Cygnet Lodge Lewisham

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. The service was in breach of legal regulation in relation to the premises and equipment. The service had made improvements to their environment and is no longer in breach of this regulation. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew what incidents to report and how to report them. All staff had access to the hospital’s incident reporting systems and were able to report incidents when needed.

In the last 6 months, there had been 77 incidents at the hospital. Of those, 13 were related to contraband illicit substances being brought onto the ward and 12 were instances of violence and aggression. Managers told us the majority of the drug related incidents were related to one patient who has since been discharged from the hospital.

Managers reviewed all reported incidents. Incidents were discussed in daily handover meetings and monthly team meetings.

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

Staff received feedback from investigations of incidents. We saw evidence of this in team meeting minutes and staff emails. For example, the hospital manager shared an email with staff in their hospital, and the wider Cygnet group, following a patient buying vapes with illicit substances in them from local shops. The email contained pictures and details of the incident.

Most staff we spoke with were able to tell us about recent incidents and the learning that came from those incidents. For example, staff told us they were now extra vigilant in monitoring and escalating patient vital signs. This was following an incident where a patient had a prolonged epileptic seizure.

There was evidence that changes had been made as a result of learning from incidents. For example, changes had been made to the garden fence to reduce the likelihood of patients being able to climb it. Additional training had also been provided to all staff around epilepsy and medicines following a seizure incident on the ward. Following a rise in incidents related to illicit substances being brought onto the unit, the hospital implemented routine visits from dogs who have been trained to find illicit substances, and more robust person and room searches.

Staff were debriefed and received support after a serious incident. Staff told us they also had reflective practice where they were able to discuss serious incidents with a psychologist. Incident reports documented that debriefs happened with staff and patients. However, 2 patients told us they did not have a debrief following a restraint incident.

The hospital’s referral processes ensured that essential information about the patient was received to determine if the patient’s needs could safely be met by the service. The provider had a central team to accept and initially assess all referrals. Once deemed appropriate for the hospital, a team from the hospital would meet with the patient to assess their needs. This assessment process also involved speaking with community teams and carers, where appropriate.

Managers told us they do not accept patients with a moderate to severe learning disability. Due to the environment, they would also not be able to accept a patient who required a wheelchair, or someone with high sensory needs. Managers told us they assessed patients with these factors in mind, and would only accept a patient if they felt their needs could be met by the hospital.

Staff involved the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. We saw evidence of community teams being invited to ward rounds.

Staff received training on how to recognise and report abuse, appropriate for their role. All staff were up to date with their safeguarding training. Staff who worked closely with patients were required to complete level 3 safeguarding training; this was also completed by 100% of staff. The service did not specifically have children’s safeguarding training; however, managers told us the training that staff received contained information on both children and adults.

In the past 6 months, 10 safeguarding referrals had been made to the local authority. The majority of these referrals were following violence and aggression on the ward.

The hospital had a social worker who took the lead on managing safeguarding referrals. They had links with their local authority safeguarding team and discussed cases with their allocated local authority social worker as needed.

Staff knew how to recognise adults at risk of or suffering harm and worked with other agencies to protect them. Staff could give examples of safeguarding concerns. For example, financial exploitation. The hospital’s social worker told us staff reported safeguarding concerns as an incident and shared the concerns at multidisciplinary handovers. The social worker or hospital manager would then make a referral to the local authority, after reviewing the incident. In February’s team meeting minutes, the hospital manager reminded staff that they should follow the safeguarding procedures outside of multidisciplinary work hours. We did not see any evidence of delayed referrals to the local authority.

The hospital did not have a formal procedure in place to manage children visiting the service. Managers told us there had not been any requests for children to visit the service. They told us, if a request was made it would be risk assessed and planned on an individual basis.

The hospital had some blanket restrictions in place that were appropriate and to keep people safe. For example, not having plastic bags in patient areas.

We reviewed 5 patient care records at the hospital. All records had risk assessments that were regularly updated and contained all relevant risk information.

Staff also completed a daily risk assessment for all patients, which included a summary of any concerns over the past 24 hours. During the week this was completed by a multidisciplinary team member in the handover meeting. At the weekend, this was completed by the nurse in charge.

Care plans were created for patient risks. For example, there were care plans in place to manage a patient’s epilepsy, a patient’s aggressive behaviours and a patient’s finances where there were concerns around exploitation from others.

All staff received and completed training on prevention and management of violence and aggression.

Staff told us they avoided using restraint by using de-escalation techniques and restrained patients only when these were not effective and when necessary to keep the patient or others safe. In the past 6 months there had been 2 incidents of full restraint at the hospital. During the inspection we observed staff verbally de-escalating situations successfully.

Managers told us they continued to talk about de-escalation techniques in team meetings and supervision. They had a noticeboard in the lounge area with staff pictures and some information about them. Staff told us this helped patients feel more comfortable with staff.

Multidisciplinary staff met with patients regularly to discuss their risks, care and treatment plans. Patients told us they regularly met with their named nurse. However, one patient told us he would like to meet with staff more regularly.

Staff carried out different levels of observations, determined by assessed need. Observations were mostly carried out in line with hospital policy. However, we did see some examples where intermittent observations were being carried out at pre-determined intervals. Following the assessment, managers have re-shared hospital policy with staff, and met with the nursing team at handover meetings to remind them of the policy. They also made this policy their policy of the month for June. Staff were required to review a different policy each month and sign to say they had read and understood its contents.

Staff completed and updated risk assessments of all ward areas. This risk assessment had pictures of ligature anchor points, as well as pictures of the ligature cutters. It contained the location of these risks and the mitigations in place.

The hospital was across 3 floors, with patient bedrooms on all floors. Staff were therefore not able to observe all parts of the hospital. There were blind spots and ligature points throughout the hospital. These were managed through convex mirrors, staff observations and individual risk assessments of patients. Managers told us their current patients were low risk for self-harming behaviours and staff knew their patient’s risks. Staff were aware of the ligature points and where the ligature cutters were stored.

Whilst their current patient group was low risk, there was a potential for new admissions to have these risks. We noted ligature anchor points which could be made safer, for example, the stair rails in the garden. The service should consider whether the ligature anchor point risks in the garden could be reduced.

Each room within the hospital had a purpose. Some staff told us there were not enough rooms, which made it difficult to find space for 1:1 sessions or group activities. The hospital had one quiet room, a small multifaith room, an OT kitchen and a cabin in the garden where sessions could take place. However, if meetings were scheduled, or there were visitors, these rooms were often occupied.

At the time of the assessment, the alarm system had been deactivated as it had broken. There was a plan in place for the new alarm system to be fitted the following week. In the meantime, staff were using radios to communicate and signal for help where needed. Staff told us the radios worked well for safety, and staff came to support them when they signalled for help. At this time, patients did not have access to a call bell system.

Patients told us they felt safe on the ward. However, some said the ward was on occasions unsettled with unwell, and sometimes violent, patients. They reported staff intervened promptly and tried to keep all patients safe.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. The emergency resuscitation equipment was stored in the nursing office.

The hospital was compliant with fire safety requirements and carried out regular fire drills. A fire risk assessment was completed by an external agency which recommended a number of actions. These actions were showing as pending; however, the majority of these recommendations had been actioned.

All patients had personal emergency evacuation plan’s (PEEP) in place. A PEEP is a personalised plan to support a patient who may need assistance evacuating a building during an emergency, ensuring their safe and timely evacuation. However, these plans were a number of pages long, with lots of text, potentially making it difficult to see important information in an emergency. Managers told us these forms were newly implemented across the whole provider.

All patients told us there were enough staff on each shift, who were available to support them. One patient mentioned there seemed to be less staff at the weekend. Patients told us they regularly met with staff for 1:1 sessions, however one patient said they would like to meet with staff more often.

Staff told us they felt adequately staffed through the week. Managers told us they adjusted staffing levels according to the needs of the hospital and patients. For example, when a patient was being nursed on enhanced observations or there was a ward round happening that day.

There were no staff vacancies at this hospital. Bank and agency use for nurses and healthcare assistants was low. In the last 3 months. the hospital used bank staff 9% of the time and agency staff 0.2% of the time. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. There were no unfilled shifts in the last 6 months.

Staff turnover was low, with only one staff member leaving in the last 6 months. This was an occupational therapy assistant who left for further development opportunities.

There was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency. The hospital had one consultant and one specialist doctor. An on-call rota covered out of hours emergencies.

Staff were required to complete mandatory training. The training was appropriate for the patient group using the service. Managers were able to source specific training to meet patient’s needs, for example, on learning disabilities and personality disorders. However, one patient told us they felt staff needed more training in their condition, which was a personality disorder. All staff had completed basic life support or immediate life support training, depending on their role.

The hospital provided monthly face to face emergency physical health and resuscitation simulation training. The hospital’s physical health nurse led these scenario training sessions and documented the outcomes. However, it was not clear what action had been taken when areas of learning had been identified. For example, we saw for the last 3 months it was documented that staff did not carry out chest compression in line with best practice. There were actions for this to be shared with the hospital manager, but there was no specific action plan documented to improve this finding of concern.

All ward areas were clean, had good furnishings and were well-maintained. We saw housekeeping staff cleaning ward areas throughout the day, and they kept records of their work.

Staff maintained equipment well and kept it clean. Staff kept logs of cleaning equipment and the clinic room. Whilst the clinic room was clean, some areas were cluttered, and there were heavy carboard boxes on top of the cupboards, which could pose as a falling risk.

Staff adhered to infection control principles, including handwashing.

Staff carried out an infection control audit every 3 months. The most recent audit showed 98.4% compliance with policy.

Medicines were generally managed in line with national guidance and legislation. The service had clear processes for ordering, storing, administered and disposing of medication. Controlled drugs were managed in line with national guidance and legislation.

We saw that the service ensured that people always had enough medicines. However, we saw that there was excess stock of some high-risk medicines that could not be explained by staff. This was raised with leaders to review.

We also saw that medicines for people on leave were not being supplied in line with the services policy. Staff did not keep records of people's medicines that they re-dispensed from the pharmacy supplied packaging when people went on leave. This meant the process was not auditable to ensure it was being carried out safely. However, staff could clearly describe how they carry out the process to ensure risks of mistakes were reduced.

People's physical health was monitored in line with guidance which was overseen by a nurse practitioner. This included when people who were prescribed high risk medicines and needed regular assessing. The service had completed a quality improvement project in ensuring physical health monitoring was carried out for all patients. We saw the actions and learning from the project were embedded into staff's usual practice.

Staff were provided medicines management training, and their competencies were assessed. They knew how to report incidents. We saw incidents were reviewed, discussed and learning shared with staff.

The service was supported and overseen by corporate leaders. Staff spoke highly of this support.

People's behaviour was not inappropriately controlled using medicines. We saw positive behaviour support plans to help staff support people, including supporting them to take their medicines.

The service was supported by an external pharmacy for clinical support and auditing. The service had a process for managing patient safety alerts and we saw this in use.

Medicines were given in line with the Mental Health Act consent to treatment authorisations. All consent to treatment forms we reviewed were up to date.

People generally received their medicines as prescribed. People received their regular medicines on time, and we observed staff following care plans to support people with their compliance. However, we saw when required (PRN) medicines were not always given as prescribed. We found for one patient, there had been multiple instances where medicines that required a specific interval between administrations was not being followed. This had been identified prior to the inspection by the services supporting pharmacist, but we did not see evidence of actions or improvement.

Most patients told us they knew what medicines they took, and the side effects had been explained. However, one patient told us he did not know what his medicines were. We saw staff discussing medicine side effects in ward round meetings.