Special review of mental health services at Nottingham Healthcare NHS Foundation Trust: Part 1 (Care Quality Commission, 26 March 2024)

Summary

Following the conviction of Valdo Calocane in January 2024 for the killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber, the Secretary of State for Health and Social Care commissioned the Care Quality Commission (CQC) to carry out a rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) under section 48 of the Health and Social Care Act 2008.

This is the first of two reports as part of this review, which sets out the CQC’s findings of their assessment of patient safety and quality of care provide by NHFT, and progress made at Rampton Hospital since their last inspection in July 2023. A second report was published in August 2024, which provided a rapid review of available evidence related to the care of Valdo Calocane.

Content

The rapid review identified three enduring areas of concern at the trust including:

• demand for services and access to care
• staffing
• leadership.

The CQC stated that the gaps and challenges they have identified at NHFT are longstanding issues at the trust which need to be addressed. However, looking more widely, we can see that other community mental health services are facing many of the same challenges as NHFT.

Recommendations

The CQC recommended that NHFT must:

(a) ensure that services do more to provide safe care and treatment, and to protect patients, families and the public from the risk of harm. This includes, but is not limited to, ensuring:

• all patients receive appropriate ongoing assessment of their risks including those waiting to receive treatment and care
• appropriate and effective risk management plans are formulated and implemented
• patients can access crisis services without delay
• escalations in risk are identified with timely access to inpatient care as appropriate.

(b) review how it monitors and measures waiting times in community mental health services by setting measurable targets at team, service, and trust level. These targets must be monitored to ensure equity of care across services and that deterioration in people’s conditions are monitored.

(c) ensure services do more to meet the needs of people who need care and treatment. This includes, but is not limited to, ensuring:

• patients receive timely access to care and treatment
• patients can equitably access the full range of evidence-based care and treatment through multidisciplinary teams with clear pathways, including psychological therapies regardless of where patients live
• services, including GP practices, are integrated and use shared systems to provide patients with seamless transitions in care and treatment.

(d) ensure services do more to identify and learn from incidents where patients, families and the public have come to harm from failures in how treatment and care is provided. This includes, but is not limited to, ensuring:

• incidents and the level of harm caused are identified in a timely way
• incidents are investigated in a timely way by appropriately trained and competent staff, ensuring lessons are learnt and changes in practice are made immediately
• lessons learnt are shared appropriately with all services to improve safety.

For community mental health services for working age adults, the CQC recommended that NHFT must:

(a) change the current of approach to providing community mental health services to ensure that evidence-based care and treatment is provided through clear pathways to care and treatment. There must be cohesive multidisciplinary teams, including psychological therapy staff, which are equitable across all geographical areas covered by the trust.

(b) ensure it reviews and amends its approaches to bed management to ensure beds are available when needed.

(c) ensure that community mental health teams’ approach to risk management is reviewed to ensure that teams are able to monitor, mitigate and respond to people at risk of harm to themselves or others.

(d) ensure that staff are appropriately trained and that mandatory training is available to support staff in working with autistic people and people with a learning disability.

(e) ensure that joint working protocols are in place with GP practices, which ensure that patients with complex mental health needs have joined up care.

(f) improve their responsiveness to people’s immediate needs by ensuring calls to the crisis line are answered and that 4-hour and 24-hour targets are met more often and consistently.

In relation to Rampton Hospital, the CQC recommended that NHFT:

(a) pair Rampton Hospital with another high secure hospital as a ‘critical friend’. This needs to go further than current working relationships, and include regular oversight and monitoring by senior staff from a different NHS trust. NHFT may wish to discuss implementation with the National Oversight Group to ensure expertise from the other two high secure hosting trusts can be engaged.

(b) appoints an independent team, organisation or person to review the staffing requirements of all disciplines across Rampton Hospital. This review should include terminology used and ensure consistency of approach. From this review, clear processes should be implemented to ensure continued safe staffing levels.

(c) properly identifies the scope of the new culture team and devise a plan of action within an agreed timescale.

(d) puts in place a dedicated team at Rampton Hospital to support a full review of the medication audits and medication governance process to bring about positive and sustainable change for the application of Section 58 of the Mental Health Act 1983, high dose antipsychotic therapy and controlled drugs.

(e) immediately stops using therapy and education staff to increase nursing staff numbers on the wards to enhance the therapeutic offer to patients.

(f) ringfences British Sign Language (BSL) trained staff as able to only work with deaf patients to increase support and communication of deaf patients within Rampton Hospital. The trust should ensure that BSL trained staff are not removed from the deaf high secure ward for emergency vehicle keyholder purposes or to prop up staffing in other wards.

(g) ensures that the IT equipment is fit for purpose and used effectively to record patient information (for example, iPads for observations).

The CQC also made the following recommendations to NHS England:

(a) recommends to the Secretary of State for Health and Social Care relicenses Rampton Hospital for a period of no more than 12 months, to allow for improvements to continue along with expected improvements at trust level. Throughout the 12-month period, we will carry out further assessment activity along with a well led review.

(b) works with DHSC to define and agree clear standards in waiting times for community mental health services alongside those already established for EIP services and crisis services.

(c) together with CQC work to establish what datasets are needed for monitoring the quality and safety of community mental health services, particularly around waiting times, unexpected deaths and suicide, crisis response times, incidents of serious harm to the public involving people using mental health services and treatment outcomes.