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Inspection Summary


Overall summary & rating

Inadequate

Updated 13 October 2017

We rated Cygnet Hospital Woking as Inadequate because:

  • Young people had repeatedly self-harmed when on enhanced observation levels and staff had been slow to respond to incidents of self-harm.
  • There were a high number of incidents reported in CAMHS and a high use of restraint, of which 10% of restraints were carried out in the prone position.
  • Staff in the CAMHS did not possess the experience, skills and competencies to safely manage the complex behaviours of young people in their care.
  • Physical health care conditions, including significant weight gain, were not managed effectively on the CAMHS ward.
  • Risk assessments in the CAMHS ward did not contain the latest risk factors and the care plan progress was not measured.
  • Safeguarding alerts were not always made to the locality authority or CQC when young people were assaulted by other patients.
  • Staff on the CAMHS ward did not always log, report or review adverse events. Staff did not manage complaints and issues of concern according to hospital policy. Staff therefore did not always take opportunities to learn from the investigation of incidents and complaints.
  • Collectively, the young people felt frustrated, said they were not listened to and felt that staff did not read or follow care plans.
  • Lengths of stay on the CAMHS psychiatric intensive care unit ward were not in line with NHS England service specification guidance (no longer than eight weeks). Two young people had been resident for eight months due to delays in transfer to adult services once they had reached eighteen.
  • Staff reported that calls for assistance were not always responded to.

However:

  • Staff working within the low secure service rarely used physical restraint.
  • Staff on the low secure wards, used nationally recognised tools to support their assessment of patients and were actively involved in clinical audit.
  • There had been only one delayed discharge in the low secure service in the six months period prior to the inspection.

We found a number of concerns during our visit to CAMHS on Park View First ward. However, the provider was responsive to the issues we raised and took immediate action to address them. The provider has continued to engage with the Care Quality Commission and NHS England to resolve issues and ensure that in the future patients will receive care that is in line with the standards expected.  The provider closed the ward in question and has undertaken a significant review of staffing and workforce.

Inspection areas

Safe

Inadequate

Updated 13 October 2017

We rated safe as Inadequate because:

  • In the past 12 months there had been 24 serious incidents recorded on the CAMHS ward. These included alleged sexual assault, significant self-harm, absconsion, serious medication administration error and failure to return from official leave. The service had not introduced sufficient safety improvements or learning from incidents to prevent repetition of these serious incidents although the Hospital had recently started holding monthly risk management meetings to look at learning and actions from incidents.
  • Staff on the CAMHS wards did not protect young people from harm. Young people were occasionally able to breach security and gain access to the ward office which contained confidential information and items that could be used to self-harm. The procedures followed to clean the ward meant that young people had access to potentially harmful equipment and objects. Staff on the CAMHS ward did not follow the provider’s engagement and observation policy nor were managers supervising its application. As a result, young people who were on enhanced observation levels had harmed themselves and there had been allegations that patients had been sexually assaulted by other patients whilst on enhanced observation levels. Staff on the CAMHS ward did not review and update risk assessments frequently enough to ensure that they took account of the most recent risk information for each patient.
  • We identified incidents on the CAMHS ward that were not reported as safeguarding alerts to the local authority when they should have been. Some incidents which had been raised as safeguarding alerts on datix (an incident reporting system) were dealt with internally when they should have been reported to both the local authority and the Care Quality Commission.
  • Restraint was frequently used within CAMHS.

  • Staff from all wards reported that they had raised calls for urgent assistance and there had not been a response from staff from other wards.
  • In a three month period prior to the inspection, the hospital had covered 464 shifts with bank or agency staff and 110 shifts were unable to be filled by bank or agency staff and therefore the wards were understaffed. This meant that some new staff were not familiar with the risks and care needs of patients and that on occasions, the wards did not have the numbers of staff that the ward staffing assessment tool had indicated were required.
  • On the CAMHS ward, some permanent staff members reported that there were not enough staff working on the ward. Staff told us the ward was unpredictable and that there were only sufficient staff numbers to undertake the basic duties. In addition, staff reported that incidents were higher when staffing numbers were low.
  • Staff on the CAMHS ward did not report all incidents that should have been reported. This meant that the service lost the opportunity to investigate and learn lessons from all incidents.

However:

  • The low secure wards had enough staff on duty to ensure that patients’ needs were met. Patients from the low secure wards said that there were always enough staff available to support them to attend to the local community for their prescribed leave.
  • In contrast to the CAMHS ward, the use of physical restraint was very low within the low secure service. The psychology team carried out reflective practice sessions where the multidisciplinary team discussed and formulated responses to support the management of some of the more challenging patients and their behaviours.

Effective

Inadequate

Updated 13 October 2017

We rated effective as Inadequate because:

  • Care plans for patients in the CAMHS were brief, lacked substance and did not include measurable outcomes. Although goals were identified there was no progress towards achievement of these goals recorded on the care plans. The care plans were not recovery oriented or focused upon return to a less restrictive environment.
  • Care plans for young people did not include whether therapeutic input, either individual or group based, was being provided to the young person to assist with reducing problematic behaviours, such as self-harming. No young person reported having a copy of their care plan.

  • Although there was some evidence of monitoring of ongoing physical health problems within the CAMHS, strategies were not in place to manage physical health problems effectively. One young person had a long-term physical health condition. Whilst this was being monitored by an external specialist team, the day to day management of the condition by ward staff was poor.

  • Psychological interventions were offered in isolation on the CAMHS PICU ward and did not guide the daily management and treatment of young people on the ward, for example in the management of self-harm and/or relapse prevention.

  • The CAMHS PICU did not ensure staff had specific training to work with young people with complex needs. No nursing staff held specific qualifications for working with young people although the hospital had provided service specific training for all staff as part of their CAMHS PICU induction.

However:

  • Within the low secure service, all the patients’ notes reviewed had a comprehensive assessment on file completed prior to admission by at least two members of the multidisciplinary team.
  • The hospital had implemented the “my shared pathway” tool across all adult wards. This recovery based tool was used well in the forensic services and focused on patients’ strengths as well as their risks. All 11 sets care plans on the low secure wards consistently followed this care planning structure.
  • Within the low secure service, assessments took place using nationally recognised tools and staff were actively involved in clinical audit.

Caring

Requires improvement

Updated 13 October 2017

We rated caring as requires improvement because:

  • Some young people that we talked with on the CAMHS PICU were unhappy about the attitude and behaviour of staff. Some young people reported being intimidated by some staff. Two young people told us that staff had been unsympathetic and vindictive towards them. We received nine comment cards completed by the young people in the CAMHS service. Five comment cards stated that some staff did not care or respond to young people when they were in distress or when they self-harmed
  • The young people from the CAMHS ward that attended the focus group felt frustrated as they were not listened to and felt that staff did not read or follow care plans. Young people also told us that staff did not approach them after an incident to discuss how incidents of self-harm could be better managed in the future.
  • Young people from the CAMHS ward told us at interview that they were not made to feel welcome on arrival and had not been given copies of their care plans.
  • Parents of young people on the CAMHS ward told us at interview that it was difficult to access information from the ward, or to raise issues of concern. Parents told us they felt ignored by ward staff, some of whom they described as rude and unhelpful.

However:

  • On the two low secure wards we observed positive and caring interactions between the staff and the patients. Staff expressed a caring approach when they were talking about the patient group. It was clear that ward staff understood the patients’ individual presenting issues and how best to support them on a daily basis.

  • All of the patients we spoke to on the low secure wards were very positive about the support and care they received from the staff team at the hospital. Patients felt there were always enough staff available and they felt their needs were being met.

  • The eight CQC comment cards from the low secure wards stated that patients felt safe and that it was peaceful on the unit. There were repeated comments that patients felt that the staff were doing a good job in supporting their needs.

Responsive

Requires improvement

Updated 13 October 2017

We rated responsive as requires improvement because:

  • In the six month period to March 2017, there had been 37 delayed transfers of care across both services. The main reason for delay was the lack of suitable available beds in specialist services.
  • In accordance with the NHS England CAMHS PICU specification, lengths of stay in these restrictive environments should be no longer than eight weeks. Some young people had been on the CAMHS PICU ward for eight months due to the delayed transfers to specialist hospitals and adult services when the young person turned eighteen.

  • Young people reported that there were no structured activities at the weekend and some young people told us they were bored.

  • Young people were aware of how to complain but they told us they often felt they were not listened to or taken seriously.

  • Staff did not handle complaints by parents of young people in the CAMHS in line with the hospital’s complaints policy. Some parents told us they now raised complaints directly with NHS England due to the poor response from the hospital.

  • Complaints were under-reported and therefore the service lost the opportunity to investigate and learn lessons from all complaints.

However:

  • There had been only one delayed discharge in the six month period prior to inspection on the low secure wards. This patient’s discharge was delayed due to a lack of availability of appropriate local authority housing provision for the patient’s particular needs.

  • The wards had small enclosed garden areas. On the low secure wards, patients were encouraged to become involved in maintaining their garden space. We observed patients working with enthusiastic staff members to maintain the ward gardens.

  • There was information on how to complain displayed on notice boards and in the patients’ welcome packs. The welcome pack explained that detained patients had the right to raise complaints about the Mental Health Act directly with the Care Quality Commission. It also explained how to make complaints and the support available from the advocacy service.

Well-led

Inadequate

Updated 13 October 2017

We rated well-led as Inadequate because:

  • Non-permanent staff (agency, bank and locum) made up a large proportion of the work force on the CAMHS ward. These staff did not have regular supervision meetings or appraisals. One permanent senior staff member had not received supervision in the past six months.

  • The service did not have systems in place to ensure that there were sufficiently experienced staff in the CAMHS wards at all times to keep young people safe.
  • Not all CAMHS staff routinely took part in clinical records audit, environmental audit or infection control audit or report all incidents on the electronic Datix system. Not all agency staff had access to electronic systems for recording purposes.

  • The hospital did not have effective processes in place to ensure that all complaints and incidents relating to the CAMHS ward were recorded or investigated.
  • The hospital did not ensure that safeguarding procedures were followed by staff on the CAMHS ward. Some incidents of harm to young people recorded on the datix system were not routinely raised as safeguarding alerts and had not been reported to the Care Quality Commission.
  • Management and leadership training was not available for CAMHS staff in positions of senior responsibility.

  • Staff did not meet their duty of candour obligations as issues of concern were not always raised, recorded or investigated. Staff were not always transparent or gave explanations to young people when things had gone wrong.

However:

  • Staff working in the low secure service felt that the operational objectives for the service were positive. These staff had also been involved with recent organisational developments.
  • Staff were aware of the local senior management structure and knew who to contact if there was a particular issue with safeguarding, facilities or human resource (HR) issues. The ward managers had a visible presence across the hospital and staff told us they felt that the hospital had a stable management structure.

  • All managers collected data in relation to key performance indicators. Managers completed a daily return regarding staffing to the HR department.

  • The hospital supported the service user involvement programme by recently completing a comprehensive service user feedback report. A Cygnet People’s Council had been introduced. This forum captured patients’ views of the service and shared them at senior management meetings.
Checks on specific services

Child and adolescent mental health wards

Inadequate

Updated 13 October 2017

Forensic inpatient/secure wards

Good

Updated 13 October 2017