Cygnet Hospital Godden Green

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We reviewed all 8 quality statements in the safe key question. This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has changed and is now rated as Requires Improvement. This meant people were not always safe and protected from avoidable harm.

Care plans were not always being followed in respect of patients’ medicines and were sometimes out of date. Rapid tranquilisation on the wards did not always follow national recommendations for what medicines to use and where an alternative medicine was used this was not done in line with the provider’s own policy. Physical health checks following the use of rapid tranquilisation were not always being completed appropriately to ensure people were being kept safe. Because of this, we have found the provider to be in breach of regulation 12, Safe care and treatment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff understood what type of incidents to report and were able to describe the process for reporting, reviewing and responding to incidents. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed and signed off by the ward manager. Incidents with a severity of moderate harm or above were escalated to more senior managers. Staff were able to give examples of identified learning and improvements that had been made following incident investigations.

Managers investigated incidents thoroughly. They reviewed closed-circuit television (CCTV) recordings of incidents as part of their investigation. During the review of one incident, inappropriate restraint techniques were observed. They discussed these concerns with staff involved and agreed further training was needed.

Staff understood the processes for managing and investigating complaints and supported patients, relatives and carers to raise concerns. Staff told us there was an open and honest culture in the service. They were encouraged to raise concerns and were aware of the freedom to speak up and whistleblowing processes.

Patients we spoke with felt safe on the wards and were supported to understand and manage their risks. Some of the patients we spoke with told us that staff had supported them after incidents. This included staff spending time with the patient to offer reassurance.

The service received referrals from NHS trusts across England. The decision to accept a referral could be made by a registered nurse or doctor. Managers oversaw referral response times, admissions and bed management. There were clear processes to monitor and manage length of stay and patient flow and to ensure people did not stay in hospital for longer than was necessary.

Staff ensured that patients’ discharge to their local mental health teams was managed safely. Staff ensured that patients were only discharged if they had a crisis plan, including contact details for their local community mental health team.The service had a discharge checklist to ensure that all tasks relating to discharge were completed. We observed ward rounds that included representatives from the patient’s external care team. Staff worked together towards the best outcome for the patient.

Patients we spoke with said they felt safe, supported and approached staff if they had any concerns or felt unsafe. Staff supported them to manage risks and when needed would act to maintain their safety and offer support.

Staff identified and reported safeguarding concerns and demonstrated good knowledge of protecting people from harm. They identified different forms of abuse, and the signs associated with these. Staff attended regular patient safety and safeguarding meetings where important information, and lessons learned were shared.

Staff engaged with patients in a caring and meaningful way, having a genuine interest in the patient. Staff approached patients in a compassionate and caring manner. Relevant safeguarding information was displayed on the ward information boards.

There was a clear process when raising a safeguarding concern. Senior leaders had regular contact with the local authority safeguarding team to discuss progress on investigations.

Appropriate systems and governance processes were in place to ensure people were safeguarded. There was a database of safeguarding incidents to enable oversight and effective management. Senior managers and clinicians had oversight of all the safeguarding incidents, and these were discussed during the daily morning meeting which we observed, with actions assigned and follow up completed. We also observed a multi-disciplinary patient review meeting (ward round) where safeguarding was discussed.

Staff received annual training in safeguarding individuals at risk (adult and children). Staff had access to a safeguarding policy and hospital safeguarding lead and corporate safeguarding team for support and guidance.

All patients we spoke with felt safe and supported to manage their risks. Patients felt confident to raise any concerns they had with staff and were involved in their care and treatment.

We reviewed 10 patient records and all of them had an up-to-date risk assessment in place. Risk assessments covered key areas and captured relevant information to support the ongoing management of risk. However, there were no restraint care plans which were required in line with the provider’s own policy. There were some patients who had physical health needs which could have meant that usual restraint methods would not be appropriate. Restraint care plans should have been completed to inform staff what safe practice to use with those patients. We raised this with the hospital director as part of our inspection feedback, and shortly after the inspection we were assured that restraint care plans had been reinstated for all patients.

Staff had a good understanding of patients’ individual risk management and acted to prevent or reduce risks.They were able to describe how risk was assessed at referral, admission and as an ongoing process during treatment. Staff felt involved and able to contribute to the assessment of patient risk, including within multi-disciplinary reviews. Staff were knowledgeable about individual patient risks and were able to provide examples of effective risk management.

Staff followed trust policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. Staff said they conducted room searches when they suspected that a patient had prohibited items. Staff routinely searched patients when they returned from leave.

The service monitored and reviewed the use of restraint and seclusion. The use of restrictive practices was low and reducing. There was a least restrictive culture and a reducing restrictive interventions policy to guide staff. Managers monitored and reviewed the use of restrictive interventions through the daily morning meeting, and through the governance process.

All the wards had outside space that patients could access. On Oakwood ward the garden was easily accessed via the communal area and during our inspection we noted the doors to always be unlocked and staff within the area observing. However, patients on Castle ward did not have direct, unrestricted access to outside space as the ward was located on the first floor of the building. However, staff facilitated access to the garden during each shift.

Staff completed thorough risk assessments of all the wards and communal areas and removed or reduced any risks they identified. For example, the service had completed a ligature anchor point risk assessment. This included a form for recording risks and an associated action plan, covering all areas of the ward and external areas. The security lead for each ward conducted daily environmental checks of the ward environment.

Staff we spoke with displayed a good understanding of environmental risks. They were aware of the ligature risk assessment that had been completed and were able to describe how they used individual risk assessments, care planning and observations to manage environmental risk. Patients’ bedrooms and communal areas were fitted out to a high standard with anti-barricade doors and anti-ligature features.

Staff had easy access to personal alarms which they carried on them and patients had easy access to nurse call systems in their bedrooms.

The service had access to a seclusion room on Castle ward. The seclusion room allowed for clear observation and included a two-way intercom. Patients in seclusion had access to toilet and showering facilities. A clock was in place to allow orientation to time and day. The lighting and temperature of the room was controlled by staff. Staff told us that if a patient from Oakwood or Upper Oakwood ward needed seclusion, they would use this room. Oakwood ward had a quiet room which had seating and beanbags should a patient need space for some quiet time or to be deescalated with support from staff.

We observed staff engaging with patients in a supportive manner and encouraging them to join in activities that were meaningful to them. Staff were familiar with patients and were able to tell us about individual patients’ background, risks, interests and dislikes. During the inspection and on review of staffing rotas, we saw there was sufficient staffing levels to meet the required level of observations and to respond to peoples’ individual needs.

We observed a daily morning meeting where managers and staff discussed staffing across the hospital. They discussed the immediate staffing levels for that day and night, and the next few days and they adjusted and made changes where necessary. They identified factors that impacted on staffing levels such as how busy the wards were, enhanced observations, patients having leave off the ward, and other activities. They took account of the number of staff, but also whether staff were permanent or temporary, new or experienced, and male or female. Vacancies and recruitment of nurses and support workers, as well as medical staff was also discussed.

Patients rarely had their escorted leave or activities cancelled. There were sufficient staff on the ward to facilitate these activities.

Staff completed mandatory training. Staff we spoke with also described additional specialist training they had completed. For example, emotional wellbeing and personality disorder training. Staff received regular supervision. There was a policy and guidance documents to support the supervision process and promote individual development, including management opportunities. At the time of our assessment supervision compliance across the hospital was 96%.

Managers monitored mandatory training and alerted staff when they needed to update their training. Managers received a regular report showing compliance with mandatory training.

At the time of our assessment, the service had a sickness rate of 2.9%. Staff had access to support services including human resources and occupational health.

The service had enough daytime and night-time medical cover and a doctor available to go to the ward quickly in an emergency. The service operated an out-of-hours rota for consultants and specialty doctors and for management.

Staff made sure cleaning records were up-to-date, and the premises were clean, and clinical equipment was appropriately cleaned and maintained.

Staff completed infection prevention and control checks and audits to ensure required standards were met. Staff had access to an infection prevention and control policy and support from infection prevention and control leads within the hospital and wider provider. Staff completed infection prevention and control training as part of the mandatory training programme.

The hospital had procedures for preventing and managing outbreaks of infection.

The service had systems and processes in place for the appropriate and safe handling of medicines. However, these processes were not always being followed. Care plans were not always being followed and were sometimes out of date. Rapid tranquilisation on the wards did not always follow national recommendations for what medicines to use and where an alternative medicine such as zuclopenthixol acetate was used this was not done in line with the provider’s own policy. Physical health checks following the use of rapid tranquilisation were not always being completed appropriately to ensure people were being kept safe.

People’s care and treatment was regularly reviewed by a multidisciplinary team of clinicians, nurses, therapists and included where appropriate the person. Staff and people could use this time to discuss the medicines being used and address concerns with side effects to ensure treatment was having the most beneficial outcome for the people.

People’s care plans for the use of rapid tranquilisation (where a medicine is administered via injection for the purpose of rapid sedation when a person is highly distressed or agitated) were not being followed. Where certain medicines were recommended to be used prior to others in a person’s care plan, we saw that in practice this was often being ignored and second and third-line options were being used before the care plans recommended first line treatment. People’s care plans appeared to either not be updated routinely or were actively not being followed on the wards.

People were sometimes administered rapid tranquilisation (RT) pre-emptively without this being adequately supported with a written care plan to ensure that its use was justified. This puts people at risk of being given medicines inappropriately for the purpose of sedating them.

People prescribed medicines with a higher risk of physical health side effects, or at doses which could increase the risk of physical health complications (such as high dose antipsychotic therapies) had these monitored and reviewed regularly in line with national recommendations. This ensured people were kept safe whilst prescribed these types of medicines.

People were sometimes administered medicines where there were known side effects reported from the use of specific medicines. We found records that showed that one person had reported side effects from the use of Clopixol Accuphase (zuclopenthixol acetate) and this was recorded in the care plan, but then further doses were given of this medicine. For the same person we also saw the medicines being administered on consecutive days which would mean that the risk of over sedation and increased side effects was greatly increased.

Staff told us that clinical pharmacy support was provided weekly to the wards by an external company. The pharmacy could be contacted outside of this time for additional support if needed. The pharmacist would also attend clinical governance meetings and would share any lessons learned from audits with the doctors.

Staff told us they could access advice from a pharmacist about people’s medicines whenever they needed.

Senior staff at the hospital would gather and discuss any ongoing incidents that required further input from the senior leadership team. This provided an opportunity for escalation and guidance if needed for any matters occurring on the wards.

Staff told us the provider had recently employed a Registered General Nurse (RGN) who supported the wards with managing and monitoring people’s physical health. They had found the addition of this role beneficial to ensuring that people’s physical health was being actively supported whilst on the wards.

We saw that people were receiving regularly prescribed medicines in a safe and person-centred way. We observed good interaction between staff and people when administering medicines.

We observed that the correct Mental Health Act (MHA) consent to treatment documents were in place in people’s medicines folder alongside capacity assessments. We did however see that changes to prescriptions would sometimes be made without the required change being made to the consent to treatment document at the same time.

We observed that medicines were stored safely and securely on the wards in a temperature-controlled environment.

We saw that when a medicine was being used to manage a person’s agitation or aggression staff were not always recording clearly what non-medicine de-escalation were used first before resorting to medicines. Care records also did not specify if any offer of oral anxiolytics was given prior to the use of an intramuscular injection (RT).

Staff used a paper-based system to prescribe and record the administration of medicines. There was an electronic system in place to record other care plans, risk assessments and daily care notes.

We saw evidence of learning from incidents being shared with staff within the hospital via a ‘lessons learnt’ bulletin that was in staff areas. This also shared learning from incidents that had occurred at other locations operated by the provider.

For some medicines with known side effects such as the antipsychotic Clozapine, there were bespoke side effect monitoring forms in place that were being completed daily and ensured known risks associated with these medicines were monitored and acted upon appropriately.

We saw a high use of the medicines zuclopenthixol acetate (Clopixol Accuphase) as a rapid tranquilisation on the wards. This medicine is usually only used as a last option rapid tranquilisation where other options available have not worked. The provider had a policy in place for the use of Clopixol Accuphase stating that any use of this medicine had to have a signed authorising document in place following discussion between the prescribing clinician and the medical director. However, this was missing for every use of this medicine.

Where Clopixol Accuphase was being used we found that post dose physical health monitoring was completed after 2 hours which meant that close monitoring was not being offered during the period of peak sedation. This could place people at risk of deterioration of their physical health without it being monitored and escalated with appropriate and timely monitoring.

Staff told us they did not make use of patch rotation charts for controlled drug pain patches. The use of these can help staff to avoid placing medicines on the same patch of skin repeatedly which can cause a reaction to the adhesive. These charts help ensure that the previous patch is removed safely prior to administration of the new patch which helps prevent accidental overdose.

Some of the post dose physical health monitoring for rapid tranquilisation was not completed in line with the provider’s policy and national guidance. For one person staff were administering a dual dose of both Lorazepam and Promethazine intramuscular which was not in line with their care plan. There was no evidence of post dose monitoring having been completed despite the increased risk of sedation that would occur with these two medicines being given together.