You are here

We are carrying out a review of quality at Cygnet Hospital Ealing. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Inadequate

Updated 27 September 2019

Due to the concerns we found during this inspection, we used our powers under section 31 of the Health and Social Care Act to take immediate enforcement action and placed a number of conditions on the provider’s registration. This meant that the provider could not admit patients to Sunrise Ward until improvements had been made. The imposition of conditions also serves as a ratings limiter for the key questions of safe and well-led for the hospital overall.

We rated Cygnet Hospital Ealing as inadequate because:

  • The provider was not delivering safe care. Patients were at high risk of avoidable harm on Sunrise Ward. Four patients had self-harmed during a two-month period when they were being observed on a 1:1 basis by staff. There were shortfalls in the management and recording of some medicines.

  • Some nursing staff on both wards did not have experience and were not offered adequate training to enable them to care for patients with an eating disorder or personality disorder. The multidisciplinary team on Sunrise Ward had completed appropriate assessments and care plans, but the nursing team was too disorganised to implement them reliably.

  • On Sunrise Ward some nursing staff spoke to patients in an off-hand manner and did not display kindness or compassion, although patients on New Dawn Ward said staff were kind.

  • Sunrise Ward did not offer a therapeutic environment for patients with eating disorders Nationally recommended psychological therapies were not available and some nursing staff had no insight into how to work with patients around meal times and snacks. There was a lack of weekend activities on both wards.

  • Some parts of the building were poorly maintained. For example, the patient alarms and the lift.

  • The service was not well led. There had been a high turnover of senior staff within the hospital and, whilst posts had been covered for most of the interim period, this was impacting adversely on the nurse leadership. Staff on both wards reported instances of bullying. Patients on both wards complained about a lack of timely feedback when they raised any issues. The provider had appropriate systems in place to monitor quality and safety, but no one was systematically checking that they were being used or looking at what needed further follow up.

  • The provider had not made all the necessary improvements from the previous inspection in November 2018. The provider’s self-assessment said that the work had been completed. We concluded that, although some improvements had been made to paperwork, this had not led to a consistent improvement in practice. This failure was linked to the ongoing leadership changes which meant that the oversight was not in place.

However:

  • New Dawn Ward had a permanent ward manager in place and was better managed than Sunrise Ward.

  • Most clinicians within the multidisciplinary team were working hard to build good working relationships internally and externally. They were using clinical tools and guidance appropriate for their professions on both wards and they were participating in clinical audits.

  • Patients’ mental and physical healthcare needs were assessed on admission and regularly monitored. Referrals were made to specialists when required.

  • All permanent staff received annual appraisals and most staff received regular supervision, although it did not always cover all relevant issues.

  • Discharges were well planned in conjunction with patients’ local health and care teams.

  • There was sufficient space for all the on-ward activities to be carried out; a range of rooms were available.

  • Patients had access to independent advocacy and staff carried out their duties in line with the Mental Health Act and the Mental Capacity Act.
Inspection areas

Safe

Inadequate

Updated 27 September 2019

The Notice of Conditions, served under section 31 of the Health and Social Care Act limits the rating that can be awarded for safe across the hospital as a whole.

We rated safe as inadequate because:

  • There was a poor track record on safety on Sunrise Ward, with four incidents of patient self-harm taking place in two months when the patients concerned were meant to be under close observation. Due to the disorganisation of the nursing team on Sunrise Ward, we concluded there was an ongoing risk and took the step of requiring the ward to cease admissions immediately.

  • Staff did not fully mitigate risks associated with the layout of both wards. Whilst there was a ligature risk assessment in place, there was a lack of clarity about responsibility for managing the risk of the ligature anchor points. Outstanding actions on the ligature risk assessment did not have specific completion dates.

  • There were long-standing maintenance issues on New Dawn Ward with no date for repair. Patient alarms had been out of order for some time and patients said they could not easily call for help at night. The sluice room on Sunrise Ward was used as a storage cupboard for patient belongings so could not be used for disposing of human waste. Sunrise Ward clinic room was disorganised, some medical and clinical equipment was dispersed around the ward. This impacted on the timing of some patients’ nasogastric feeds as staff struggled to find the equipment required. Some items were beyond their use-by date and the blood glucose machine had not been calibrated within the last year. The Sunrise Ward nursing office was chaotic, and this impacted on the ability of staff to find clinical and non-clinical information in a timely way. Information was dispersed between different systems and this was an issue on both wards.

  • The service had enough nursing and medical staff, but the nursing team on Sunrise Ward was not deployed to best effect or well-inducted. There was high use on this ward of agency staff who may not know the patients. Staff turnover at the hospital was running at 22% which impacted on continuity of care and the level of staff experience in respect of the patient groups.

  • Whilst the assessment and management of risk had improved on Sunrise Ward with robust written plans in place, they were not being implemented during one-to-one observations of patients so risks remained. Patients told us that staff frequently fell asleep.

  • Nursing staff on Sunrise Ward did not follow the provider’s policy on recording in relation to controlled drugs. There was a similar issue on New Dawn Ward; in addition, on New Dawn one of two oxygen cylinders was empty and emergency medicines were dispersed rather than kept in one convenient place; this could cause treatment delays.

  • Sunrise Ward simply stopped using members of agency staff if they had been implicated in an incident in any way. There was no evidence of feedback to the agency or any wider learning opportunities for the staff team to reduce similar incidents in future.

  • There was no evidence of the duty of candour being applied when a serious incident had taken place on Sunrise Ward, but this was not the case on New Dawn Ward.

However:

  • Both wards were clean and well equipped. Shared bedrooms were in use within the hospital, but the provider was considering how to eliminate them.

  • Over 83% of permanent staff on Sunrise Ward and 88% on New Dawn Ward had completed their mandatory training.

  • There had been improvements in the recognition and review of restrictive interventions. Blanket restrictions were only used when appropriate. However, post-incident debriefs did not always take place as planned on Sunrise Ward due to the disorganised nature of the ward.

  • Staff had training on how to recognise and report abuse. They were working with external bodies to identify themes and issues.

  • Staff regularly reviewed the effects of medications on each patient’s physical health.

Effective

Requires improvement

Updated 27 September 2019

We rated effective as requires improvement because:

  • Whilst there was some good practice by individual staff members on Sunrise Ward, this was undermined because the ward did not provide a therapeutic environment for patients with eating disorders. Evidence-based recommended psychological therapies were not available on Sunrise Ward and the disorganised nursing team was unable to reliably deliver nasogastric feeds on time.

  • Some members of the Sunrise Ward nursing team did not have experience or training in supporting patients with an eating disorder. For example, they lacked insight into the implications of not delivering feeds, meals or snacks in a timely way. Patients were left distressed and there was a risk to their health.

  • Some staff on New Dawn Ward said they had not received any training in personality disorders; it was not included in the training provided.

  • Nursing staff induction was minimal on Sunrise Ward, but more comprehensive on New Dawn Ward.

  • Staff on New Dawn Ward avoided discussing personal matters in supervision as they were not assured of confidentiality.

  • It was not always clear from the records whether clinical supervision included discussions that helped staff to maintain or improve their clinical performance had taken place.

However:

  • Staff assessed the physical and mental health of all patients on admission. They developed individual care plans with patients, which they reviewed regularly through multidisciplinary discussion and updated as needed.

  • A range of psychological interventions and support was available to patients on New Dawn Ward.

  • Since the last inspection, the multidisciplinary team on Sunrise Ward had been joined by a dietician with experience in eating disorders, which increased the range of specialists that patients had access to.

  • The multidisciplinary team on each ward had effective working relationships with staff from services that provided aftercare and engaged with them to plan patient discharges.

  • Some recommended clinical tools and guidance for working with patients with eating disorders were being used by relevant staff members and clinical audits were taking place with follow up action plans if required. The same applied to New Dawn Ward where patients with personality disorders were treated.

  • Staff ensured that patients had good and timely access to physical healthcare and patients’ physical health was regularly monitored.

  • Permanent staff members received regular supervision.

  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Staff explained patients’ rights to them.

  • Staff supported patients to make decisions about their care for themselves. They understood the provider’s policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.

Caring

Inadequate

Updated 27 September 2019

We rated caring as inadequate because:

  • Patients and former patients of Sunrise Ward independently told us some staff did not treat them with compassion and kindness. We noted the consistency of the concerns raised over the last ten months. However, patients on New Dawn Ward said staff were kind.

  • On Sunrise Ward we observed that nursing staff communication with patients was perfunctory.

  • Two patients on New Dawn Ward said confidentiality was not always maintained by staff.

  • Patients complained they were bored at times, particularly at weekends when there were few planned activities.

  • Patient feedback was invited on both wards but was not reliably responded to in a timely manner.

However:

  • Patients’ privacy and dignity on Sunrise Ward had improved; due to the low number of patients, no patients were sharing rooms and the use of male staff on one-to-one observations had reduced.

  • Staff on both wards involved patients in care planning and risk assessment. They ensured that patients had easy access to independent advocates.

  • Staff informed and involved families and carers appropriately.

Responsive

Requires improvement

Updated 27 September 2019

We rated responsive as requires improvement because:

  • The service could not be relied upon to treat concerns and complaints seriously, to investigate them thoroughly and feedback consistently to patients and staff members. There was little analysis of complaints to identify and address themes.

  • The hospital lift was subject to breakdowns which impacted on patients with mobility needs and those who were meant to avoid burning calories through exercise.

However:

  • Staff planned and managed discharge well on both wards. They liaised well with services that would provide aftercare and Sunrise Ward staff were working with NHS England to overcome obstacles to discharge.

  • Staff supported patients to external medical appointments and if they required admission to a general hospital.

  • Patients’ access to food and drink on Sunrise Ward was planned on an individual basis with the dietician. Patients on New Dawn Ward praised the food.

  • Advocacy and cultural and spiritual support were available to patients.

Well-led

Inadequate

Updated 27 September 2019

The Notice of Conditions, served under section 31 of the Health and Social Care Act limits the rating that can be awarded for well-led across the hospital as a whole.

We rated well-led as inadequate because:

  • The service was not well led. A newly appointed permanent hospital manager and ward manager had both decided not to take up their posts which meant the provider was still working to find replacements. An interim hospital manager and ward manager were in place but could not provide the long-term stability. This was impacting adversely on the nurse leadership and on Sunrise Ward the nursing staff were working in a chaotic manner and struggling to meet the complex needs of the patients.

  • The provider had not made all the necessary improvements from the previous inspection in November 2018. However, their self-assessment said that the work had been completed. This failure was linked to the ongoing leadership changes which meant that the oversight was not in place.

  • Staff knew and understood the provider’s vision and values, but they were not consistently applied to the work of the Sunrise Ward team. They were better applied on New Dawn Ward.

  • Staff on Sunrise Ward felt they were not respected, supported and valued. New Dawn staff felt the organisation did not value them. Some staff told us there was a blame culture within the hospital and individuals had been bullied.

  • Our findings from the other key questions demonstrated that governance processes operated ineffectively at ward level and that performance and risk were not consistently well-managed.

  • Sunrise Ward’s nurses’ office was very disorganised, so records were not easily found and could be hard to follow. The dispersed record system also meant information was hard to find on New Dawn Ward.

  • Feedback from staff and patients was not always responded to in a timely way or at all.

However:

  • Sunrise Ward had participated in a national accreditation scheme for eating disorders.

  • There was good leadership within some professions.

Checks on specific services

Specialist eating disorder services

Inadequate

Updated 27 September 2019

We rated the eating disorder service as inadequate because:

The provider was not delivering safe care. Patients were at high risk of avoidable harm.

Issues identified at our focused inspection in November 2018 had not been fully addressed. The provider had informed us that they were no longer in breach of the regulations, but this was incorrect although some improvements had been made in a few areas.

The ward was not well-led. In particular, the management and oversight of the nursing team was very poor.

Personality disorder services

Requires improvement

Updated 27 September 2019

We rated the personality disorder service as requires improvement because:

There were shortcomings with the physical environment, medical equipment and controlled drugs which were not well managed.

Systems in place to monitor the quality of the service and drive improvements were not always effective.