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Cygnet Hospital Ealing Inadequate


Inspection carried out on 11, 12 and 13 June 2019

During a routine inspection

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.


  • 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 carried out on 28 and 29 November 2018

During an inspection to make sure that the improvements required had been made

We did not re-rate this hospital as a result of this focused inspection. This was because we only looked at specific issues on one ward that staff and patients had contacted us about. We issued two warning notices immediately after the inspection telling the service it must make immediate improvements around the documentation and management of risk and the governance of the service. We will return to inspect the service shortly to ensure that actions taken by the provider are embedded and that patients at the service are safe.

We found:

  • Sunrise ward did not have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Many of the patients were being supported using one-to-one observations. High numbers of temporary staff were used to carry out this role. This meant permanent staff, including registered nurses in charge of shifts, spent a disproportionate amount of time managing staff who were unfamiliar with the ward. This had the potential to impact on the quality and safety of patient care.
  • Despite the high use of temporary staff there were still shifts with insufficient staff on duty to carry out one-to-one observations of all patients with an assessed need for this.
  • Staff did not keep up-to-date and accurate records of patient care and treatment. Key information about risk was missing from patient records. This meant that information needed by staff to keep patients safe was not always available. This was a concern as many of the staff on the ward did not know the patients well and therefore relied on the accuracy of these records.
  • The one-to-one observations were not recognised as a restrictive practice, so their use was not kept under careful review.
  • Patient and carer feedback indicated that patients were not consistently listened to and provided with compassionate care by all staff.
  • The ward did not have effective governance systems in place to monitor actions to improve the service. The hospital risk register and the CQC action plan did not accurately reflect work that still needed to take place.
  • Staff had little opportunity to discuss learning from incidents, complaints and audits.
  • Staff morale on the ward was low. Staff told us about divisions within the ward team and this affected the ability of staff to work together productively for the benefit of patients.


  • Staff and patients were positive about the impact of the new ward consultant who had recently started at the service
  • The service management along with the new ward consultant, were committed to the improving the care model provided within the service. We received positive feedback about the moves already taken to improve the service.
  • Patients told us that there were some staff who responded to them with kindness and care.
  • The service provided an independent advocacy service which patients were positive about.

Inspection carried out on 24 May, 25 May and 2 June 2017

During a routine inspection

We rated Cygnet Hospital Ealing as good because:

  • When the service was last inspected in March 2016, we made a number of recommendations. Most of these recommendations were met, although there were some outstanding issues. When the service was last inspected in March 2016, we found that the service had not ensured that all incidents where it is necessary to report directly to CQC had been reported. We found an improvement at this inspection.

  • We also issued a number of recommendations for the service to consider improving. At this inspection we found that most of these recommendations were being met.

  • Where there were ligature risks, these were identified in ligature risk assessments and managed depending on the individual risk presented by patients and their needs.

  • The hospital had a comprehensive multi-disciplinary team which worked well together.

  • The service had begun to look at specific ways to improve patient engagement including bringing in corporate experts by experience. This had had some success in developing user-led policies and input but needed to be further embedded.

  • Medicines were managed safely.

  • Members of staff on New Dawn had all undertaken training in dialectical behavioural therapy.


  • When the service was last inspected in March 2016, we recommended that the provider should continue to address poor staff attitude and ensure that patients were treated with dignity and respect. During this inspection, patient feedback from Sunrise ward raised concerns that some staff were not consistently respectful in their approaches to patients.

  • Issues raised by patients during community meetings were not being addressed in a timely fashion.

  • Some patients did not have sufficient access to activities at the weekends

  • The staff team on Sunrise ward were not having the opportunity at team meetings to learn from incidents, complaints and audits.

  • Supervision records for staff on Sunrise ward were not available for the hospital manager to review which meant the quality of supervision could not be audited.

  • While there had been improvements in reducing restrictive practices in the service and some new initiatives had been rolled out, continued work needed to be done in this area.

Inspection carried out on 8 and 9 March 2016

During a routine inspection

We rated Cygnet Hospital, Ealing as good because:

  • The wards were clean and well maintained. Furnishings were in good condition and there was a programme of redecoration and refurbishment in place. Staff had undertaken infection control training and followed infection control practices. Emergency equipment in the clinic rooms was checked regularly. Staffing levels and skill mix were planned, implemented and reviewed to keep patients safe.

  • The hospital protected patients from the risk of abuse and avoidable harm. There were clear, open and transparent processes for reporting and learning from incidents. Staff reported incidents, and managers shared learning locally and within the wider organisation. Staff undertook appropriate mandatory and specialist training for their role. They had regular supervision and an annual appraisal.

  • Patients’ care and treatment was planned, delivered and reviewed regularly, in line with best practice guidance. Outcomes of patients’ care and treatment were collected and monitored. Care and treatment records showed physical health checks took place and there was on-going healthcare investigations and healthcare monitoring.

  • Patients were involved in their treatment and had been included in decisions about their care. Records and patients confirmed this. Multidisciplinary teams were pro-actively involved in patient care, support and treatment.

  • Patients had access to the complaints process. Staff and managers listened to complaints and concerns from patients and made improvements when required.

  • We observed positive interactions between staff and patients throughout our visit. The majority of patients spoke positively about the care, support and treatment they received. Patients spoke positively about the advocacy service at the service. There was an extensive programme of group and individual activities that were recovery focused.

  • Senior managers were visible and proactively engaged staff in the vision and values of the organisation. Staff were supported, felt valued and were listened to by the management team. Staff were confident to raise any concerns they had and bring forward ideas that could make improvements to the service. The provider had systems in place to monitor performance and make improvements through its governance structures.


  • There had been a number of notifiable incidents such as, safeguarding, police involvement and detained patients being absent without leave where the provider had not submitted statutory notifications to the CQC as required.

  • There was a high use of prone restraint at the hospital. The service had in place a Reducing Restrictive Practice strategy and policy. Two reducing restrictive practice leads had been appointed by Cygnet Health to assist with implementing the strategy. The provider reviewed all prone restraints at the monthly integrated governance meeting and was a member of the Restraint Reduction Network.

  • Information on some incident forms for New Dawn ward was not available, for example the level of severity of harm, whether the patient received a debrief after the incident or their MHA status.

  • Patient records were in paper format and regularly archived. There was no log recording how often care plans and risk assessments had been completed as only the most recent one was kept on file.

  • It was not clear how staff followed up outstanding shortfalls identified following the Short Term Risk Assessment and Treatability tool (START) risk assessment audit and care programme approach (CPA) report audits.

  • Staff demonstrated a working knowledge of the principles of capacity to consent and the Mental Capacity Act (MCA) and how they put these into practice on a daily basis. However, nursing staff were not fully aware of their responsibilities in carrying out capacity assessments and told us these were completed by the consultant psychiatrist.

  • We received comments that a few members of staff had a poor professional attitude towards the patients. Patients confirmed they had raised these concerns with the ward manager who was addressing them with individual staff.

Inspection carried out on 27 September 2013

During a routine inspection

During our inspection we spoke with twelve people who use the service and a minimum of seven staff. People who use the service generally spoke positively about the support they received. They said the majority of staff were caring and attentive to their needs.

The staff conveyed an in-depth knowledge of each person's needs and how they liked to be supported. We observed that the people who use the service and the staff had developed positive relationships with each other and there was good communication and a relaxed atmosphere within the hospital.

People were involved in identifying where they needed support and how this was to be provided. This was reflected in the care plans and risk management plans which detailed how people’s needs were to be met during their stay at the hospital.

Staff received support and training to ensure they were competent to support people with their needs.

Inspection carried out on 18 February 2013

During a routine inspection

During our visit we spoke with ten people who use the service and five staff.

The majority of feedback we received from people who use the service was that they felt the treatment they received was well structured and met their needs. People said they were treated well by the staff. They said they felt the majority of staff were committed to their work and that there were generally enough staff to meet their needs.

People said they were given explanations about what to expect from their treatment and their stay at the hospital, though some people said that they would like to have known more about the ‘rules’ before they starting using the service. One person commented that they would like a slower pace of treatment. The staff we spoke with were knowledgeable about different people’s needs and how to give individualised support. We saw staff being respectful towards people and speaking to people calmly and discreetly.

There was appropriate documentation to show that people consented to their treatment, or their capacity to consent had been assessed. The care planning was individualised to each person’s needs and involved people in identifying what was important to them and where they felt unsafe.

There were systems to oversee the administration of medicines and to minimise risks of people being given incorrect medicines.

At the time of our inspection there were 20 people using the service and the staffing was sufficient to meet people’s needs.

Inspection carried out on 18, 19 January 2012

During an inspection in response to concerns

We had received information of concern from patients at this hospital that they had not been safeguarded against the inappropriate use of control or restraint.

Two patients on the Eating Disorder Unit said that specific aspects of their needs were not being met due to insufficient staffing levels.

However, we found evidence at our inspection the hospital had followed appropriate processes to ensure that people’s rights were upheld.

Inspection carried out on 29 September 2011

During a routine inspection

Almost all the patients we spoke with told us that they had received a full assessment of their medical and personal needs when they began to use the service. All patients are involved in decision-making about the service through fortnightly community meetings which they attend by choice.

Patients told us that they have access to their care plans and that their treatment is discussed with them during weekly ward rounds. They confirmed that there is a range of activities available to them each week and that they are involved in making decisions about trips and other activities. One patient on the eating disorders unit (EDU) told us that “It’s a really good unit – the manager listens” and another said that they couldn’t fault the care there.

All of the interactions we witnessed between staff and patients were polite, respectful and friendly.

Most of the patients we spoke with reported no problems with their medication.

Patients we spoke with on both units told us that they felt that their dignity and human rights were upheld and that they felt safe. Those who had experienced the use of restraint told us that it was never excessive and only used when necessary.

Reports under our old system of regulation (including those from before CQC was created)

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.