All inspections: Cygnet Hospital Colchester

Highwoods ward at Cygnet Hospital Colchester is an independent hospital ward which provides 19 beds and is a men’s acute inpatient service.

Cygnet Learning Disabilities Ltd is the registered provider. The hospital is registered with the Care Quality Commission to carry out the following regulated activities:

• Treatment of disease, disorder or injury

• Assessment or medical treatment for persons detained under the Mental Health Act 1983

The service had a registered manager.

The Care Quality Commission last inspected this location in June 2021 where the service was rated good in all domains, and we found no breaches of the Health and Social Care Act regulations (2008).

We carried out an inspection on the 03 and 04 December 2025 due to an aged rating; at this time there were 17 patients admitted to the ward.

At this inspection we found that the service was performing well and is meeting our expectations.

Our View of the Service

The service provided safe care, the environment was pleasant, safe and clean. The ward had enough staff and had access to the full range of specialists to meet the needs of patients. Staff minimised the use of restrictive practices and followed good practice with respect to safeguarding. Staff completed thorough risk assessments of the ward and individualised risk assessments with patients and updated these regularly and/or when risk changed. Managers ensured that staff received training, supervision and appraisal and had developed strategies to support staff wellbeing and recognise staff achievements. Feedback from patients and carers about the service was mostly positive. Most patients told us they felt safe, and that staff were caring and treated them with kindness and respect.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

The service admitted patients under the Mental Health Act 1983. At the time of the inspection, 14 patients were detained under the Mental Health Act (MHA) and 3 had been admitted as informal patients.

Staff received and kept up to date with training on the Mental Health Act and the Mental Health Act Code of Practice. Mental Health Act Code of Practice training was mandatory for staff, and the compliance rate was 100%.

Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice. Staff could receive assistance from the Mental Health Act administrator at the hospital and a regional Mental Health Act administrator.

The service had clear and relevant and up-to-date policies and procedures that reflected all relevant legislation and the Mental Health Act Code of Practice.

Staff explained to each patient their rights under the Mental Health Act and repeated as necessary, recording it clearly in the patients’ notes each time.

Staff made sure patients could take section 17 leave (permission to leave the hospital) when this was agreed with the responsible clinician.

Mental Capacity Act

Staff received and kept up to date with training in the Mental Capacity Act and had a good understanding of the five principles. Training on the Mental Capacity Act was mandatory for staff, and the compliance rate was 100%.

Staff completed an assessment of each patients’ capacity to consent to admission and treatment on admission. Further assessments took place during weekly reviews by the multi-disciplinary team.

The assessment of long stay or rehabilitation mental health wards took place on 03 and 04 December 2025. We inspected the service due to an aged rating. This service was last inspected in June 2021. At that inspection, the service was rated good in all domains, and we found no breaches of the Health and Social Care Act regulations (2008).

At this inspection we inspected 1 ward - Ramsey Unit. This is a 21-bedded unit for men of working age who had experienced multiple placement breakdowns, failed treatment programmes or were stepping down from higher acuity services. The focus of the unit is to maximise positive outcomes and recovery while focussing on discharge planning from the moment patients arrived. At the time of our inspection, 17 people were using the service.

We rated the service as good. We found no breaches of regulations.

Mental Health Act and Mental Capacity Act Compliance Summary

The service admitted patients under the Mental Health Act 1983. Staff received and kept up to date with training on the Mental Health Act and the Mental Health Act Code of Practice and could describe the Code of Practice guiding principles. Training on the Mental Health Act was mandatory for staff, and the compliance rate was 91.7%.

Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice. Staff received assistance from designated Mental Health Act staff.

The service had clear, accessible, relevant and up-to-date policies and procedures that reflected all relevant legislation and the Mental Health Act Code of Practice. For example, there was a process in place to monitor patient’s legal status and renewal dates, which meant staff were able to ensure reviews took place in a timely manner.

Staff explained to each patient their rights under the Mental Health Act in a way that they could understand, repeated as necessary and recorded it clearly in the patient’s record each time.

Staff made sure patients could take section 17 leave (permission to leave the ward or hospital) when this was agreed with the responsible clinician. The use of leave from the ward was agreed by the multidisciplinary team (MDT). Arrangements for leave were made at daily planning meetings and nurses carried out an assessment of each patient’s mental state before each occasion of leave was utilised.

Staff requested an opinion from a Second Opinion Appointed Doctor (SOAD) when they needed to.

Staff stored copies of patients’ detention papers and associated records correctly and staff could access them when needed.

Mental Capacity Act

Staff received and kept up to date with training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act. The training was initially provided as part of the induction process and thereafter staff had regular refreshers.

Staff assessed and recorded capacity to consent clearly each time a person needed to make an important decision. Staff took all practical steps to enable people to make their own decisions. Staff completed an assessment on admission of each person’s capacity to consent to admission and treatment. Further assessments took place during reviews by the multidisciplinary team.

Staff knew where to get advice regarding the Mental Capacity Act, including deprivation of liberty safeguards.

We carried out an inspection of Cygnet Colchester on 03 and 04 December 2025. We inspected the service due to an aged rating. This service was last inspected in June 2021. At that inspection, the service was rated good in all domains, and we found no breaches of the Health and Social Care Act regulations (2008).

We have assessed the service against ‘right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

The service demonstrated how they met the principles of ‘right support, right care, right culture’. The provider had developed their own model of care in which the multi-disciplinary team (MDT) adopted a values-based social model of disability with ‘My Choice, My Voice, My Life’ sitting at the heart of the model. Patients received person-centred care that promoted their dignity, privacy and human rights. Patients were treated as individuals and care was provided flexibly in line with their preferences. There was minimal use of bank or agency staff, and staff knew the people they cared for, and their needs, very well. Leaders and staff shared a passion for supporting people which shaped the culture across the service.

We rated the service as good. We found no breaches of regulations.

The service provided safe care. The ward environments were pleasant, safe and clean. The wards had enough staff and ward teams had access to the full range of specialists to meet the needs of patients. Staff minimised the use of restrictive practices and followed good practice with respect to safeguarding. Staff completed thorough risk assessments of wards and individualised risk assessments with patients and updated these regularly and/or when risk presentation changed. Managers ensured that staff received training, supervision and appraisal and had developed strategies to boost staff wellbeing and recognise staff achievements. Feedback from patients and carers about the service was very positive. Patients told us they felt safe, that staff were caring and treated them with kindness and respect. We saw positive and kind interactions between patients and staff who knew them well. Families were happy with the support being given to their loved ones.

Mental Health Act and Mental Capacity Act Compliance Summary

The service admitted patients under the Mental Health Act 1983. At the time of the inspection, all patients were detained for assessment and/or treatment or subject to Deprivation of Liberty Safeguards (DoLS). The Deprivation of Liberty Safeguards (DoLS) were introduced under the Mental Capacity Act (MCA) 2005. These safeguards were designed to protect the human rights of people aged 18 or over if they do not have the mental capacity to consent to their care arrangements and they need to be deprived of their liberty.

Staff received and kept up to date with training on the Mental Health Act and the Mental Health Act Code of Practice. Mental Health Act Code of Practice training was mandatory for staff, and the compliance rate was 91.7% at the time of inspection.

Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice. Staff received assistance from the Mental Health Act administrator based at the hospital and a regional Mental Health Act administrator.

People had easy access to information about independent mental health advocacy and people who lacked capacity were automatically referred to the service.

Mental Capacity Act

Staff received training in the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLS) safeguards. Compliance rates for the provider training in MCA/DoLS in Principle and Practice was 97.1% at the time of inspection.

For patients who may have had impaired mental capacity, staff assessed and recorded capacity to consent to decisions appropriately.

Staff gave patients all possible support to make specific decisions for themselves before deciding a patient did not have the capacity to do so. Psychology and speech and language therapy staff worked together to assess patient’s capacity and communicate with patients. Staff assessed and recorded capacity to consent clearly each time a patient needed to make an important decision.

When staff assessed patients as not having capacity, they made decisions in their best interest and considered their wishes, feelings, culture and history. They consulted with patient’s representatives as appropriate when making decisions on a person’s behalf. We saw an example where staff had completed a capacity assessment around a patient’s capacity to understand his support needs in the community and were planning a best interest meeting once accommodation options had been identified.

Cygnet Hospital Colchester is a 59 bed hospital providing a range of intensive support and rehabilitation services for men with learning disabilities, autism spectrum disorders or mental health needs. The provider is Cygnet Learning Disabilities Ltd. There are 3 core services:

Acute wards for adults of working age
Long stay rehabilitation mental health wards for working age adults.
Wards for people with a learning disability or autism.

This location is registered with the Care Quality Commission to provide the following regulated activities:

Assessment or medical treatment for persons detained under the Mental Health Act 1983
Treatment of disease, disorder or injury.

The service had a Registered Manager.

On 03 and 04 December 2025, we conducted a comprehensive inspection of the 3 core services within the hospital. This inspection was undertaken due to an aged rating. We inspected the following wards as part of this inspection:

Wards for people with learning disabilities or autism

Chestnut Court opened in May 2024 and supports 5 men with autism, learning disabilities and complex needs. The service is for people who are detained under the Mental Health Act, as well as those who have complex behaviours, or significant difficulties with social engagement.

Oak Court is a 10-bedded ward that provides support to men with a learning disability, associated complex needs and behaviours that may challenge. At the time of the inspection there were 7 patients admitted to this ward.

Larch Court supports 4 men with autism, learning disabilities and complex needs. The team also supports people who are detained under the Mental Health Act, as well as those who have complex behaviours, or have significant difficulties with social engagement.

Acute wards for adults of working age

Highwoods Ward is a 19 bed male acute service. At the time of inspection there were 17 patients admitted to this ward.

Long stay or mental health rehabilitation wards for working age adults

Ramsey Unit is a high support inpatient rehabilitation (level 2) service for men.

We last inspected this service in September 2021. At that inspection, the service was rated good in all domains, and we found no breaches of the Health and Social Care Act regulations (2008). Following this inspection the service has again been rated as good. We found no breaches of the Health and Social Care Act regulations (2008).

The service provided safe care. The ward environments were pleasant, safe and clean. The wards had enough staff and ward teams had access to the full range of specialists to meet the needs of patients. Staff minimised the use of restrictive practices and followed good practice with respect to safeguarding. Staff completed thorough risk assessments of wards and individualised risk assessments with patients and updated these regularly and/ or when risk presentation changed. Managers ensured that staff received training, supervision and appraisal and had developed strategies to boost staff wellbeing and recognise staff achievements. Feedback from patients and carers about the service was very positive. Patients told us they felt safe, and that staff were caring and treated them with kindness and respect. We saw positive and kind interactions between patients and staff who knew them well. Families were happy with the support being given to their loved ones.

Cygnet Hospital Colchester was placed into special measures by the CQC Chief Inspector of Hospitals in May 2019. This followed findings of significant concerns about the safety and leadership of the service. Since then the CQC has continued to monitor the service closely and has found some improvement. We have judged that enough improvement has been made to remove the provider from special measures.

Our rating of this location improved. We rated it as good because:

The service provided safe care. The ward environments were safe and clean. During this inspection, we found the provider had made improvements since our inspections in 2019 and 2020. Staff were now following the provider’s infection prevention control policy and disposed of clinical waste appropriately and managers had ensured processes of monitoring and learning from restraint incidents had improved. Managers held de-briefs with staff to ensure learning had been identified after incidents of restraint. Managers also ensured improvements had been made to ligature risk assessments which were comprehensive with timeframes for actions to be completed and staff ensured alarms were regularly checked, there were enough of them and they were repaired if necessary.

The wards had enough nurses and doctors. Staff assessed and managed risk well. Patients were involved in managing their own risks whenever possible. Improvements were made since our inspection in 2019 where staff now completed daily risk assessments of patients and risk assessments of patients prior to going out of the hospital. Patients, where possible, were involved in developing their positive behavioural support plans.

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff met patients’ physical and sensory needs. Staff minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.

The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. This had improved following our inspection in 2019 where staff did not receive regular supervision for their work. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. Patients had their communication needs met and information was shared in a way that could be understood. Staff involved patients and families and carers in care decisions.

The service managed beds well. At the time of the inspection beds were available. Although there were some delays to patients being discharged, staff worked actively with commissioners and allocated staff to improve timeliness of discharges. Advocates would assist patients with their discharge, where necessary.

Staff supported patients through recognised models of care and treatment for people with a learning disability or autistic people. Patients were supported to be independent and had control over their own lives. Their human rights were upheld, and they made choices and took part in activities which were part of their planned care and support. Staff supported them to achieve their goals and ensured their care, treatment and support plans, reflected their sensory, cognitive and functioning needs. Care focused on people’s quality of life and followed best practice.

The service was well led, leadership was good, and governance processes helped the service to keep people safe, protect their human rights and provide good care, support and treatment. The provider had made significant changes to their senior management team and had ensured staff were now in roles to enhance improvements to systems and processes at the service. Managers had made improvements to their processes in ensuring duty of candour was followed.

We found that the provider had made improvements to their recruitment, selection and appointment of staff policy. Since our last inspection in 2020, staff files were now in line with the provider’s policy when recruiting, selecting and appointing all new staff.

Staff said the changes in leadership and management were positive and had improved their experience of working at the service. Staff were keen to talk to us about the improvements they had made to the service and were passionate and enthusiastic in demonstrating this.

However:

Although some work had been completed on diversity and ethnicity at a local level, the provider had further work to do in ensuring their action plan for the Workforce Race Equality Standard was fully embedded.

Although infection prevention control guidelines were followed and the service was clean, staff on Highwoods ward, had not always recorded that they had cleaned high touch areas every three hours in line with the provider’s Covid-19 Healthcare Cleaning Manual and Schedule policy.

Staff on Oak and Larch Court did not always clearly document in people’s records when their next yearly physical health checks were due to ensure that appointments were not missed or delayed. The provider acknowledged this during our inspection had had plans to make immediate improvements.

Staff did not always follow the provider’s Covid-19 policy or infection prevention and control guidelines set out by the government. Staff did not always wear face masks, some staff wore them inappropriately and did not always dispose of them correctly. This posed a risk that patients, staff or others could transfer infection.
Managers failed to monitor staff wearing face masks appropriately and failed to take appropriate action when staff breached infection prevention control guidance. We also found that managers failed to monitor the appropriate disposal of clinical waste in some areas.
Managers had not taken every step to ensure they recruited staff that had the right skills, experience and values to work with a vulnerable patient group. Of a sample of 38 staff employment records we looked at, 25 (66%) did not follow the provider’s recruitment, selection and appointment of staff policy.
Managers had not assured themselves that staff practice during restraint was appropriate. The providers guidance on the volume of closed circuit television to review was unclear. We were not assured that managers completed a sufficient number of closed circuit television reviews to evidence staff safely restrained patients.

However:

We reviewed 79% of all available closed circuit television linked to restraints across all wards, between 19 July and 18 August 2020. We observed staff using restraint techniques effectively and staff managed most incidents well. Managers held staff and patient debriefs and were supported after any serious incident. Managers shared learning from serious incidents with their staff, both internal and external to the service.

We saw examples and patients told us staff treated them with kindness and respect. Staff were available when patients needed them.

Cygnet Hospital Colchester is a 54-bed hospital for men aged 18 years and above based in Colchester, Essex. There are three core services: acute wards for adults of working age; long stay rehabilitation mental health wards for working age adults and wards for people with a learning disability or autism. We undertook a focused inspection of this service to check the provider had completed agreed actions after we issued a section 29 warning notice at our last inspection in November 2019, when we told the provider it must take action to: make improvements to their systems for reviewing or investigating staff restraints on patients; ensure that staff followed patients’ management plans and ensure that staff involved in incidents made accurate reports.

At our inspection in November 2019 we rated the provider inadequate overall. The provider had already been placed in special measures at a previous inspection in May 2019. We did not rate the hospital at this inspection, so the rating remains the same and the provider remains in special measures.

The warning notice related to Ramsey ward, a long stay rehabilitation mental health ward for working age adults. Our findings also apply to other services, we do not repeat the information but cross-refer to the long stay rehabilitation mental health wards for working age adults service level.

At this inspection we found the following area still needed improvement:

The provider’s system for checking closed circuit television (CCTV) to review staff restraints on patients was still developing and embedding. Senior staff lacked a clear understanding of the process for checking CCTV and had therefore had not clearly communicated this to staff. Staff described different versions of how the system operated. The provider did not have a clear policy for staff to follow and was not auditing its implementation. The provider’s system relied on closed circuit television footage being available for managers to check. There was not a robust system in place to check this was working. There were two occasions in March 2020 where it was not available due to a system’s failure on Highwoods ward and on Oak Court.
We checked two patients’ care and treatment records and found their positive behavioural support plans did not give clear information to staff about how best to support the patient to reduce the need for restraint. For example, they did not capture information held elsewhere in the patients’ notes about their specific communication needs.
Staff did not always fully complete incident reports. For example, we found 16 examples when the nurse in charge or ward manager had not documented their review of staff actions. This posed a risk that staff actions might not be fully effective to reduce risks. Staff had not always signed reports or given start and end times when incidents occurred. The provider did not have clear archive systems to ensure easy tracking of incident forms. Staff gave us reports often not in chronological order of completion. Staff did not always detail linked incident report references when more than one person was involved in an incident, as was in their policy.
In addition, we found that most bank nurses, had not completed safeguarding training relevant for their role. This posed a risk staff would not know how to identify and report incidents of abuse towards patients.

However, we found that the provider had made the following improvements:

The provider had systems in place to safeguard patients and for staff to reflect on incidents and escalate any issues that concerned them or any improvements in practice that could be made following incidents.
We did not observe any incidents which indicated that inappropriate staff restraint or abuse of patients had occurred, either when checking closed-circuit television footage or during ward visits.
The provider had made improvements to its incident reporting processes. The provider monitored themes and trends. They had completed thematic reviews to identify any actions required to reduce risks to patients and others. Managers shared learning from incidents with staff.
Patients told us staff took time to speak with them after restraint about their experiences. We saw examples where staff treated all patients with kindness, dignity and respect on Highwoods, Ramsey and Oak Court.
Additionally, the provider had recently increased leadership and senior management team at the hospital. The hospital manager had a clear means of communication to the executive board to raise any concerns and gain extra resources they needed.
The provider had ensured that the majority of staff had completed de-escalation and restraint training.

We rated Cygnet Hospital Colchester overall as ‘inadequate’ because:

Until recently the hospital manager did not have a robust management team in place to support them to develop governance system effectively and manage risks in the hospital. The provider had not addressed all risk areas identified from our 2018 and 2019 inspections, such as ensuring staff had regular supervision. The provider needed to improve processes for incident investigations, including sharing learning or actions with staff, duty of candour and, have a quality assurance system to ensure actions were completed. The provider also did not ensure there were systems established and operating effectively for the review or investigation of reported staff restraints on patients. We had concerns that the provider had not given the hospital manager sufficient support and resources to implement the required changes in a timely manner.
Not all staff treated all patients with kindness, dignity, respect, compassion and support on Ramsey, Oak and Larch Court. We found an example when reviewing CCTV footage for Ramsey ward where staff were seen to be intimidating towards a patient prior to a restraint incident and staff did not follow the patient’s management plan. Five of six Oak and Larch patients care plans held limited information about how staff involved patients or carers. This was an issue from our 2018 inspection. Patients on Oak and Larch Court and Highwoods wards did not have robust discharge plans. Staff did not regularly communicate with carers and engage them in the development of the service.
Staff did not consistently administer medication to patients under the correct legal authority. We identified four errors on Oak and Larch Court where staff had not correctly completed two patients’ prescription charts relating to the ‘T2’ consent to treatment form and had not correctly completed two patients’ prescription chart relating to a ‘T3’ form where they lacked consent to treatment. Highwoods ward needed to make improvements to their recording and storage of mental capacity assessments.
There was a gap in the leadership presence and oversight on Ramsey ward. The manager had recently left the ward and staff told us the team lacked cohesion. We identified risks for this ward for all domains.
The provider needed to make improvements to ensure ligature risk assessments were thoroughly completed and Ramsey ward and Oak Court to ensure staff knew how to manage the risks for their wards.
Staff alarms did not work across wards and it would not be easy to identify if urgent response was needed for another ward.
Staff on Oak Court did not consistently follow the provider’s observation policy. We found 10 examples in one week, of staff continuously observing patients for more than two hours. This was not in accordance with the provider's policy and protocol for the management of enhanced observations.
The provider’s systems for communicating risk information between the hospital and board were not fully effective as we found gaps relating to risks on the risk register and the hospital managers reports to the Operations Director.
Managers on Highwoods and Oak Court did not have easy access to information to support them with their management role, such as training, staff sickness and turnover data. The provider’s system for recording staff on shift was confusing. There were inconsistencies in Highwoods ward, Oak Court and Larch Court records.
The provider had implemented a no smoking policy at the hospital since our April 2019 inspection. However, the provider had not formally reviewed the effectiveness of this with staff and patients. Staff did not routinely record their risk assessment of Highwood patients before they went on leave to smoke outside the hospital. Staff had not developed care plans on Highwoods ward, to support patients with smoking reduction. Highwoods and Ramsey staff said they had difficulties allocating staff to escort patients for leave to smoke, and for searching patients on return to the ward.
The provider had not ensured that Highwoods patients had regular access to activities. The Joy Clare centre activity programme was not fully operational at the time of the inspection as there were occupational therapy posts vacant. Patients on Highwoods and Oak and Larch Court were dependent on staff to give them access to the kitchenette to make drinks and snacks. The provider needed to make some improvement to the environment on Highwoods ward for staff offices, property storage and the assisted bathroom.
The provider had not completed a specific assessment of how they were meeting the accessible information standards to meet patients’ needs, in line with section 250 of the Health and Social Care Act 2012. The provider's Workforce Race Equality Standard action plan was not specific, measurable, attainable, relevant, and time-based.

However:

The provider had made notable changes to improve and strengthen the leadership of the hospital in the last 12 months and since our last April 2019 inspection. Oak and Larch Court and Highwoods had newly employed ward managers. The majority of staff told us the management structure of the hospital improved and they felt more confident in their ability to lead and improve the hospital. The provider had closed Flower Adams wards following our inspection in April 2019 where we identified a number of risks and imposed conditions on the provider’s registration to restrict admissions.
The provider had acted since our April 2019 inspection, to ensure there were sufficient staff to meet patient’s needs; that staff received essential training (including restraint) and that agency staff had checks before working at the hospital. The provider had employed a staffing coordinator lead on these improvements. The hospital manager now employed a governance assistant and other staff to help them with implementing processes and was in the process of advertising for quality assurance staff posts.
Staff completed a comprehensive mental health assessment of each patient either on admission or soon after. Staff identified patients’ physical health needs and recorded them in their care plans.
Twelve of 13 patients across all wards said staff treated them well and behaved kindly. Highwoods and Ramsey staff involved patients in developing their care plans and risk assessments.
Staff and patients had access to the full range of rooms and equipment to support treatment and care (clinic room to examine patients, activity and therapy rooms).

Our rating of this location went down. We rated it as inadequate because:

The provider had not ensured adequate leadership for the governance systems to adequately monitor, assess, manage and mitigate risks and did not address issues of concern as identified in this report in a timely manner for Flower Adams wards. Consequently, we found risks to patients’ safety had increased since our last inspection in November 2018.
The provider’s system for assessing and admitting patients was not robust to ensure adequate management and monitoring of patient risk. Staff had admitted two out of 15 patients to the service who needed a higher level of care than that which was available. This did not adhere to the provider’s own admission and exclusion criteria. Staff did not assess patients adequately. They had not fully completed risk assessments on admission for six patients admitted to Flower Adams 2 ward. Admitting staff’s rationale for managing patients’ risks was not evident neither was their judgement on determining the level of staff observation required. Flower Adams 2 staff were not effectively implementing a daily risk assessment system designed for staff to use with patients. Agency staff and staff from other wards did not have easily accessible information to patient care and treatment records to ensure staff could easily find information to deliver care and treatment, for example to know items restricted to patients to reduce self-harm. Patients’ care plans held limited details about risk issues and did not detail the level of care staff needed to give the patient.
The provider had not ensured that staff received regular training, supervision and appraisals, and had not ensured that staff had specialist training as identified as to implement national best practice to work with patients with personality disorders. This was also identified at our 2018 inspection. The provider had not made thorough checks on agency staff to ensure they were all suitably safe or skilled to work with patients. Not all agency and permanent staff were trained in safeguarding vulnerable adults or the safe management of restraints. We checked a sample of recent observations records from 1 to 08 April 2019 and found gaps in staff’s completion of records to show observation checks were taking place. We found three examples of staff using judgmental language about patients across these wards either verbally or documented in care records. Five out of 12 staff we spoke with expressed concerns about the quality of training they had received to support them in their role.
There was insufficient staffing to maintain a safe ward environment. There were 70 occasions between January and March 2019 where there was insufficient nursing staff available on shifts. This included occasions when there was a lack of female staff to observe patients.
The provider did not have a robust quality assurance system in place to ensure thorough investigations of incidents to identify learning and actions to be taken to prevent a reoccurrence of risks to patient safety. We checked a sample of 44 incidents investigation reports and found the terms of investigation were not always clear. They did not detail if the investigating staff member had adequate training to complete the investigation and once actions were identified, how these were audited to ensure they were completed. There were not effective systems in place to cascade learning from incidents to staff to reduce the risk of future reoccurrence. The provider had not acted swiftly to ensure suitably competent staff were deployed to carry out observation of patients. Numerous incidents had occurred when staff were allocated to observe patients. At the site visit we found gaps in staff observation records on Flower Adams 2 wards. We were not assured the provider was checking the competency and of staff and addressing the risks.
The provider was not delivering a specialist therapeutic programme for patients with a personality disorder on these wards. The programme offered to patients was not in line with National Institute for Health and Care Excellence guidelines and the provider was not offering patients therapy recognised as best practice.
On Flower Adams 2 wards, we identified errors relating to medication management relating to staff’s prescription and administration of medication.

However:

The provider had started to make changes to the management of the hospital. They had brought in a new operational director and a hospital director who had skills, knowledge and experience of working in or developing personality disorder services. They had identified improvements were required for the management of the hospital and had access to extra resources.
Senior hospital staff had started to implement governance systems to address risks such as daily ‘situation report’ meetings to monitor staffing needs and any shortfalls. These were not fully embedded at the time of inspection. We saw examples where they shared staff between wards or gained bank or agency staff to try and cover any shortfalls. The provider was reviewing their recruitment and retention plans to gain permanent staff.
Staff were completing a short-term assessment of risk and treatability document or risk formulation for patients. This gave staff some information about risk histories and management of patients.
The new hospital director had requested additional support from the provider to get the backlog of incidents investigations completed and extra staff support had been gained from outside the hospital. They had proactively reviewed historical incidents to ensure they were reported and investigated which had contributed to the backlog. The provider had developed some ways to share learning with staff. Staff displayed ‘lessons learnt redtop alerts’ in ward offices. This gave staff some information on how to reduce risks to patients.
Staff ensured that patients had access to physical healthcare when needed.
Patients could access wellbeing activities such as for mindfulness, yoga, massage, sensory integration and guided imagery techniques to assist with relaxation.
Staff had ensured the ward environments were clean and completed regular assessments of the care environment.
Staff said they could raise concerns about disrespectful discriminatory or abusive behaviours or attitudes towards patients without fear of the consequences.

We rated Cygnet Hospital Colchester as requires improvement because:

Safety was not a sufficient priority. The provider had not ensured all ward environments were safe. Managers had not identified, rated and mitigated against all ligature risks on all wards. The provider did not ensure the environment on Oak Court was clean, that maintenance issues were repaired, or the décor was updated. There was little evidence of learning from events or of action taken to improve safety. Managers completed investigations of incidents but did not record the outcome of investigations on their incident recording form. Managers did not share lessons learnt with staff in team meetings which posed a risk that similar incidents could reoccur.
Staff on Flower Adams wards did not consistently assess, monitor or update risks to patients. Four out of six records either did not identify needs, had incorrect information within them, were a repeat of assessment information or information had been copied and pasted from a previous placement. Staff did not always update care plans across all wards, with the exception of Ramsey ward which meant staff were not aware of the changing needs and risks of patients.
The provider made last minute changes to the service specification for Flower Adams 1 ward, immediately prior to opening. This had impacted on safe care and treatment for patients. Originally planned to be a long stay rehabilitation ward, the decision to change to an acute admission ward, had caused anxiety amongst the staff. The majority of staff told us they did not feel suitably skilled or trained to manage the complexity of needs and risks of this patient group. Patient care records showed high numbers of incidents across both Flower Adams wards since opening. Staff did not receive regular supervisions or appraisals. The provider did not ensure that minutes of team meetings were available for staff reference on all wards except Oak and Larch Court.
Staff across all wards said moving away from a learning disability service to a service with wards for people with a personality disorder had been challenging and they were still in the process of adjusting to this change. Staff were often moved between services to cover vacant shifts including on both Flower Adams wards. Some staff did not feel adequately trained to meet the specific needs of these patients. We were concerned that continuity of care for patients was disrupted when staff moved between services.
Staff did not involve all patients in their care plans. We reviewed 23 care plans and eighteen of these were not person centred and lacked the patient voice. Not all patients had signed or had access to a copy of their care plan. Some patients said they were not involved in developing their care plans and said they did not receive a copy.
Patients on Flower Adams 2 ward were not receiving care and treatment in line with best practice for rehabilitation wards. Staff did not provide patients with training or work opportunities that would enable patents to acquire living skills. No patients had unescorted leave or were responsible for managing their medication as part of gaining independence to move out of hospital. Patients on Flower Adams wards did not all receive psychological formulations and the psychological model had not yet been fully embedded on the wards which meant patients were not receiving all their required treatment in line with National Institute for Health and Care Excellence guidelines.

However:

Staff were discreet and respectful when caring for patients. We observed staff interacting with patients in a way that was responsive to their needs. Staff described the needs of their patients and how they worked with patients to support them.
Patients on some wards had access to work opportunities. This included car washing and cleaning jobs. The provider was installing computers in their activity centre for patients to use and were due to open a tuck shop for patients to promote patient socialisation and employment experience. Staff were developing a career skills and Curriculum Vitae writing group on Ramsey ward to support patients with seeking employment. Patients were encouraged to attend a local college to develop their educational knowledge and develop skills and confidence in seeking employment. Patients on Flower Adams wards did not access these opportunities.

We did not rate wards for people with learning disability or autism or long stay/rehabilitation mental health wards for working age adults at this focused inspection. We found the following areas of good practice:

The provider had reduced the risk of patients accessing the security fence and roof by improving the physical environment of the garden area on Oak Court. Staff completed risk assessments for patients and updated these regularly, including specific risk assessments in relation to accessing the security fence and roof.
The provider deployed sufficient staff to maintain the safety of patients on all wards and to undertake enhanced observations for patients. Managers ensured they offered regular breaks to staff. The provider had established systems to provide accurate information about staffing levels and monitor this across the service.
The provider had reviewed the paperwork for allocating enhanced observations and monitored how managers allocated staff to work with patients. The provider had established a clear protocol and rationale to explain why staff worked outside the therapeutic engagement and observation policy on Larch Court to meet the needs of patients with autistic spectrum disorders. Managers had also applied this rationale to some of the staffing arrangements on Oak Court where staff supported some patients separately due to the closure of another ward.
The provider had ensured that staff admitted patients to the service within their referral and admissions criteria.

However, we found the following issues that the provider needs to improve:

The therapeutic engagement and observation policy did not always accurately reflect the working arrangements across the service. On some occasions, managers recorded that they had allocated staff to enhanced observations for longer than stated in their policy.

We did not rate the provider during this focused inspection as we did not cover all aspects of each domain. The provider was last rated at the comprehensive inspection, published 12 June 2017, when the service was rated as 'requires improvement.'

We found the following issues that the provider needs to improve:

The provider had not ensured that there were sufficient staff on duty for safe care and treatment of patients. There were insufficient staff on duty and staff were not always able to take breaks during their shift. Access to activities and escorted leave was limited for those patients not on enhanced observations. Although patients had access to activities at the Joy Clare centre, most patients required section 17 leave to access this facility. Patients not on 1:1 observations who required an escort could not always participate in activities at this facility when staffing levels were low. The provider was not able to provide clear, accurate and easily accessible information about staffing levels across the hospital. Information submitted did not show how staff had been moved around the hospital to cover vacant shifts, but did indicate significant shortfalls.
Staff did not always complete enhanced observations correctly, in accordance with patient care plans and the provider’s policy. This included gaps in observation recording and failure to adhere to strategies identified in positive behavioural support plans and daily routines. We observed eight occasions where staff did not follow guidance contained in the patient’s care plan.
Staff did not always engage with patients whilst on observation. We observed long periods where staff had not interacted with patients. We also observed that staff did not always respond to patient requests. We observed examples where patients asked for support and this was not forthcoming because staff said they were busy or that equipment, such as a phone or a razor, was broken. Staff interactions with patients rarely offered therapeutic engagement.
The provider had not ensured the safety of patients. On Oak Court, two patients had accessed the roof, and climbed the security fence on a number of occasions. The provider had not put sufficient plans in place to protect patients and mitigate the risk of further incidents. The provider had further not ensured the safety of staff, patients and the public when transporting a patient on home leave.
Although the provider had appropriately excluded some patients from admission, they had not ensured they could meet the needs of some patients they had admitted. The provider had not consistently followed the exclusion criteria contained in their admission policy prior to admitting these patients.
The provider used closed circuit television to review some incidents on Laurel Court, Oak Court and Redwood Court. However, closed circuit television was not available across all wards and, where available, did not cover all communal areas. We were concerned that the confidentiality of patients was not protected.
There was little evidence of patient involvement in care planning. Seven carers also said that the hospital did not communicate effectively with them concerning their relative.
The provider had not ensured that all mental capacity assessments had been followed up with best interest decision meetings, where appropriate.
Ongoing monitoring and management of physical health issues was not consistently maintained or recorded.

However we found the following areas of good practice:

Staff completed physical interventions for patients, when required, appropriately and in accordance with taught techniques and the provider’s policy.
Staff knew what incidents to report and reported them appropriately.
Staff participated in regular multi-disciplinary meetings and effective discharge planning meetings for patients.
The provider addressed staff performance issues and took action when appropriate.
We observed some positive interactions with patients.
Patients had access to advocacy services.
The provider had successfully discharged 42 patients over a 12 month period of which 76% were transferred to less restrictive placements.
The provider had developed effective systems to ensure that safeguarding concerns were reported to the police, local authority and Care Quality Commission.
The provider had ensured that new staff received a two week period of induction prior to working on the wards.

From our inspection we found:

Patients were not always monitored in line with the provider’s policy after receiving rapid tranquilisation.
Some risk assessments had not been updated within the provider’s timescales. This included assessments for patients with epilepsy and at risk of choking.
Handover discussions took place in environments which made it difficult to convey information effectively. Rooms were small and there was a lack of other facilities.
Some handovers took place in communal areas which lacked confidentiality and did not maintain patients’ privacy and dignity.
Care records were difficult to navigate and it was difficult to access information about patients quickly. Some care plans had not been updated in line with the provider's own policy.
There was no systematic monitoring of physical healthcare for those patients receiving high doses of antipsychotic, antidepressant and anticonvulsant medication.
The provider did not demonstrate that it was following NICE guidance for challenging behaviour and antipsychotic medication by identifying target behaviours and stopping at six weeks if there was no response.
As required medication protocols were not individualised and lacked clarity.
Mental capacity assessments were not person centred, did not evidence family involvement and did not show how decisions had been reached in relation to patients’ capacity.
The provider had not conducted an audit of positive behavioural support plans to ensure their quality and that they had been updated regularly.
Six carers said that communication from the hospital was minimal, poor or inconsistent and that they often had to ring the hospital to get information about their relative.

However:

Restraints across the hospital had reduced since the last inspection in February 2017, showing a downward trend.
The provider ensured patients had a behavioural support plan and had taken steps to put this approach at the centre of its care planning. Staff received training and the psychologist and behavioural therapist offered support to staff on the wards.
Staff were caring and treated patients respectfully and showed understanding of patients’ needs.
The provider had developed a robust and clear system to monitor the performance of staff and the hospital through key performance indicators.
The provider had appointed a safeguarding lead to ensure the quality and timeliness of safeguarding information to the local authority, police and the CQC.

We rated Cambian Fairview Hospital as requires improvement because :

Staff did not manage medication consistently across the hospital. We found errors in the storage and recording of controlled drugs and errors on patient medication records.
The provider’s policy relating to seclusion and long-term segregation was not clear. The policy stated that seclusion could only take place in low-secure services where there were dedicated seclusion facilities. The policy did not contain any guidance for staff if seclusion occurred within their service.
The provider did not act on recommendations it identified in ligature risk assessments. Assessments completed in February 2017 were in many cases identical to the ones completed the previous year.
The provider did not have timely access to physical health checks for patients and interventions such as blood tests and electrocardiograms on site. Staff relied upon GPs to fax over results to the service, meaning they would not be available out-of-hours or at weekends.
Not all staff received an annual appraisal. Forty per cent of staff on Larch Court and 73% on Cherry Court had received an appraisal in the past 12 months.
There was little evidence of patients being involved in developing their care plans or risk assessments.
The provider did not record how they responded to concerns expressed through patients’ forum meetings. Patients had expressed concerns at meetings, which managers had not responded to at the next.
The provider had not developed a robust system to ensure that key performance indicators were used to assess the performance of the service.

However:

Staff undertook thorough risk assessments of patients prior to and immediately after admission.
Debriefs were held with staff after incidents of challenging behaviour to establish what could be learnt and to promote staff and patient safety.
The provider offered a range of psychological therapies both in groups and individually.
The provider made assessments using a recognised tool to gather detailed information about a range of behaviours in order to develop a clear plan of interventions.
Patients had detailed positive behavioural support plans for patients to help them understand their behaviour and to look at ways to help them respond differently.
Staff interacted with patients in a calm, respectful and caring way. We observed staff supporting patients support when they were distressed.
Patient records contained detailed and holistic assessments, behavioural support plans and risk assessments, which referred to patients’ views and preferences.
Staff provided information to patients about treatments, how to complain, advocacy and rights in easy read format.
There was evidence of good teamwork and mutual staff support at both ward and multi-disciplinary team levels.

From our inspection we found:

The provider’s governance systems and processes for sharing learning from incidents with staff as part of risk management were not robust.
Staff investigation reports were not detailed and information was lacking as to if action plans were completed to reduce further risks.
Staff had not updated six patients’ risk assessments, care plans and positive behaviour support plans to reflect a change in risk management following safeguarding incidents.
We found incidences where staff had not adequately observed patients when they posed a risk to themselves or others.
Staffing rotas were not always updated to reflect staffing levels.
Management and leadership was not consistent as there were several changes to head of care posts who managed the wards. Three staff expressed concerns about the effectiveness of management support and the lack of feedback on issues raised.
Staff meetings were not regularly taking place and minutes did not always detail how decisions were taken to evaluate and improve the service.
Staff were not achieving mandatory training targets identified by the provider, for example relating to safeguarding adults.
A staff member said they had not had restraint training and had been involved in restraint.
We found examples where the provider’s policies and procedures had not been improved to reflect current national guidance.
The provider had not improved their practice, responding to feedback from the CQC regarding notifications and providing updates in a timely manner.

However:

Patients told us they felt safe on the ward living with others and were able to tell staff if they had any concerns.
We saw good examples of positive staff and patient interaction and individual support.
Staff knew how to report incidents and safeguarding concerns. Managers had systems for reporting and tracking safeguarding referrals to the local authority, police and CQC.
Managers told us that they had identified problems with their governance systems and communication with staff. They had contacted the provider’s quality team to improve processes.
The provider had consulted the National Autistic Society to improve their service.

We rated Cambian Fairview Hospital as requires improvement because:

Emergency equipment checks were not being carried out effectively. We found that equipment had not been calibrated and defibrillator electrode pads had passed their expiry date.
There were ligature points in all wards. They had been identified in a ligature risk assessment but no action had been taken to minimise the risk to patients. Ligature points are places to which patients intent on self-harm could tie something to harm themselves.
Staffing did not always meet the numbers set by the hospital to meet the needs of the patients. This meant there were high levels of bank and agency staff being used to cover shifts. The hospital did not provide figures that showed the exact use of bank and agency staff.
Medication stock was not managed effectively and we found errors when we completed random counts of medication.
Hospital-wide learning from incidents and audits was not shared across the staff team.
Refurbishment and redecoration was required on Oak Ward to promote recovery and comfort.
Wards’ systems and procedures were inconsistent. Staff told us this made it difficult when they were asked to cover shifts on other wards. This meant that staff’s time was used understanding the systems on the ward and not always focussed on patient care.
Future developments and improvements for the hospital did not have timescales for completion.
One notifiable incidents had not been reported to the Care Quality Commission as required. This meant we were not aware of a serious incident affecting patient care.

However:

There were robust systems to check that personal alarms for staff were working effectively as required.
Staff had recently been trained in MAPA (Management of Actual or Potential Aggression) restraint techniques that were less restrictive than previous techniques used.
There were no episodes of prone restraint used.
Staff produced comprehensive assessments of the risks to patients, reviewed them regularly and updated them when risks changed.
There were robust processes to monitor the physical healthcare needs of patients.
Staff prepared detailed care plans and reviewed them regularly.
Staff and patients interacted positively and we saw evidence that staff had an understanding of individual patients’ needs and preferences.
Patients had a wide variety of food choices and the hospital provided food for people with specific dietary requirements.
Patients knew how to complain and the provider investigated these appropriately and told patients their findings.
Staff said there was visible leadership in the hospital and that team morale was good.
The hospital was working towards National Autistic Society accreditation.

We last inspected this service on 06 and 07 November 2013 and we identified areas where the provider needed to take action. The provider sent us a report detailing the actions they had taken. This included an updated action plan dated 20 June 2014. We carried out this inspection to check on the actions taken.

During this inspection we found that overall improvements had been made by the hospital that ensured the provider was now compliant with the relevant regulations.

The service was safe. We found the provider had policies and procedures in place to protect people from abuse or harm. Staff had received relevant training. People told us that they usually felt safe in the service.

The service was effective. We noted that clear assessments and care plans were in place for each person using the service to ensure people’s needs were being effectively met.

The service was caring. Most people gave us positive feedback about staff and the service given. However the provider may find it useful to note that some people expressed concerns about access to Section 17 leave and activity provision.

The service was responsive. We saw that staff gave support to people to ensure individual choice and the records seen demonstrated that people received support from an effective independent advocacy service.

The service was well led. Robust management systems were in place and the provider had taken steps to address the areas of previous non-compliance.

We visited Beech Court, Cherry Court, Oak Court and Redwood Court where we spoke with 16 people using the service and 16 staff and an independent advocate. People told us that they had community meetings once a week where they were able to talk about things that mattered to them, including food, smoking and going out. One person said, “Sometimes things get changed”. Another person told us, “I like being here, I have been here for four years and now I’m going to move on. I have been to see a place”. Other comments from people who used the service included, “Well it’s nice here. I have no problems” and “It is lovely here”.

We found that the care, treatment and support people received varied depending on which unit they resided. On Oak and Beech Court we found that people’s care was not consistently effective, caring and responsive to their needs. The design and layout of these units did not ensure people’s rights to privacy and safety. People on Oak Court told us that they did not always “Feel safe” on the unit because of the behaviour of others”. We found that people who used the service were not being protected against the risk of unlawful or excessive control or restraint.

We found that there was not qualified, skilled and experienced staff to meet people’s needs. Staff were not being supported to deliver care and treatment safely and to an appropriate standard.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

We gathered evidence of people’s experiences of the service by talking with people, observing how they spent their time and noting how they interacted with other people living in the hospital and with staff.

During our inspection we visited three areas and on two of the units we were shown around by people who use the service. They told us about the things they liked to do and what it was like to live at Cambian Fairview Hospital.

One person told us about their interest in monitoring the weather and that they had enjoyed a visit to the BBC weather centre. Another person told us that they enjoyed playing football and listening to music.

There was a wide range of activities for people both on site and in the wider community and records confirmed that people were encouraged to take part in activities and pastimes they enjoyed.

We saw good interactions between staff and people using the service. Staff spent time with people supporting them with activities such as working on the computer and making arts and crafts.

We found that staff received the training they needed to provide care and support safely and were able to demonstrate that they understood the needs of the people using the service. We saw that staff had good communication skills and it was evident that they knew people well and understood their needs, likes, dislikes and preferences.

We were informed on the first day of our visit that there were 61 patients staying at Fairview Hospital. We visited each of the seven units, but focused on Cherry Court in more depth to ascertain the outcomes for people living there. We met and introduced ourselves to all nine patients living in Cherry Court; however we spoke with four patients in more detail to get their views of the service. All patients living in Cherry Court were female.

One patient told us that, 'Fairview is a good place', and that they were 'Quite happy'. One patient told us they had opportunities to take part in cooking, computer sessions and table tennis. Other patients with whom we spoke were excited about the new building work to create a new 'Therapy Hub', which included an internet caf' and a hairdressing and beauty salon.

We asked patients if they felt safe living in Cherry Court. Overall patients told us that they felt safe and that staff were kind and that this made them feel 'good and respected'. We spoke with an independent advocate who visited the service on a regular basis. They told us that they had 'no concerns' about the care of patients using the service or the attitude of staff. They confirmed that they were able to speak with patients, in private or within a group setting. We also spoke with a social worker with regards to a patient who had no family. They told us that they had initial reservations about whether the placement would be suitable for this patient; however they commented that they had no specific concerns. They informed us that the patient was due to move into a supported living placement later in December and records showed this was progressing to plan.

We spoke with three relatives of patients living in Cherry Court. One relative told us they were not happy that their daughter had been admitted to Fairview Hospital, as it was a long distance from the family home. However, they confirmed they had visited the service twice and felt that staff were 'doing the best they can' to support their daughter. They said that they were aware that their daughter had been given a copy of their care plan and had staff support on a one to one basis. A second relative spoken with said that they had been in regular contact with their daughter's key worker, for whom they had the, 'utmost respect'. They told us that they had not been involved in the development of their daughter's care plan; however they felt their daughter was getting the right care and support. They told us that their daughter 'goes out often' and was supported to cook her own meals. The third relative spoken with told us that they were unable to visit the unit; however they received regular reports of their daughter's treatment and progress and had no concerns for their welfare.

During our visit we were able to meet with six people who were receiving care and treatment at this hospital. Other people greeted us throughout our visit to their individual unit

People with whom we spoke confirmed that they were listened to and respected by staff. There were no reports of any bullying or harassment of anybody within the hospital.

People confirmed that they were involved in their own care and treatment programmes. For example some people had just attended their individual clinical review and as part of this process were granted section 17 leave at the weekend. Two people told us that they were being transferred to services closer to home and were looking forward to this happening.

People told us that they were generally satisfied with the care and treatment provided by staff. They said they felt able to approach staff if they had any concerns and were confident that these would be addressed appropriately.

During our visit we were able to meet with 10 people who were receiving care and treatment at this hospital. Two further patients were also able to give us non-verbal cues assisted by staff during the visit.

People with whom we spoke confirmed that they were listened to and respected by staff. It was reported by the people using the service that there were a range of activities available and these include unit based activities as well as a range of off-site activities facilitated by staff and the availability of hospital transport.

People confirmed that they were involved in their own care and treatment programmes. For example they had regular meetings with their named nurse and key workers and were involved in the drawing up and implementation of their care plans.

People told us that they were generally satisfied with the care and treatment provided by staff. They said they felt able to approach staff if they had any concerns and were confident that these would be addressed appropriately.

The people with whom we spoke said they were generally satisfied with the choice, quantity and quality of the meals provided and the cleanliness of their individual unit.

It was confirmed by people using the service that they could hold discussions with staff about any concerns they may have and were confident that staff would address these where possible.

People told us that they felt able to approach staff with any complaints that they may have and were confident that staff would address these where possible or refer them to the provided independent advocacy service.

People with whom we spoke were invited to their care reviews and their CPA meetings. They explained that they had regular meetings with their key nurse and that these were used to discuss any concerns they may have.

These older reports are from our old approaches to inspection, including those from before CQC was created.

All Inspections