Cygnet Health Care Limited

Background to this inspection

Updated 3 June 2021

Cygnet Health Care Limited provides services to children and adults across England, Scotland and Wales. It provides the following types of service in health and social care settings:

Secure mental health wards
Psychiatric intensive care units
Acute admission wards for adults
Older people’s services
Rehabilitation and recovery
Personality disorder wards
Child and adolescent mental health services
Eating disorder wards
Learning disabilities services
Mental health services for deaf people
Autistic spectrum disorder services
Neuro-psychiatry wards

Cygnet Health Care has 15 providers registered with the CQC. The findings of this responsive well-led review are being reported under Cygnet Health Care Limited but includes information from across all 15 providers and their registered locations. There is a single executive board and senior leadership team for all the 15 registered providers.

Cygnet Health Care is an independent provider founded in 1988. Since September 2014 it has been a wholly owned subsidiary of Universal Health Services (a health care provider in the USA).

Cygnet Health Care provides approximately 734 beds across their social care services and approximately 2,130 beds across their health care services.

Cygnet Health Care has developed significantly since 1988 with several acquisitions taking place:

Alpha Hospitals Group in August 2015
Cambian Adult Services (CAS) from Cambian Group plc in December 2016
Danshell Group in August 2018.

As of January 2021, there were 119 active registered Cygnet locations in England (62 of these are hospital sites and 57 are adult social care sites). Of the 119 active locations, 17 were previously run by the Danshell Group and 71 were previously run by Cambian Adult Services. There were also four former Danshell locations that were subsequently de-registered (Whorlton Hall and Newbus Grange in 2019, Yew Trees and Thors Park in 2020).

At the time of the current inspection, the overall breakdown of CQC ratings of Cygnet locations was as follows: 7 Outstanding (6%); 80 Good (67%); 17 Requires improvement (14%); 6 Inadequate (5%); 9 not yet inspected (8%).

The breakdown of Cygnet services in each region were as follows:

London and the South

18 hospital sites and 9 adult social care sites
14 hospital sites rated as ‘Good’, 4 rated as ‘Requires Improvement’
8 adult social care sites rated as ‘Good’, 1 not rated

Midlands

26 hospital sites and 22 adult social care sites
4 hospital sites rated as ‘Outstanding’, 15 rated as ‘Good’, 4 rated as ‘Requires Improvement’, 3 rated as ‘Inadequate’
1 adult social care site rated as ‘Outstanding’,15 rated as good, 2 rated as ‘Requires Improvement’, 4 not rated.

North

18 hospital sites and 26 adult social care sites
1 hospital site rated as ‘Outstanding’, 7 rated as ‘Good’, 3 rated as ‘Requires Improvement’, 3 rated as ‘Inadequate’, 4 not rated
1 adult social care site rated as ‘Outstanding’, 20 rated as ‘Good’, 4 rated as ‘Requires Improvement’, 1 not rated.

Analysis of the ‘Must do’ actions in the latest inspection reports for Cygnet locations found that the regulations with the most frequent breaches were as follows:

38 breaches of ‘Regulation 12: Safe care and treatment’ between December 2018 and February 2021
23 breaches of ‘Regulation 17: Good Governance; between December 2018 and February 2021
14 breaches of ‘Regulation 18: Staffing’ between December 2018 and February 2021.

The most common Regulation 12 themes identified in the regulatory breaches were in regard to risk management procedures, failure to follow observations policies and serious incident reporting and management. The most common Regulation 17 themes leading to regulatory breaches were around keeping accurate records, not having procedures in place to make necessary improvements and not following recruitment policies. The majority of Regulation 18 themes were regarding training, specifically induction and life support. Another theme was not having adequate levels of staff in place.

Prior to the publication of the reactive provider well-led assessment a number of Cygnet Health Care’s services were subject to enforcement or in special measures as follows:

Cygnet Hospital Clifton
Cygnet Hospital Colchester
Cygnet Acer Clinic
Cygnet Appletree
Cygnet Woodside
Cygnet Views
Cygnet Hospital Hexham (formerly Cygnet Hospital Chesterholme)

Cygnet Health Care Limited employed 10,600 staff across all its geographical areas, of which approximately 7,000 work in England. The majority of care provided by Cygnet Health Care is funded by the NHS and social services.

Overall inspection

Updated 3 June 2021

The Care Quality Commission (CQC) carried out a follow-up reactive provider well-led assessment of Cygnet Health Care between 27 January and 4 March 2021.

The purpose of this inspection was to follow up on the areas where improvement was required by Cygnet Health Care at the previous well led assessment which took place from July to August 2019. It did not revisit areas that were covered in the previous assessment and where there were no concerns or significant changes to review. This assessment did consider additional concerns which had arisen at 13 services following inspections at 20 services which had taken place since the previous assessment and feedback from other stakeholders.

The CQC regulates health and social care providers in England and so this assessment did not consider Cygnet services in Scotland and Wales.

Overall we found that Cygnet had made progress in meeting the requirements from the previous well led assessment although there was more to do.

CQC has not published a rating as part of this assessment as this is not part of the current methodology for independent health care providers.

We found a number of areas where significantly more work was needed:

Cygnet Health Care did not have a longer term strategic plan. The organisation lacked an organisational development approach. Members of the senior leadership team were not able to articulate which groups of service users they were planning to support in the future and how they would ensure they had the appropriate estate and skilled staff to meet their needs. As a consequence of this Cygnet had continued to close and ‘repurpose’ services and at times this took place with short notice and in response to serious concerns. This could have an adverse impact on the care of service users with the distress resulting from moving to other services. In an organisation with a clear strategic direction service changes would largely happen in a predicted measured manner, reducing the unanticipated repurposing of services to a minimum. Cygnet Health Care also had a number of service users where they were struggling to meet their needs, sometimes where their condition had deteriorated, and where the placements were breaking down. While they had made positive progress in reducing this through the development of clinical models for different types of services with inclusion and exclusion criteria, this work still needed to embed further. Cygnet Health Care needed to further develop their strategic planning for learning and development, to ensure there were staff with the appropriate skills and experience to meet the needs of the service users.

Cygnet Health Care did not have a good balance between its assurance and improvement work. They had invested very heavily in assurance processes since the last well-led assessment. While it was positive to see that Cygnet Health Care was taking its responsibilities to identify and improve services seriously, there was also the unintended consequence of services being constantly checked, having action plan overload and potentially not having the time to identify and improve services for themselves. In contrast their work on quality improvement was still in its infancy and was poorly understood by the leadership team who described a methodology, but did not recognise that to effectively implement continuous improvement there needed to be a significant change in the culture of the organisation to enable front line staff and service users to drive this forward.

While leaders and managers from Cygnet were very proud and positive about their work, many also found it hard to be self-critical and reflective. For example, they struggled to answer questions about areas for further development or improvement. There were a number of risks associated with this, including a potential failure to identify areas for improvement; a potential disconnect between senior leadership and frontline services; a potential to create an environment where people are unable to be open and transparent; and the potential to create a culture where local ownership and empowerment is unable to flourish.

The performance of leaders and managers at different levels of the organisation was variable and so a more tailored approach to meet individual needs, including access to coaching and mentoring and where appropriate a talent management approach. The leadership and management apprenticeships currently in place may be suitable for some individuals, while others may benefit from an alternative arrangement.

While the new governance systems gave improved oversight of service user safety there were still a number of areas where further action was potentially needed to safeguard people using services. Cygnet Health Care was aware of these and they were on their risk registers but they still needed significant ongoing action. These included staff recruitment and retention with staff turnover of over 30% each year and some services really struggling to maintain safe staffing; use of restraint in social care services with around 500 restraint incidents recorded a month across the services; the need for further ligature reduction work where an environmental audit had taken place and some work completed but a programme with clear timescales was needed for the remaining work.

We found a number of areas where there had been considerable progress but there was more to do:

There had been significant progress in bringing together the legacy organisations (companies that joined Cygnet Health Care as a result of acquisitions or mergers). Staff now identified themselves as working for Cygnet Health Care. However, further work was needed to grow the collaborative working between health and social care services within the organisation. Social care staff still felt that at times health care services were prioritised, for example some said the new business information systems were more suitable for health than social care services.

Cygnet Health Care had recognised the value of having arrangements for the independent challenge of the executive team. They had appointed four outstanding independent advisory board members. However, the arrangements needed further consideration to ensure they had the capacity to perform their roles. Also, board development using an external facilitator needed to be taken forward now all the independent advisory board members were in post.

Cygnet Health Care had put in the systems to ensure their executive team and independent advisory board members had the necessary fit and proper person checks. We reviewed this for five people and the checks were complete. At the time of the well-led assessment employment tribunal findings were published raising potential Fit and Proper Persons Requirement issues and Cygnet were considering these findings.

Staff working for Cygnet Health Care needed to feel more confident about speaking up within the organisation and knowing that their concerns would be heard and addressed without fear of retribution. While good progress had been made with the recruitment and introduction of a Freedom to Speak Up Guardian and ambassadors, in 2020 there had been 173 contacts from staff, service users and relatives with the CQC. This reflected a culture where people did not feel able to raise concerns directly with Cygnet, or where they felt those concerns had not been addressed. There were still some pockets of staff who reported that they were being bullied and harassed.

There had been significant progress in implementing an outline governance structure but some of these arrangements were very new and more work was needed to refine this further and ensure it worked effectively. There were still services where incidents of concern were taking place that had not been identified through the governance systems. This highlighted the importance of visiting services and making good use of ‘soft’ information, especially feedback from service users, carers and staff. It was also evident that important areas, such as the monitoring of the use of the Mental Health Act and Mental Capacity Act, received very limited oversight and minimal reporting to the associate board. The feedback from Mental Health Act Reviewer visits was not collated to ensure learning from themes. There was no organisation-wide monitoring of the use of the Mental Capacity Act, such as Deprivation of Liberty Safeguards in place across the services. However, staff had a significantly improved understanding of the clinical governance arrangements and how they promoted improved care and treatment across the organisation through the consideration of data and other information.

Cygnet Health Care had successfully introduced business information systems across all the services including service user records and incident reporting. These systems supported the automated production of data used for governance. However, further work was needed to analyse this data so it could be used to support the understanding and improvement of the services. The data produced by Cygnet fed into a number of different dashboards – clinical, quality and financial. This data was not yet brought together into an integrated performance report which would enable the advisory board and sub-committees to have all the key information they needed in one place. It was also found that HR records were still held at individual services and could not be accessed centrally which was an area for development.

The reporting and management of serious incidents had improved. However, there was scope to further progress the sharing of learning from incidents across services so this reached front line staff and reduced the same types of incidents happening.

While Cygnet had displayed their strategic priorities and these were now known by staff, they were not yet fully embedded in the work of the organisation.

The previous well-led assessment was positive about how Cygnet Health Care engaged with people who use services. This continued to be the case although there was scope to further strengthen the engagement and co-production with service users and Experts by Experience to promote improvements in the individual services.

Since the last well led assessment Cygnet had established an Inclusion and Diversity Committee and BAME (Black, Asian and minority ethnic) network which was a welcome development. However, there was more to do to promote equality and inclusion across the organisation.

Since the previous inspection Cygnet Health Care had introduced safeguarding supervision for staff. However, the support for safeguarding leads to perform their role from a specialist safeguarding team was limited and this needed to be reviewed to ensure adequate support was available.

Cygnet Health Care worked to promote positive relationships with external stakeholders including commissioners and regulators. However, ongoing effort was needed to ensure communication was of a consistently high standard.

We found a number of areas where the provider was performing well:

There had been a strengthening of the operational leadership capacity. The first key appointment was of a second managing director for health, which meant there were now two people in post covering the North and Midlands, and London and the South. This provided more capacity for operational leadership to Cygnet’s healthcare services although during the well led assessment some senior operational leaders in the health care division lacked insight into the challenges and how these might be addressed across the hospitals. A managing director for social care had also been appointed and was widely welcomed across the social care operational teams.

Cygnet Health Care now had effective arrangements in place to identify and escalate risks from services to the leadership team, aligned to their governance processes. This was enabling risks to be identified and monitored.

Since the last inspection Cygnet Health Care had remained financially sustainable. They recognised the importance of ongoing support from Universal Health Services and identified this as a risk but had arrangements in place to maintain effective working relationships.

Cygnet Health Care had largely managed the risks associated with the pandemic well. This had taken considerable time and energy and offered opportunities for organisational learning. At the time of this assessment the risks associated with COVID-19 were still identified as a major risk on the operational risk register, mainly due to the potential adverse impact on staffing levels. Where a few inspections identified shortfalls, such as staff not wearing PPE correctly, this was addressed as a matter of urgency.

Cygnet Health Care had worked to develop one set of policies and procedures across the organisation with arrangements in place to keep these under review.

For more information about what the provider must and should do to improve, see the Areas for improvement section.

Professor Ted Baker

Chief Inspector of Hospitals

Forensic inpatient or secure wards

Updated 8 June 2015

Identified risks were being managed appropriately. For example, the fixtures and fittings associated with curtain rails have been changed across the hospital to reduce any potential self-ligature risk. Most patients felt safe on the wards and told us that staff reacted promptly to any identified concerns.
We reviewed the current and previous staff rotas and these showed us that there was enough staff on duty to meet the needs of the patients on both wards. Additional staff had been rostered to meet the need for enhanced staffing due to assessed patient need.
Assessments took place using a nationally recognised risk assessment tool; the historical current risks 20 framework. Outcomes were being monitored using the health of the nation outcome scales. Patients were receiving cognitive analytical therapy and dialectical behaviour therapy (DBT).This was being provided in four modules as group therapy. Self-reported and other outcome measures were being documented. The length of stay on these wards ranged from six months to four years.
Staff received training via a monthly mandatory training week. Most staff reported receiving effective training opportunities.
Different professions worked effectively to assess and plan care and treatment programmes for patients. The wards had a dedicated social worker and they liaised closely with patients’ families and with statutory agencies as applicable.
We saw good examples of effective staff and patient interaction and individual support being provided.
The provider had a clear complaints policy and procedure systems for them to be investigated and complainants to be given a response.
Most staff were aware of the provider’s vision and values. Senior hospital managers had access to governance systems that enabled them to monitor the quality of care provided. This included the provider’s electronic incident reporting system, corporate and unit based audits and electronic staff training record. Senior staff were visible throughout the hospital and staff approached them to raise concerns.

However:

We found examples of poor practice in relation to restrictive practices. Staff did not record incidents of seclusion and restraint in a consistent manner. Some seclusion records were inconsistent and difficult to follow. There was inappropriate use of segregation in some cases. Staff sometimes recorded food and fluid intake inconsistently whilst patients were in segregation.
A number of care plans had not been consistently reviewed and updated to reflect changes in assessed risk levels. Individual assessment and treatment records seen did not always demonstrate an involvement in their care and treatment by all patients. The reasons for this were not clearly recorded.
Training records for agency staff were difficult to review. Often the main agency of choice subcontracted to other agencies to provide staff for the hospital and this meant that the provider could not be assured of the level of training provided to all agency staff.
Across all four wards we noted that patients were subjected to blanket restrictions and that not all of these had been subject to a clear risk assessment.
The time allocated by the provider across the hospital for handover between staff shifts was insufficient at 15 minutes. This meant that staff worked longer that their allocated shift time in order to ensure a comprehensive handover took place.

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