You are here

Inspection Summary


Overall summary & rating

Good

Updated 7 June 2016

We rated Cygnet Hospital Kewstoke as good because:

  • The environment was well risk assessed, adapted and both patients and staff told us they felt safe on the wards. Personal and hospital alarm systems were robust and well documented.

  • There were enough suitably qualified and trained staff to provide care to a good standard. Staffing vacancies had been recruited to and the team were able to access increased numbers of staff easily.

  • Medicines management was safe and regularly audited by an external agency. Medication errors were discussed in integrated governance meetings and ward rounds. Recent external audits from the hospital pharmacy had increased awareness around medication errors.
  • Patients were involved in developing their own care plans and their views were clearly documented in their own words. Care plans we saw were personalised, holistic and recovery focused. The wards used the ‘my shared pathways’ (a programme to allow patients to chart their own progress through secure services and set their own agreed outcomes/achievements) approach for planning and evaluating care and treatment. Staff were well supported by the hospital to have training on the successful implementation of ‘my shared pathway’.
  • Patients had access to regular physical healthcare checks and a GP was employed by the hospital to provide regular contact with patients. Occupational therapists worked as part of the multidisciplinary team.
  • Staff showed patience and gave encouragement when supporting patients. We saw that staff showed warmth and acceptance towards their patients despite the very challenging situations arising, often involving high levels of distress and self-harming behaviours. We saw that staff were non-judgemental towards their patients and empowered them consistently to encourage their involvement.
  • There were quiet rooms that patients could access during the day and a full range of therapy rooms and equipment. There was a varied, strong and recovery orientated programme of therapeutic activities available.
  • Patients knew how to complain and had access to advocates who had assisted patients to make a complaint in the past. The hospital had a detailed policy and procedure about how they dealt with complaints.
  • Staff told us that the senior management team regularly visited the wards and were well known amongst the team. Staff felt well supported by the senior management team.
  • All staff had good morale and said they felt well supported and engaged with a visible and strong leadership team, which included both clinicians and managers. Staff were motivated to ensure they achieved the ward objectives.

  • Governance structures were clear, well documented, adhered to and reported accurately. There was a robust audit plan and any actions resulting from the audit were completed in a timely fashion. The wards conducted several audits to ensure they were monitoring and improving the systems that supported the ward to achieve set standards and targets.

  • Recruitment was value based, sickness and absence was well monitored and staff were well supported back into work.
  • Staff received regular clinical, managerial and group supervisions. Appraisal rates were almost at 100% throughout the hospital and included 360 degree appraisals for clinicians.

However:

  • The hospital’s medicines management and rapid tranquillisation policies were overdue to be reviewed.

  • Staff had not been given any training in the changes to the MHA’s new Code of Practice and that the on-going Mental Health Act training did not address these changes either.
  • Mental Capacity Act assessments were brief and needed more information about how best interest decisions had been made.
Inspection areas

Safe

Good

Updated 7 June 2016

We rated safe as good because:

  • Knightstone, Milton and The Lodge wards were clean and well maintained and patients on all wards told us that they felt safe. Staff told us they felt safe in the work environment.
  • Staff had assessed environmental risks, including photographing ligature risks (a ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation). Ligature audits were completed on a six monthly basis and we saw evidence to show that these were up to date with actions completed.
  • Staff had good systems in place to control contraband items and high risk property.
  • Staff personal and hospital alarm systems were robust and well documented. There were regular medical emergency scenario tests.
  • All patients had received a comprehensive and detailed risk assessment on admission. Staff used the ‘short term assessment of risk and treatability’ (START) tool to assess potential risks. We found that patients’ risk assessments and plans were recovery focused and person centred.
  • Where restraint had been used, efforts to de-escalate the situation through verbal communication had been made and paperwork relating to the use of restraint had been completed. Secondary and tertiary interventions were recorded as well as primary intervention strategies, so staff could demonstrate the use of a more holistic approach to de-escalation. At The Lodge, patients who required periods of time out from the communal areas could access a quiet room, external garden room or their bedroom.
  • Staff were recording all episodes of rapid tranquillisation (the use of medication to calm/lightly sedate the patient, reduce the risk to self and/or others and achieve an optimal reduction in agitation and aggression) in line with policy and were recording both intramuscular and oral administrations.
  • There was a safeguarding folder on every ward. All staff had received training in safeguarding vulnerable adults and children.
  • Staffing vacancies had been recruited to and the team were able to access increased numbers of staff easily.
  • Managers told us wherever possible, they employed bank and agency staff who had worked there before and were familiar with procedures and policies. This helped ensure continuity of care for patients.
  • Wards were over 90% compliant with mandatory training. Staff demonstrated sound knowledge about recent prevention and management of violence and aggression training and the least restrictive principle.
  • Medicines management was safe and regularly audited by an external agency. Medication errors were discussed in integrated governance meetings and ward rounds. Recent external audits from the hospital pharmacy had increased awareness around medication errors. Staff that were subject to performance monitoring due to medication errors were encouraged to write reflective practises which they submitted to the weekly audit feedback.
  • However:
  • The hospital’s medicines management and rapid tranquillisation policies were overdue to be reviewed.
  • Staffing levels were determined by the organisation that used a staff matrix tool which based its need for staff on bed occupancy levels. Due to the nature and unpredictability of a PICU environment, staff we spoke to on Nash ward told us that this was unsafe as although bed occupancy levels may reduce, clinical activity may remain the same and or increase. Rotas on Milton ward were not always updated to identify all staff who had worked on the ward. The provider used a staff matrix tool to determine staffing levels. However lodge staff told us that staffing levels had been set three years previously when The Lodge had a male client group with different levels of dependency.
  • The wards on Nash and Sandford were dirty and areas of the wards had maintenance issues and damage to fixtures and fittings.
  • On Nash ward, there were 26 medicine fridge temperatures recorded above or below the recommended range. As a result the staff were unable to ensure that medicines in the fridge were safe to use.
  • Controlled medication was not disposed of in a timely manner on Knightstone ward.
  • Staff did not routinely test how long it took to collect the defibrillator from Milton ward.
  • A first aid box on Milton ward was not routinely tested and contained out of date items.
  • Nurses on Milton ward were not counter signing observation sheets.

Effective

Good

Updated 7 June 2016

We rated effective as good because:

  • At least two staff undertook assessments for new patients. Staff responded verbally within two days and written paperwork confirming a patient’s placement was delivered within a week.
  • Staff completed regular physical healthcare checks and recorded these in care plans. All patients had a physical health assessment on admission. All patients had access to a general practitioner who visited weekly.
  • The senior management team were able to share ‘the national institute for health and care excellence’ (NICE) guidelines with the ward manager and to the teams directly.
  • The senior management team had improved the implementation of ‘my shared pathway’ (a programme to allow patients to chart their own progress through secure services and set their own agreed outcomes and achievements) by providing regular training for staff on writing evidence based care plans in line with the guidance. This training was repeated annually. Each lead in the hospital had overall responsibility in the completion of each section of the care plan.
  • The psychology team were well resourced and stable with no team vacancies. There were five psychologists for five wards. Patients had access a wide range of therapeutic services. The psychology team were able to provide support to staff members following serious incidents. All psychologists were trained in dialectical behaviour therapy, had broad expertise and offered a drug and alcohol service to patients.
  • Patients had access to regular occupational therapy and patients told us they benefited positively from the therapy they received.
  • Care plans were created with patients and their views and goals were recorded in their own words.
  • Staff and managers received regular managerial, clinical and group supervision. We saw evidence of regular reflective practice group supervision meetings.
  • There was a robust audit programme in place, with deadlines for actions to be completed and a quality assurance check. The medical director conducted clinical audit checking to ensure that doctors were involved in auditing. High dose anti-psychotic audits were carried out every year. We saw the results of the last audit that was carried out in December 2015, which reviewed previous usage. The hospital had reduced the percentage of patients receiving anti-psychotic medication by 31% from 2008 to 19% in 2015. The hospital also conducted audits for the use of lithium.
  • Physical health audits addressed any issues around healthy living, dietary plans and weight monitoring, focussing on patients who were reluctant to engage and difficult to motivate. The quality and compliance lead for the hospital monitored this progress.

However:

  • The hospital’s Mental Health Act and Mental Capacity Act training programme needed updating. We were concerned to find that staff had not been given any training in the changes to the MHA’s new Code of Practice and that the on-going Mental Health Act training did not address these changes either.
  • Mental Capacity Act assessments were brief and needed more information about how best interest decisions had been made.

Caring

Good

Updated 7 June 2016

We rated caring as good because:

  • Patient community groups occurred regularly and patients had the chance to talk openly and feedback about the service they received.
  • Feedback from patients about the care they received and the attitudes of the staff on the wards was generally very positive.
  • A buddy system had been established where an existing patient would provide support as appropriate to someone who was newly admitted.
  • We observed interactions between staff and patients that were respectful, friendly and professional. We utilised a tool called a short observational framework for inspections to observe the interactions between patients and staff throughout meal times. These observations were taken at five minute intervals. We observed staff interacting with patients with their meals in a good humoured manner.
  • Patient involvement was monitored through recovery meetings and the clinical manager had worked with patients to conduct presentations at local colleges. The hospital had involved patients in recent charity events, such as a sports day, the Christmas craft fayre, red nose day, race for life 2015, a hospital bake off and the ‘bringing people together’ conference 2015. Patients had been empowered to deliver talks about personality disorder at a university in Bristol and had been involved in anti-stigma talks at a local college. Last year patients had taken part in a presentation on preparing students with mental health issues for employment.

  • Staff on the wards had a good understanding and knowledge of individual needs of the patients. We saw that staff showed warmth and acceptance towards their patients despite the very challenging situations arising, often involving high levels of distress and self-harming behaviours or aggression.

  • The hospital supported carers by offering phone conferencing appointments to families who lived far away.

However:

  • One carer did not feel they were kept informed of their relative’s care

Responsive

Good

Updated 7 June 2016

We rated responsive as good because:

  • Beds were available for patients when they returned from leave. Beds on psychiatric intensive care units were available to those needing more support. Management of beds systems were robust and effective.
  • There were quiet rooms that patients could access during the day and a full range of therapy rooms and equipment. There was a varied, strong and recovery orientated programme of therapeutic activities available, every week including weekends on all wards but Nash.
  • Most bedrooms had a sea view, patients had privacy and could personalise their rooms.
  • On Knightstone ward, there was a clear care pathway through the service for women with a diagnosis of personality disorder into less restrictive community living.
  • On Milton ward, patients were fully involved in their discharge meetings and their opinion was sought on relevant issues.
  • Patients were encouraged to use the outside space outside of smoking times
  • Mobile phones were permitted on all wards.
  • Patients had access to the kitchen to make themselves hot drinks and snacks 24 hours a day. There was normally a chef employed to cook meals and assist patients with food preparation.
  • Patients on all wards apart from Knightstone told us they liked the food and it was of good quality. We saw evidence that staff had sought feedback about the quality of food on Knightstone and made several changes to adapt to the preferences of patients who had complained about the food.
  • Patients knew how to complain and had access to advocates who had assisted patients to make a complaint in the past. The hospital had a detailed policy and procedure about how they dealt with complaints.

However:

  • There were 111 out of 188 ‘out of area’ placements in the last six months, meaning that patients had to travel long distances to visit family and friends on their leave and vice versa. Transport was provided by the hospital for patients but still, patients told us they wished they could be closer to home.
  • The outdoor smoking area on Sandford ward was bleak and an open door policy to the outdoor area meant the dining room was cold and smelt of cigarettes.

  • Information leaflets and display boards were limited on Nash ward and there was no information available about IMHA support.
  • There was a schedule of activities available for patients; however these were limited to week days and core hours on Nash ward. Activities outside of these were provided by nursing staff.

  • There was no information available in languages other than English

Well-led

Good

Updated 7 June 2016

We rated well-led as good because:

  • Staff told us that the senior management team regularly visited the wards and were well known amongst the team. Staff felt that they were approachable and got very involved in the care and support of the patients. Staff felt well supported by senior management.
  • The hospital had monthly governance meetings for senior management staff to consider issues of quality, safety and standards. This included oversight of risk areas in the service to ensure quality assurance systems were effective in identifying and managing risks to patients. Any identified risks were discussed and added to the hospital’s risk register or ‘overarching local action plan’ during the meeting. The integrated governance meeting had a full agenda and included discussions around the use of prone restraint following recent ‘prevention and management of violence and aggression’ ( PMVA) training, seclusion rates, complaints, Clozapine administration and physical health monitoring. All actions were ‘RAG’ rated; i.e. colour coded to indicate severity.
  • The wards conducted several audits to ensure they were monitoring and improving the systems that supported the ward to achieve set standards and targets. The ward managers and their team were fully committed to making positive changes. We saw that changes had been made to ensure improvements to quality were made.
  • The wards evidenced learning from incidents; for example, recent environmental changes on Sandford ward and updated pre-leave checklists on other wards. The hospital manager collated all incidents and presented these to the operations director, who aggregated these for the area. Incidents were then reviewed by the chief executive and chief operating officer who wrote a company report on the arising themes.
  • The hospital’s overarching local action plan (OLAP) detailed ways to improve recording systems. For example, as the recording of primary interventions on Nash ward was high, the OLAP action plan evidenced how this ward was now also recording secondary and tertiary interventions so a more balanced picture of how patients in distress were supported could be seen. The OLAP also identified how pre-leave checklists were being highlighted amongst all staff and used more consistently following the death of a patient whilst on leave. The hospital pharmacy audits were highlighted on the OLAP as the hospital aimed to reduce medication errors to less than five per cent. The OLAP showed how this had been achieved in December by the hospital decreasing errors to 1.8% in December 2015 (this figure did not include self-administration of medication). The OLAP identified engagement and observation audits as being highlighted to all staff following thee absconsion of a patient at night. This produced a new headcount form and a one-to-one recording form. The corporate risk manager ran a group called the ‘safer therapeutic practises group’ which met every three months and reviewed the hospital’s risk register and corporate risks.
  • There was a high level of compliance with mandatory training. The senior management team shared updates on training figures in leadership meetings. The hospital worked with local colleges to support their staff through national vocational qualifications. The hospital also supported additional training for staff wanted specific experience in a certain field of work. For example, the head of psychology recently attended training on ‘eye movement desensitization and reprocessing’ (EMDR) therapy (an integrative psychotherapy approach for the treatment of trauma) as this had become relevant for one of the patients at the hospital.
  • Ward managers monitored sickness and absence via leadership meetings. They discussed where staff were in terms of reporting of injuries, diseases and dangerous occurrences regulations 2013 (RIDDOR), occupational health, physiotherapy and counselling sessions and when staff were expected to return to work. Information about staff performance and disciplinary procedures were also shared and reviewed in these meetings. The data collected in these meetings was shared across other departments with the aim of shortening periods of sickness absence and the impact of extended absence on the ward. The hospital ran an employee assistance programme to support staff who were experiencing any problems, or to provide emotional support following a serious incident at work.
  • The senior management team had adapted the interview process to include personal values and behaviours as well as qualifications, competence and experience. Recruitment checks showed that personnel files included the required documentation for legal employment. The hospital manager compiled a weekly report to monitor and review the challenges around recruiting registered mental health nurses. Although staff were asked to complete 11 hour shifts, this decision arose from the results of a staff survey where staff said they preferred to work the longer hours and have an extra day off.
  • The hospital manager had undertaken a large piece of work to improve the content and frequency of staff appraisals. The lead psychologist actively took part in consultations with the department of health and was a registered tutor to provide training and clinical supervision to Kewstoke staff. Supervision took the form of management, clinical and weekly group supervision, as well as a weekly reflection group for staff and patients. The weekly reflection meeting was facilitated by advocates and feedback was recorded via a ‘you say, we do’ document which was responded to within a week.
  • Team morale was high at the time of the inspection and staff told us they enjoyed working at Cygnet Hospital Kewstoke. Staff were motivated to ensure they achieved the ward objectives. Staff had attended an away day focusing on team building; more had been scheduled later this year.
  • Sandford ward and Nash ward had achieved an ‘excellent’ accreditation for inpatient mental health services with the college centre for quality improvement. Milton ward had achieved accreditation with the quality network for forensic mental health services for medium and low secure mental health services.

However:

  • Mental Health Act and Mental Capacity Act training was out of date and the hospital ran the risk of not complying with the changes made to the Code of Practice last April 2015. The quality assurance manager was aware that the hospital needed to update its MHA and MCA training.
Checks on specific services

Acute wards for adults of working age and psychiatric intensive care units

Good

Updated 7 June 2016

Forensic inpatient/secure wards

Good

Updated 7 June 2016

Long stay/rehabilitation mental health wards for working age adults

Good

Updated 7 June 2016

Personality disorder services

Good

Updated 7 June 2016