staff made sure cleaning records were up-to-date and the premises were clean. Staff completed weekly and daily environmental checks.

During the inspection, the ward appeared clean and tidy. Staff followed infection control policy, including handwashing. We saw records of the checks, including highlighting any issues needing attention, such as changing lightbulbs.

87% of staff had completed infection prevention and control training. In the most recent hand washing audit for the eating disorders unit, there was 95% compliance. Following audits, managers ensured that any actions were addressed swiftly.

Patients’ feedback indicated that they were supported with medicines appropriately, were provided with relevant information about their treatment and were given opportunities to discuss this with the medical team. Patients were satisfied with the support staff provided with their medicines. One carer noted that staff on the ward could have been more helpful in providing their relative with cold remedies when they were on the ward, although they acknowledged that this was complicated by protocols in place to protect people with eating disorders.

We spoke with staff who administered medicines (registered nurses) and the consultant psychiatrist who prescribed medication at the service. We reviewed all 3 patient medicine prescriptions charts on the first day of our inspection and found people’s medicines were appropriately prescribed and administered. Staff said that the last time nasogastric feeding was carried out for a patient was in December 2023 - January 2024. They said that they had regular training on this procedure updated every 2 years, with all staff receiving an update this year.

The clinic room was clean, tidy, and well arranged. Medicines were stored securely and at appropriate temperatures, which were monitored. There was appropriate equipment for staff to be able to conduct physical health checks of patients. All equipment was calibrated. We did not find any concerns around the recording or storage of medicines.

The service was using electronic prescribing with support from a pharmacy organisation, and staff reported that this was going well. We reviewed 3 patient medicine prescriptions and found people’s medicines were appropriately prescribed. Prescriptions were audited regularly via an application on the electronic medication system. All registered nurses had completed recent training in medicines management training. There were no nurse prescribers on the ward, and staff did not give covert medicines. Rapid tranquilisation was rarely carried out, but there were systems in place to conduct post rapid tranquilisation monitoring of patients including a doctor’s review. The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines, and followed NICE guidance to ensure that patients' physical health needs were monitored. Inspection of medicines stored at the hospital indicated that there were appropriate systems in place for medicines storage and recording, including controlled medicines and emergency medicines. Stock levels recorded were accurate, and all medicines were in date.  As required at the previous inspection in June 2022, the oxygen reservoir and tubing kits were in date, and the sharps disposal bin was labelled with the date of assembly. As required at the inspection in June 2022, the provider had purchased a new and more appropriate and comfortable chair for the unit and provided a specific room for patients requiring nasogastric feeding. There were appropriate medicines policies and procedures and a current nasogastric feeding policy due to be reviewed in June 2024. However, we noted that this policy did not include guidance for administering nasogastric feeding under restraint.