Cygnet Hospital Wyke

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• 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

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 remained good. This meant people were safe and protected from avoidable harm.

All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

In the 12 months prior to our inspection, the service had recorded three incidents meeting its criteria to be considered 'serious incidents'. We saw evidence that there was a clear process for identifying learning from these incidents. Staff we spoke with on both wards also demonstrated knowledge of what incidents to report and how to report them. Staff were debriefed and received support after a serious incident.

Feedback from the investigation of incidents was routinely shared with staff. We saw evidence of learning being shared within staff team meeting notes and documentation from handover meetings. Staff we spoke with described how the ward team worked together to implement this learning through a supportive culture. For example, we heard how staff supported each other to implement learning from a recent incident by reminding each other to ensure their keys were safely secured to their belts.

Staff understood the duty of candour. They were open and transparent, and gave patients and families an explanation if and when things went wrong.

Formal and informal complaints were regularly reviewed by the service. The service kept logs of these which documented actions taken as a result of feedback. The logs we reviewed were up-to-date and showed evidence that patient feedback was actioned where appropriate.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They worked to support continuity of care, including when people moved between different services.

The provider had clear policies in place for both referral and admission processes. These policies outlined how staff from the service were able to challenge the appropriateness of a referral and request more information prior to admission to determine if the patient’s needs could safely be met.

In the weeks leading up to our inspection there had been an increase in the number of incidents of violence and aggression on Phoenix ward, and staff we spoke with raised concerns that the referrals and admissions process did not always ensure staff had important information relating to patients care and their risks prior to their admission. Examples given included missing information on medications and forensic history. Staff were also concerned that overall risk levels and acuity on the ward were not being effectively considered as part of the referrals process.

When we asked leadership at the service about these concerns, they told us that the missing information staff had mentioned was often information that they would be unable to obtain due to the circumstances of the patient. We also saw evidence in the referrals form that this information was routinely requested from the referring organisation. We also saw evidence that Phoenix ward had been closed to admissions on several occasions in the months prior to our inspection and leadership at the service explained that this had been due to acuity and risk.

It was unclear whether staff had raised these concerns with leadership at the service prior to our inspection. When we raised this feedback with leaders at the service, they were not aware of staffs’ concerns and provided assurances that they would speak with staff to ensure they were clear on how to challenge a referral. We saw evidence that this meeting took place with staff immediately following our inspection.

Despite reporting these challenges, staff on both wards worked to support patients safely and in a least restrictive manner. Most patients we spoke with told us staff made them feel "safe and comfortable". The carers we spoke with also all told us they felt their relative was safe on the wards and that incidents were managed effectively.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff received training in safeguarding as part of their mandatory training. Staff we spoke with demonstrated their knowledge of key safeguarding principles and how to raise concerns. The service regularly notified the appropriate external organisations of safeguarding concerns.

Staff followed safe procedures for children visiting the service. Staff told us how these visits were supported appropriately to ensure the safety of all involved.

Staff we spoke with told us about the importance of caring for patients with a ‘least restrictive’ approach. For example, on Bennu Ward (PICU) patients were supported to access leave through an individualised approach. This meant that some patients had been supported to safely access unescorted leave despite remaining on a PICU ward.

Patients were routinely involved in reviewing restrictive practices on both wards. Patients were invited to reducing restrictive practice meetings, and restrictive practice was a standard agenda item for patient community meetings. Feedback from these meetings informed the service's approach to reducing restrictive practice, which was also discussed in a variety of staff meetings. Both wards also had routine processes for reviewing blanket restrictions to ensure they were appropriate and only remained in place for the shortest time possible. For example, access to the garden from Bennu ward was restricted as access was down a staircase with concerns about ligature risks in this area. Patients therefore had to be escorted to access this outdoor space. However, the service was reviewing other ways of managing access to this area which provided more flexibility, such as installing a magnetic lock for the door.

Blanket restriction registers were up to date, reflected restrictions in place on the wards, and showed evidence that service users had been involved in reviewing the restrictions. The restrictions in these registers were appropriate, and mitigations were in place where necessary.

The carers we spoke with all told us that they felt their relative was safe on the ward and did not have concerns about the use of restrictive practice at the service. One carer told us how staff had “worked hard” to minimise the use of restraint when supporting their relative by focusing on de-escalation and preventing potential distress.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. Training compliance for mandatory training on the Mental Capacity Act and deprivation of liberty safeguards was over 90% on both wards.

Staff we spoke with could tell us when a capacity assessment was required and demonstrated an understanding of key principles such as ensuring capacity is assessed on a decision-specific basis and the 'best interests' process. The service had arrangements to monitor adherence to the Mental Capacity Act which included a quarterly audit of patient records and the availability of information on the Mental Capacity Act to staff on both wards.

Staff took all practical steps to enable patients to make their own decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During our inspection we reviewed 2 care records for patients from Bennu ward, and 4 for patients from Phoenix ward. These records included risk assessments and care plans for each patient which appeared up to date and complete.

We also reviewed data provided by the service on reported incidents involving physical intervention. In the 6 months prior to our inspection, the service reported 26 ‘physical restraints’ on Phoenix ward and 65 on Bennu ward. The service also reported 5 instances of rapid tranquilisation on Phoenix ward, and 6 on Bennu ward.

Patients were supported to understand their care and treatment, and staff communicated effectively with patients. Patients were offered regular one-to-one sessions with their named nurse, and we saw evidence that most patients engaged in these sessions. During our inspection we also observed positive interactions between staff and patients which demonstrated the rapport built between them.

Patients and their carers were supported to be involved in meetings and decisions about the patient’s care and treatment. Both patients and carers told us they felt listened to and their requests and preferences were taken into account by staff at the service. Across all the care plans and risk assessments we reviewed, we saw evidence that patients had been given the opportunity to be involved. Where patients had declined to be formally involved in their care plans, this was clearly documented. Even in cases where a patient had declined to be involved, these care plans still showed evidence that staff had considered a patient’s individual needs and preferences wherever possible.

Patients we spoke with knew how they could access advocacy support and demonstrated an understanding of what this support was. There were two advocacy agencies available for patients to access according to their individual choice and needs. Staff told us they felt it was important that patients had choice in any representation. We saw evidence within community meeting notes that information on both advocacy services was regularly shared with patients, and information on advocacy was clearly displayed in communal areas on both wards.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular risk assessments of the care environment. This included both wards and off-ward areas accessed by patients. Environmental risk assessment tools had been completed and were up to date. They reflected all the potential risks observed by the inspection team and contained clear actions for managing these risks. Risks relating to potential ligature anchor points had been mitigated appropriately.

Ward staff had access to personal alarms and patients had access to nurse call systems. Additional alarms were available for visitors to the ward.

The layout on both wards allowed staff to observe all parts of ward. Where there were potential blind spots, convex mirrors were used to ensure staff were able to safely monitor these areas. Staff on Bennu ward told us about how they had made changes to the ward environment following a suggestion by staff who had identified a theme in incident data surrounding the location of incidents. The door to the main lounge area had been removed and widened into an open-plan archway. Staff told us how this had improved visibility into the lounge area and helped the ward to feel brighter and more open. They told us the impact of this change had been positive and incidents in this area had since reduced.

Seclusion room facilities were appropriately designed to ensure patients' privacy and dignity were respected as far as possible. The space allowed necessary visibility for staff to observe patients in seclusion. Seclusion rooms allowed clear observation and two-way communication, and had toilet facilities and a clock.

Patients on both wards had access to outdoor space. At the time of our inspection, patients on Bennu ward had to be escorted to access the internal courtyard due to concerns surrounding ligature risks in this area. Patients on Bennu ward reported no concerns about their ability to access this space. Staff on Bennu ward told us about upcoming plans to change access to this area to support patients to access it independently where risk allowed.

Clinic rooms on both wards were clean and well-maintained. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Space in both clinic rooms was limited and neither clinic room had an examination couch for completing clinical procedures. At the time of our inspection, there were no plans to increase the space available for clinical procedures. Staff told us that procedures which required this space, for example dressing wounds or taking blood, would take place in a patient's bedroom. Staff and patients we spoke with did not raise any concerns about this practice and the necessary infection prevention and control procedures were followed.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing levels consistently matched the services expectations from their safe staffing matrix. The service regularly reviewed the matrix which calculated expected staffing levels and accounted for changes in factors such as bed occupancy and the number of patients requiring enhanced observations.

Staff turnover at the service was low. In the five months prior to inspection, staff turnover averaged less than 2%. Over the 12 months prior to inspection, the service had an average overall staff sickness rate of 9.9%. The average short-term sickness was 6.9%, and the average long-term sickness was 3%.

Some staff we spoke with told us that the ward had sometimes felt short-staffed in the weeks prior to inspection. Staff told us that over this time they had experienced an increase in acuity on both wards, but this was particularly notable on Phoenix ward. Phoenix ward had also seen an increase in its occupancy levels over this time. When we reviewed the staffing levels data for the service we found that whilst support worker numbers were sometimes lower than calculated, these were balanced by a higher number of qualified nurses on shift than had been calculated as required.

Patients on both wards accessed regular one-to-one time with their named nurse and patients told us that staff were available when they needed someone to talk to outside of these times. Patients also told us they had not experienced their escorted leave being cancelled due to staff availability.

The ward manager could adjust staffing levels daily to take account of case mix. Evidence in data provided by the service showed that bank and agency staff use on both wards was low. Additional staff were mostly drawn from the provider's own staff bank and were therefore usually familiar with the service and the patients. Where bank or agency staff were used, the staffing system would not allow staff who were not up to date with their mandatory training to be allocated to a shift.

Staff had received and were mostly up to date with appropriate mandatory training. On Bennu ward, training compliance was over 90% for all mandatory training. On Phoenix ward, training compliance was over 90% for most training, and 75% or above for all mandatory training. Only 75% of staff required to have Immediate Life Support training had current compliance with this, however we did see that this had been identified and training had been assigned to those staff who required it.

The hospital had adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Ward areas were clean and well-maintained. Records relating to cleaning were complete, up-to-date, and regularly audited.

Staff we spoke with could explain how to raise a maintenance request. They described maintenance staff as "helpful" and told us they were able to prioritise tasks according to patient safety and need.

During our inspection, we observed staff adhering to infection prevention and control principles, including handwashing.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management (storage, dispensing, administration, medicines reconciliation, recording, disposal) and did so in line with national guidance.

Medicines reconciliation took place at the earliest opportunity, and staff we spoke with described a variety of ways they would try to get information on a patient's medications where this information was unclear upon admission. This included examples such as reaching out to a patient's relative, GP, or the service their referral was received from.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance. This included processes in place for monitoring the use of pro re nata (as needed) medications to ensure they were not being used excessively.

Patients were included in discussions and decision making about medication. Patients told us that if they had concerns about their medication, they felt able to talk about this with staff and felt listened to when doing so. Staff told us that even where a patient may not have capacity to make decisions about medication, they still worked to listen to and reflect their preferences wherever possible.

Carers were also involved in discussions about medication where this was appropriate and reflected a patient's preferences. One carer told us how they had been involved in discussions around plans for medication management in the community as part of discharge planning for their relative. They told us that these discussions had also involved a member of staff from the community team.