The Care Quality Commission
  • Mental Health
  • Independent mental health service

Cygnet Hospital Blackheath

Overall: Good read more about inspection ratings

80-82 Blackheath Hill, London, SE10 8AD (020) 8694 2111

Provided and run by:
Cygnet Health Care Limited

All Inspections

7, 8 and 14 October 2021

During a routine inspection

Cygnet Hospital Blackheath provides psychiatric intensive care and low secure care to men over the age of 18 years.

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

The service provided safe care. All patients and staff told us they felt safe. The ward environments were safe and clean. During this inspection, we found the provider had made improvements since our inspections in April 2018 and June 2020.

Medicines were prescribed in accordance with law relating to consent to treatment under the Mental Health Act 1983. Staff managed medicines safely.

The service had improved reflective practice and processes to ensure that learning from incidents, took place.

Managers also ensured that staff received regular clinical and managerial supervision which supported them in their role. Staff told us they were able to speak up and raise any concerns they had.

The wards had enough nurses and doctors to deliver safe and care to patients.

Staff minimised the use of restrictive practices and used restraint as a last resort.

Staff followed good practice with respect to safeguarding and had improved processes to ensure learning from safeguarding took place.

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 engaged in clinical audit to evaluate the quality of care they provided, action plans were developed to make improvements.

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. The ward staff worked well together as a multidisciplinary team and with those outside the service 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. They actively involved patients and families and carers in care decisions.

Since the last inspection there were improvements to the culture of the hospital. Staff felt respected, supported and valued. They could raise any concerns without fear and reported that their concerns were taken seriously.

Staff were provided with opportunities for development and career progression. Staff reported they were positive and proud to work for the provider.

Governance processes operated effectively and performance and risk were managed well.

However:

Not all patients on Tyler ward had a copy of their care plan.

Planned activities for evenings and weekends did not always take place on Tyler ward.

2 and 4 June 2020

During an inspection looking at part of the service

Cygnet Hospital Blackheath provides psychiatric intensive care and low secure care to men over the age of 18 years.

As this was an unannounced, focused inspection we did not rate this service following this inspection. During the inspection we focused on staffing levels at night, staff members ability to raise concerns, if patients felt supported and safe, the culture of the ward and how the management team had responded to a number of serious incidents.

We undertook this inspection due to three incidents where staff allegedly assaulted patients and other staff allegedly failed to report such incidents. All of the incidents were on Tyler Ward, the psychiatric intensive care unit. The incidents were alleged to have taken place during the night.

At the time of the inspection, a police investigation was continuing and a small number of staff were not working whilst the allegations were being investigated by the provider.

We found:

  • Allegations of staff assaulting patients were responded to promptly by the managers of the service. This included staff being suspended and incidents being reported to the local safeguarding team, the police and the Care Quality Commission. In some cases, the service also made referrals to the Nursing and Midwifery Council.
  • The management team identified the need for a wide-ranging investigation and a number of the provider’s central staff supported this. This included a review of restraint incidents, unannounced night visits and an investigation of patients’ views. Actions taken following initial investigation findings included; all nursing staff to work day and night shifts and a new senior nurse role of night co-ordinator with responsibility to maintain standards of care and to ensure staff behaviour remained professional.
  • Three of the six patients we spoke with were complimentary regarding nursing staff being helpful and treating patients well. The remaining half of patients found some staff to be good and others not. The provider’s expert by experience lead also undertook an investigation of patient’s views. An expert by experience is someone who has used, or cared for, someone using services. The expert by experience lead identified that patients generally found staff to be helpful and supportive and felt listened to when they complained.
  • The nursing team had high levels of confidence and trust in the ward manager and their leadership style.
  • Following allegations of staff assaulting patients, all staff in the hospital had been asked to complete a ‘closed culture’ survey regarding the care and treatment of patients by staff. This survey aimed to identify if managers were accessible, staff were caring towards patients and if staff would report concerns. Ninety-three staff in the hospital (77%) responded to the ‘closed culture’ survey.

However:

  • The ‘closed culture’ survey identified that whilst 93% of staff felt comfortable and confident raising concerns about patients’ care, only 80% of staff felt comfortable and confident raising concerns about a colleague. This finding was concerning as some staff were alleged to have not reported incidents when staff assaulted patients.
  • Some staff did not feel managers addressed and acknowledged concerns raised by them. Although there was a record of some acknowledgement of staff issues in meeting minutes, and managers said they were open to listening to concerns, not all staff could attend meetings and said they did not always have time to read the minutes.

24-26 April 2018

During a routine inspection

We rated Cygnet Hospital Blackheath as requires improvement because:

  • Ward staff did not have opportunities to learn from incidents and improve the safety of the care provided to patients. On Tyler Ward, there were no discussions in team meetings about the frequent incidents involving actual assault, attempted assault, verbal threats and disruptive or aggressive behaviour.
  • Supervision sessions did not support staff to discuss the care they provided for individual patients in order to reflect on and develop, their professional practice. Records of supervision sessions were very brief.
  • There were a high number of medication errors on Tyler Ward, particularly errors relating to compliance with the Mental Health Act 1983. These errors had resulted in doctors prescribing medication unlawfully.
  • High use of agency staff on Tyler Ward was potentially impacting on the consistency and quality of care as these staff did not have access to team meetings or supervision to support them with meeting the challenges of patients with complex needs.
  • A majority of patients we spoke with on Tyler Ward said they did not feel safe on the ward or that they had experienced aggression from other patients.
  • Staff on Meridian Ward did not receive specialist training in relation to the complex needs of many patients such as learning disability, autistic spectrum disorders or epilepsy.
  • Staff morale was poor. Whilst staff felt well supported by managers within the hospital, they did not feel that senior managers in the organisation listened to and responded to their concerns. Staff were unhappy about changes to their terms and conditions linked to changes in the organisation.

However,

  • Senior staff within the hospital had a good understanding of the wards. This team met every morning for a daily planning meeting. During this meeting they discussed staffing, incidents, safeguarding admissions and discharges.
  • Managers had clear information that enabled them to compare their performance with other similar wards within Cygnet Health Care.
  • Most of the 15 patients we spoke with said that staff were kind, caring and respectful.
  • Carers spoke very positively about the improvements that the people they cared for had made whilst on Meridian Ward and the level of stability they had achieved.

20/21 October 2015

During a routine inspection

We rated Cygnet Hospital, Blackheath as good because:

  • Patients told us they felt supported at the service and that staff treated them with respect and dignity.
  • Staff reported incidents effectively and the hospital had systems in place to ensure that learning from incidents, complaints and near misses was captured and led to learning throughout the hospital and the organisation. We saw examples of changes which had taken place in response to incidents, complaints and patient feedback.
  • Staff were positive about working for the hospital and had access to mandatory and specialist training.
  • Supervision was up to date and staff were able to access reflective practice sessions.
  • There were multidisciplinary teams, which used the different professional skills effectively to meet the holistic needs of patients.
  • Ward staff delivered care in a clean environment.

However,

  • Tyler ward did not have a dedicated seclusion room. Seclusion incidents had taken place in patients’ bedrooms. However, if a patient required seclusion, they were transferred to an alternative facility.
  • Some patients told us that they did not have copies of their care plans.

30 July 2014

During an inspection looking at part of the service

We carried out this inspection to check whether the service had taken action following concerns identified during our previous inspection in February 2014 where we found that they were non-compliant with outcomes 4 (care and welfare of people who use services), 9 (management of medicines) and 21 (records).

During this inspection, two inspectors visited Meridian and Tyler wards. We met and spoke with people who used the service, relatives of people who used the service, members of staff and managers on each of the wards as well as the hospital and clinical manager. We found that records relating to the care of people who use the service were up to date and comprehensive. We saw medicines were appropriately monitored and recorded. The hospital had systems in place to audit the records at ward level, hospital level and organisational level.

People told us that they were involved with their care planning processes and had copies of their care plans. Risk assessments were completed thoroughly and people had current risk management plans. The hospital had ensured that when higher levels of observation were needed for people who used the service, that these were recorded comprehensively.

We found that the action plan which had been submitted to us after the inspection in February 2014 had been effective.

21 February 2014

During an inspection looking at part of the service

We carried out this inspection to assess if the service had taken action to rectify issues found at our last inspection in August 2013.

At that inspection there were gaps in recording, both in general care records for people using the service and in medication records.

On this visit we found that there were still a number of gaps in care records; There were also several gaps in medication recording, and we found that one person did not have a current care plan.

22, 23 August 2013

During a routine inspection

We spoke with eight people on Tyler ward. All but one of these spoke positively about the nursing care. One person told us "I get on with them all right". Another person said "they're excellent". All of the people we spoke with on Meridian ward talked about staff in a positive way. We observed staff interaction with people using the service and saw that people were treated with respect and dignity.

We reviewed care records on both wards. We found that they contained up to date care plans and risk assessments. We saw that staff were appropriate, considerate and supportive and tried to actively involve people in their care planning. Staff took people's physical health into consideration.

Staff received annual training in safeguarding; and in de-escalation and restraint techniques. Staff were able to attend incident learning meetings where they could discuss lessons learned from incidents that had taken place.

We found that medicines were prescribed and administered to people regularly and appropriately, but some improvements were needed with recording.

Staff told us that they felt supported by their managers. They said they were happy to be there and felt that their training needs were met.

We found that there were a number of quality assurance systems in place to monitor the quality of the service being provided.

People told us that they were aware of the complaints process and that complaints were responded to promptly.

We found that some of the care records for people using the service were incomplete in places.

2, 7 February 2013

During a routine inspection

During our inspection, we spoke with seven patients, eight staff members and looked at six sets of patient records.

We found there were enough qualified, skilled and experienced staff to meet people's needs. One patient told us staff were 'very good, very approachable'. Another told us, 'staff are...here to support me'.

In areas where patients had the capacity to consent, their views and decisions were respected; where they did not have capacity to consent, staff acted in accordance with legal requirements.

However, although patients received appropriate mental health care, sometimes immediate physical health care needs were not always prioritised. Many patients were prescribed an anti-anxiety medication which was causing them unpleasant side effects; they said they had not been advised about how to manage the side effects.

Some aspects of care did not fully protect people. The documented results of emergency resuscitation simulations showed that significant improvements were still required. There was a delay in analysing the root causes of high numbers of incidents and safeguarding concerns, which meant that people using the service might not always have been protected from the risk of abuse.

Patients did not always know what choices were available to them, not everyone understood the complaints system, and there was limited access to therapeutic and recreational activities, including access to fresh air and outdoor exercise.

13 January 2012

During an inspection looking at part of the service

This was a follow-up review of compliance, during which we undertook on-site inspection of Tyler ward only, to ensure that the hospital had complied with the requirements made after our previous compliance reviews in July and September 2011, at which we found that Cygnet Wing Blackheath was not meeting three essential outcomes and that improvements were needed. We also reviewed outcomes where we had suggested that improvements were made to ensure that compliance was maintained.

On this particular occasion we did not talk to people who used the service.

31 August 2011

During an inspection in response to concerns

We inspected Cygnet Wing Blackheath as part of a review of compliance on 18 July 2011. At our inspection, people using the service told us that they did not know who their primary nurse was and that they did not get one to one time with a specific person; they felt that more staff were needed and that staff were too busy. We also found that many staff had left or been moved to different wards since April 2011, that there were staff vacancies and overall that there were not sufficient staff available, on Tyler ward particularly, to work with people in a personal and therapeutic manner. We placed a Compliance action on the provider, Cygnet Health Care Limited, under Outcome 13, Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010 requiring the provider to take action to ensure that, at all times, there were sufficient numbers of suitably qualified, skilled and experienced staff. The provider sent us a report telling us how it would become compliant with Outcome 13 by 15 August 2011.

However, following this Cygnet Wing Blackheath notified us of a serious untoward incident, leading to a safeguarding alert, which had taken place on Tyler ward on 19 August 2011. The incident highlighted concerns about the numbers, skills and mix of staff available on the ward, which had impacted not only about the personal and therapeutic care and treatment of people using the service but also on their safety and wellbeing. The provider's own investigation found that there had been insufficient numbers of staff at the time of the incident, and to a lack of skilled, experienced and poorly inducted and supported staff.

7 July 2011

During an inspection in response to concerns

People on the low secure ward, Meridian, said the ward was clean and well-looked after, and they were content with their bedrooms. They felt that nurses tried to escort their leave at mutually agreed times, as far as was possible.

People we spoke to on Tyler ward said they did not know who their primary nurse was, that they did not get one to one time with a specific named person, and some were not aware that they had a care plan. Two people said that staff had not explained their rights under the Mental Health Act to them.

People were aware of organised activities at the hospital, but they felt that, in general, there was not much to do except sit, sleep, watch television and talk. Books were in short supply and on Tyler ward people had not been able to help themselves to a hot drink for some days.

Generally, people felt that their privacy and dignity was promoted and observed by staff. One person felt his one to one observation was intrusive and upsetting as staff watched him from the corridor through his open bedroom door and anyone else who was passing could also see into his room.

Almost everyone said staff were too busy and that more staff were needed.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.