Cygnet Hospital Stevenage

We did not rate this inspection. The ratings from the inspection which took place 14 to 16 May 2019 remain the same. This was a focused, unannounced inspection to follow up on specific concerns we had relating to the safe domain.

Following our inspection, we served a Notice of Decision because of the immediate concerns we had about the safety of patients. We told the provider they must not admit or readmit any further patients until further notice; they must submit a complete weekly log of the last seven days of incidents; they must undertake a complete, immediate and continuing review of all patients’ risk assessments and care plans; they must undertake a complete and immediate review of all patient observation levels and they must carry out a weekly review of all medication errors and how the risk of the error being repeated is being addressed. We told the provider that they must provide CQC with an update relating to these issues on a weekly basis.

We found the following during our focussed inspection:

• The service relied heavily on agency and bank staff to ensure safe staffing numbers on the wards. Overall, there was a 56% vacancy rate for qualified nurses and support workers.
• Staff were not consistently updating patient risk assessments following incidents of violence or self-harm. Overall, 43% of risk assessments had not been updated adequately following an incident.
• Staff had not reflected patient risks within patients care plans.
• We looked at 20 patient’s observation records across wards. On most records the date of next observation review was incomplete, and we saw no evidence that reviews had taken place. Details on the front sheet showing levels of observation, reasons for enhanced observation and date of next review were missing on multiple dates.
• The provider internally reported 130 incidents of self-harm across wards within a two-month period. Of those 130 incidents of self-harm, many patients were being supported by enhanced observations. We could not be assured staff carrying out observations were doing so in accordance with policy.
• There was a high number of medication errors on Orchid ward. We could not be assured that managers had taken appropriate steps to monitor and investigate the number of discrepancies.
• Overall, 42% of incidents that were notifiable to CQC had not been submitted by the provider.

We rated Cygnet Hospital Stevenage as requires improvement because:

• The provider had not ensured that agency staff providing care or treatment to patients had the qualifications, competence, skills and experience to do so safely. Mandatory training compliance for agency and bank staff was low. Managers had not carried out Disclosure and Barring Service (DBS) risk assessments when agency staff had criminal records.
• The hospital relied heavily on agency staff. At the time of inspection, the hospital had 78% vacancy rate for qualified nursing staff.
• The provider had not ensured that adequate governance systems were in place. Systems had not been fully effective to ensure that actions from meetings had been completed within the required timescale. The hospital risk register was not being updated and reviews were not documented thoroughly, some historically completed items were still documented on the risk register.
• The provider had not ensured it was using current policies. Overall, 42% of policies were out of date or were past the indicated date of review.
• Staff on acute wards had increased the use of physical restraint from our previous inspection in January 2018. The use of prone restraint on acute wards had also increased.
• Staff we spoke with knew the hospital had a Freedom to Speak Up Guardian but were not sure who it was.
• Some care plans on Orchid ward were not person centred, individualised or completed within the provider’s timescale. We found one record which had been duplicated from another patient care plan.
• Patients on Saunders ward told us the ward was short staffed on a regular basis and leave could be cancelled or delayed.
• We found discrepancies in three sets of detention paperwork we reviewed.
• Patients gave varying reviews about the quality of food provided. Most patients said the food was okay. However, some patients said that food choice was repetitive, poor quality and choice was limited.

However:

• Staff assessed risks to patients and themselves using a recognised risk assessment tool. Staff updated risk assessments regularly. Patients’ risks were reviewed twice daily.
• Staff reported all incidents that required reporting, including raising safeguarding concerns.
• Patients and staff received a debrief after incidents. in addition, staff had access to weekly reflective practice sessions.
• Staff assessed the mental health of patients within 48 hours of admission and offered a physical examination to all patients on admission.
• Patients had access to a range of activities, groups and one to one sessions delivered by the occupational therapy team, psychology team and sessional workers as recommended by the National Institute for Health and Care Excellence. Patients had access to weekend activities, including gym, football, snooker tournaments, film nights and pamper sessions.
• The percentage of staff across the hospital that had had an appraisal in the last 12 months prior to inspection was 100%. The percentage of ward staff that had received regular clinical supervision between January and December 2018 was 93%. The mandatory training compliance rate for permanent staff was 92% on acute wards and 89% on forensic wards.
• Staff attitudes and behaviours when interacting with patients showed that they were discreet, respectful and responsive, providing patients with help, emotional support and advice at the time they needed it. We observed caring interactions between staff and patients. Patients told us most staff were helpful, supportive and they spent time talking to them. Patients told us they felt informed about decisions and well cared for.
• Staff were open, honest and transparent. Staff explained to patients when things went wrong and referred to advocacy to help with this. We saw evidence in complaints records that staff had fed back openly to patients about complaints.
• Staff felt respected, supported and valued. Staff felt positive and proud about working for the provider and their team. We saw good joint working within the hospital between teams.
• The hospital responded to concerns raised by staff about pay, facilities and vacancy rates by introducing clear pay scales and hourly pay rates, refurbishing the hospital and introducing a recruitment strategy and reward system for registered nurses.