The Care Quality Commission
  • Mental Health
  • Independent mental health service

Cygnet Hospital Woking

Overall: Requires improvement read more about inspection ratings

Redding Way, Knaphill, Woking, Surrey, GU21 2QS (01483) 795100

Provided and run by:
Cygnet Surrey Limited

Important: The provider of this service has requested a review of one or more of the ratings.

All Inspections

During an assessment of Acute wards for adults of working age and psychiatric intensive care units

Date of assessment: 10 and 11 December 2024.

Cygnet Hospital Woking is an independent mental health hospital that provides specialist acute and psychiatric intensive care (PICU) services for women, across three wards and Forensic wards for males and females across two wards. We carried out an unannounced assessment of all 5 wards at the service.

  • Acorn ward is a 10 bedded female only psychiatric intensive care unit.
  • Kahlo ward is an 11 bedded acute service for women.
  • Picasso ward is a 12 bedded acute service for women.
  • Oaktree ward is an 11 bedded female only forensic inpatient / low secure ward.
  • Greenacre ward is an 18 bedded male only forensic inpatient / low secure ward.

The inspection was triggered by an increase in notifications of incidents (sent by the provider to CQC) about patients swallowing and ingesting objects We were notified of a serious incident where it was found that staff were not fulfilling their duties in terms of enhanced observations due to staff members sleeping on duty. We were also notified about concerns about the inappropriate use of seclusion and the restraint of a patient using an unapproved restraint technique. This assessment was carried out following CQC’s new approach to assessment; Single Assessment Framework (SAF). We assessed all 33 quality statements across the safe, effective, caring, responsive and well-led key questions.

In January 2023, the service had a focussed inspection of the acute wards for adults of working age and psychiatric intensive care units which changed the overall rating for the service and was rated good overall, with requires improvement in effective and good in safe, caring, responsive and well-led.

Following this inspection, we rated the service as Good overall. We rated safe as requires improvement and effective, caring, responsive and well-led as good. We identified areas of improvement that were required in relation to staff not always involving patients in planning their care and treatment, environmental concerns with the cleanliness and maintenance of the wards as well as environmental risks with unidentified blind spots which could present as a safety risk, medicines were not always managed in line with national guidance or legislation and governance processes were not always effective in monitoring and mitigating risks and therefore action to address identified issues was not always taken in a timely manner. We found the service to be in breach of Regulation 12, Safe Care and Treatment.

However:

Staff knew what incidents to report, and how to report them. All records had risk assessments that were regularly updated and contained all relevant risk information. Staff told us they avoided using restraint by using de-escalation techniques, and we saw this in practice. There were enough staff to ensure people’s safety and meet their needs. Staff completed key mandatory training, monthly supervision and yearly appraisals. Patients could access a range of interventions and activities in line with national guidance. Ward activities helped promote a healthy lifestyle for patients. Patients told us staff were kind and treated them well. They told us staff were available on the ward to support them when needed. Patients were supported to have choice and control and could give feedback on their care. All staff told us they felt respected, supported and valued by their colleagues and managers.

We have asked the provider for an action plan in response to the concerns found at this assessment.

During an assessment of Forensic inpatient or secure wards

Our view of the service

We completed an assessment and inspection of Cygnet Hospital Woking on 10 and 11 December 2024 with additional offsite interviews with carers on 6 and 7 January 2025.

Cygnet Hospital Woking is an independent mental health hospital run by Cygnet Surrey Limited. The hospital offers a range of mental health services for men and women across 5 wards.

Cygnet Hospital Woking delivers acute/psychiatric intensive care wards (PICU) and forensic care across 5 wards. Acorn ward is a 10 bedded female only psychiatric intensive care unit, Kahlo ward is an 11 bedded acute service for women, Picasso ward is a 12 bedded acute service for women, Oaktree ward is an 11 bedded female only forensic inpatient/low secure ward and Greenacre ward is an 18 bedded male only forensic inpatient/low secure ward.

We carried out an unannounced assessment of all 5 wards at the service.

The inspection was triggered by an increase in notification of incidents about patients swallowing and ingesting objects. We were notified of a serious incident where it was found that staff were not fulfilling their duties in terms of enhanced observations due to staff members sleeping on duty. We were also notified about concerns about the inappropriate use of seclusion and the restraint of a patient using an unapproved restraint technique. This assessment was carried out following CQC’s new approach to assessment; Single Assessment Framework (SAF). We assessed all 33 quality statements across the safe, effective, caring, responsive and well-led key questions. The service had previously been inspected in April 2022, and we rated it as Good overall. We rated the safe domain as requires improvement because staff were not calibrating medical equipment, did not keep the right room temperature for safe storage of medicines and staff did not monitor the effects of clozapine on patients. The service was rated good in effective, caring, responsive and well led.

At the time of our December 2024 inspection, we found that actions from the previous inspection had been addressed. Staff routinely calibrated medical equipment for measuring blood glucose levels, the provider took action to safeguard medicines supplies when the temperature of medicines storage areas fell outside of the recommended limits, and staff monitored and reviewed the effects of patients’ medication on their physical health, particularly patients prescribed Clozapine.

However, this inspection identified some areas for improvement. Overall, we rated the service as requires improvement because we identified breaches of regulatory standards. Staff did not always involve patients in the planning of their care and treatment, the provider required staff to observe patients for 4 hours without a break and managers of the service did not always use governance processes to effectively monitor, manage and take action to address identified issues in a timely manner.

During this assessment, the provider was in breach of regulation 9- Person Centred Care, regulation 12- Safe Care and Treatment and regulation 17- Good Governance.

The provider did not always ensure the care and treatment of patients was appropriate, met their needs and reflected their preferences.

The provider did not always ensure relatives and carers were involved in their loved one’s care where this was appropriate.

The provider did not always record which rapid tranquilisation medicine was first line when multiple medicines were prescribed.

The provider did not always ensure there were enough staff deployed on the wards to carry out the required observations and therefore could not mitigate risk to patients. Staff were rostered to be on observation for more than 4 hours without a break which increased risk of harm to patients. There was a risk that without a break staff would become tired and less attentive.

The provider did not ensure governance processes were always effective in monitoring and mitigating risks and therefore action to address identified issues was not always taken in a timely manner. Senior managers within the hospital did not always use governance processes to effectively monitor, manage and take action to address identified issues in a timely manner.

During an assessment of the hospital overall

We assessed Cygnet Hospital Woking form 10 to 11 December 2024.

We assessed the service following notifications we had received from the provider about increase in safety incidents across the wards. We were notified of incidents of patients swallowing and ingesting objects and staff not maintaining safe observations of patients. We were also notified about concerns regarding the inappropriate use of seclusion and the restraint of a patient using an unapproved restraint technique.

Cygnet Hospital Woking was registered with CQC in November 2010 to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of disease, disorder or injury. The service had a controlled drugs accountable officer and a Registered Manager.

We visited the following wards as part of the assessment:

Acorn ward 10 bedded adult female only psychiatric intensive care unit.

Kahlo Ward, 11 bedded adult female only acute ward for adults.

Picasso Ward, 12 bedded adult female only acute wards for adults.

Greenacre ward, 18 bedded adult forensic male only low secure inpatient ward. Oaktree ward, which is an 11 bedded adult forensic female only low secure inpatient ward.

At this assessment we identified breaches of regulations: 9 Person Centred Care, 12 Safe Care and Treatment, and 17 Good Governance.

At this assessment we assessed 2 assessment service groups; Acute wards for adults of working age and psychiatric intensive care units where we assessed 33 quality statements each for both the acute and psychiatric intensive care units and the forensic low secure wards.

We rated the service as requires improvement. In the acute wards for adults of working age and psychiatric intensive care units, we found 2 breaches of regulations in relation to: Staff were not always involving patients in planning their care and treatment, no restraint care plans in place, environmental concerns with the cleanliness and maintenance of the wards as well as environmental risks with unidentified blind spots which could present as a safety risk. The service was rostering staff to observe patients for four hours continuously without a break which put patients at risk of harm. Medicines were not always being managed in line with national guidance or legislation. Governance processes were not always effective in monitoring and mitigating risks and therefore action to address identified issues were not always taken in a timely manner. In the forensic low secure wards, we found 3 breaches of the regulations in relation to ensuring the care and treatment of patients was appropriate, met their needs and reflected their preferences, ensuring relatives and carers were involved in the care of the patients. Ensuring staff were not rostered to be on observation for more than 4hours without a break. Ensuring blind spots in patients’ bedrooms were sufficiently mitigated. Ensuring there was good record keeping of post-dose monitoring of Rapid Tranquilisation and ensuring there were enough staff deployed to work on the wards.

We have asked the provider for an action plan in response to the concerns found at this assessment.

31January 2023

During an inspection looking at part of the service

Our rating of this location improved. We rated it as good because:

  • The service provided safe care. The ward environments were safe, clean and well furnished. The wards had enough nurses and doctors. Staff assessed and managed risk well. They analysed and minimised the use of restrictive practices through clinical governance, they managed medicines safely and followed good practice with respect to safeguarding.
  • Clinical rooms and clinical medical devices were well managed and physical health monitoring had significantly improved.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audits to evaluate the quality of care they provided.
  • Patients reported that staff treated them with compassion and kindness, respected their privacy and dignity, and understood their individual needs. They actively involved patients, families and carers in care decisions.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly.

12 and 13 April 2022

During a routine inspection

Cygnet Hospital Woking is an independent mental health hospital run by Cygnet Surrey Limited. The hospital offers a range of mental health services for men and women across four wards.

Our rating of this location went down. We rated it as requires improvement because:

  • Staff did not ensure that patients who were administered rapid tranquilisation were properly monitored. For example, we did not see post dose physical health monitoring for three patients who were administered rapid tranquilisation on the Acute and PICU wards. For service users with physical health needs, their care plans were not always detailed enough and did not always contain important follow up information. We also did not always see that appropriate monitoring required by prescribed treatment was in place to review the effects of each patient’s medication on their physical health. We also did not always see that appropriate stool monitoring required by a prescription of Clozapine was in place to review potential effects on patient’s physical health on Oaktree ward.
  • Staff did not ensure clinic rooms and fridge temperatures were maintained to ensure medicines were kept safely within their specified temperature range on the acute and PICU wards. For example, we found that temperature records of clinic rooms were regularly above 25°C but no action had been taken to reduce the temperature or check the impact this had on medicines effectiveness.
  • We found concerns with the monitoring and management of medical equipment. On the Forensic inpatient or secure wards, there were out of date items in the emergency bag and oxygen cylinders were not stored securely. The service also did not always ensure the safe management of healthcare waste. On the acute and PICU wards staff did not ensure that the blood glucose monitoring machine was properly calibrated.
  • Staff did not ensure that all patients had copies of their care plans on the acute and PICU wards. Some patients told us they had requested copies of their care plan for weeks and staff were yet to give them their care plans. Care plans on the forensic wards did not always capture the patients strengths.
  • Staff on the acute and PICU wards did not ensure that patients prescribed rapid tranquilisation had a care plan in line with the organisation’s policy. In addition, there was not always a clear and detailed management plan for diabetic patients and patients admitted with low BMI in line with national guidance.
  • Staff did not always understand the rights of informal patients and they recorded information incorrectly. For example, staff on the acute and PICU wards were recording in progress notes that informal patients utilised section 17 leave when this only applies to detained patients.
  • The provider did not always provide feedback to patients when they raised concerns or issues on the forensic inpatient or secure wards. Patients told us that they did not receive updates to issues raised and we saw that community meeting minutes were not always consistent in feeding back on actions taken and “You said, we did” boards on the wards were blank.

However,

  • The ward environments were safe and clean. Staff managed patients’ risks well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding. Patients reported they felt safe on the wards.
  • Staff used recognised rating scales to assess and record severity and outcomes. They also participated in clinical audit.
  • The teams provided a range of treatments suitable to the needs of the patients and in line with national guidance and best practice. There were several suitable ward-based activities including board games, movie nights, and colouring, as well as therapeutic activities including Cognitive Behavioural Therapy, staying well groups, mindfulness and meditation.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients including doctors, nurses, support worker, social workers, psychologists and occupational therapists. Staff had access to other clinical specialists including dietitians and speech and language therapists that were external to the service.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. We observed interactions between staff and patients and found them to be warm, helpful and supportive. Patients told us that staff listened to patients and addressed their individual needs and that they felt that staff genuinely cared for their wellbeing.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Patients had easy access to information about independent mental health advocacy and patients who lacked capacity were automatically referred to the service.
  • Leaders had the skills and experience to perform their duties. They engaged actively with patients, staff and local health and social care providers

17 and 18 August 2021

During an inspection looking at part of the service

Cygnet Hospital Woking provides low secure services for men and women. We did not inspect or re rate these services on this inspection. The previous rating of good remains in place for the low secure services. We will return to inspect these services in the future.

The hospital also provides acute services and psychiatric intensive care services for women. The psychiatric intensive care service ‘Acorn Ward’ opened in June 2018. The acute service ‘Picasso Ward’ opened in December 2020. We have not inspected or rated these services prior to this inspection.

However, there has been a Mental Health Act inspection one month prior to this inspection which identified the following issues needing attention:

  • more access to advocacy services were needed
  • access to occupational therapy and therapeutic activities was needed in the evenings and at weekends
  • attention to maintenance was needed across the wards

On this inspection we only inspected the female acute and psychiatric intensive care services for women and rated these services.

We rated this core service as good overall because:

  • There was evidence that staff were monitoring patients physical health effectively. The service employed a nurse and a locum doctor who solely focussed on patients’ physical health care. The clinical teams supported patients who had challenging and complex physical health issues safely.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • The management team was responsive in developing plans to address the issues raised in the recent MHA review and we could see that the hospital was progressing with those plans and making improvements.
  • The teams on the wards included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers planned to ensure staff received the training they needed, supervision and appraisal in line with the providers policy. Staff across the wards worked well together within their multi-disciplinary teams, and with those outside the ward who would have a role in providing aftercare.

However:

  • Whilst restrictive practices across the wards were being monitored, we found that this was not carried out in a way that considered each individual patient’s needs, instead an overarching approach was being used. Some restrictive practices placed on patients were not being identified and therefore were not being reviewed effectively. The patients risk behaviours on the acute and psychiatric intensive care wards changed frequently as patients were admitted and discharged quite quickly but we found that the hospital only reviewed restrictive practices every 6 months. This meant that restrictive practices remained in place that were not always appropriate for the patient group being cared for at any one time.
  • Staff told us that the provider was offering induction and training to support them working in the acute and PICU wards. Whilst some staff felt this was adequate others felt it did not offer them sufficient acute and PICU specific training to enable them to do their job as effectively as they should or would like.
  • Staff knowledge and understanding of the rights of informal patients (those not detained under a section of the Mental Health Act) was unclear. Patients documentation referred to informal patients having "leave" and staff and patients were not clear about the differences between the rights of informal patients and the rights of detained patients. We found that in four informal patients care notes that staff had documented that they were only able to leave the ward with staff escorting them. This meant their ability to leave the ward was dependent on staff availability when they should have been allowed to leave the ward when they wished. We saw one informal patient notes that stated "leave suspended until Monday"; the patient was therefore, in effect, being detained on the ward and did not recognise their right to leave freely if they wished.
  • We found that for a serious incident that had occurred on Picasso ward in August 2021 an incident review process had not been investigated within the 40 day time period as defined in the organisations “incident reporting, management policy” or in line with nationally recognised good practice. The serious incident investigation had not been completed at the time of our inspection. Which meant the hospital could not identify and provide assurance that appropriate and immediate action had been taken to safeguard the patients and staff and that learning to mitigate or prevent further similar serious incidents could inform practice so improvements could be immediately made.

3rd and 4th December 2019

During a routine inspection

  • All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose.

  • The service had enough nursing and medical staff, who knew the patients and received basic training to keep patients safe from avoidable harm.

  • Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

  • Staff assessed the physical and mental health of all patients on admission. They developed individual care plans, which they reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected the assessed needs, were personalised, holistic and recovery oriented.

  • Staff provided a range of care and treatment interventions suitable for the patient group and consistent with national guidance on best practice. They ensured that patients had good access to physical healthcare and supported patients to live healthier lives. Staff used recognised rating scales to assess and record severity and outcomes.

  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers made sure they had staff with a range of skills needed to provide high quality care. They supported staff with appraisals, supervision and opportunities to update and further develop their skills. Managers provided an induction programme for new staff.

  • Staff from different disciplines worked together as a team to benefit patients.

  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Managers made sure that staff could explain patients’ rights to them.

  • Staff supported patients to make decisions on their care for themselves proportionate to their competence. Staff assessed and recorded consent and capacity or competence clearly for patients who might have impaired mental capacity or competence.

  • Staff treated patients with compassion and kindness. They involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided. Staff informed and involved families and carers appropriately.Staff planned and managed discharge well.

  • The design, layout, and furnishings of the wards supported patients’ treatment, privacy and dignity.

  • The food was of a good quality and patients could make hot drinks and snacks at any time.

  • The wards met the needs of all patients who used the service. Staff helped patients with communication, advocacy and cultural and spiritual support.

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and the wider service.

  • Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.

  • Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

  • Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution.

  • Governance processes operated effectively at ward level and performance and risk were managed well. Ward teams had access to the information they needed to provide safe and effective care and used that information to good effect.

    However:

  • Some medicines for individual use were not labelled for individual patients as per providers own policy.

  • Some Physical observations were not being recorded post rapid tranquilisation (RT)administration.

  • On a few occasions patients had been secluded in their bedroom as the seclusion room was already in use. The seclusion was appropriately recognised and reported with the monitoring in place. However, staff were concerned about patient safety and sought support to ensure this arrangement had been considered.

  • Some patients on Greenacre and Oaktree wards told us they did not always feel safe from other patients.

  • The maintenance systems did not ensure issues like the broken lock to the de-escalation room were identified and repaired promptly. We raised the broken lock at the time of inspection and the provider arranged to have it repaired that day.

  • Some staff did not know what to do if a fob(electronic locking system) system failed or the unit needed to be locked using another system.

  • Managers did not ensure there were always lessons learnt in relation to incidents like medication errors.

  • Staff on Picasso ward told us they relied on doctors’ assessments for determining mental capacity whenever they identified an issue.

  • There was inadequate provision of activities on evenings and weekends for patients on Picasso ward.

20-21 February 2018

During a routine inspection

We rated Cygnet Hospital Woking as Good because:

  • There were enough suitably qualified and trained staff to provide care to a safe standard. Skilled staff delivered care and treatment. Throughout the two wards, the multidisciplinary team was consistently and pro-actively involved in patient care and everyone’s contribution was considered of equal value. The staff were kind, caring and motivated and we saw good, professional and respectful interactions between staff and patients during our inspection.
  • Patients’ risk assessments and plans were robust, recovery focused and person centred. The assessment of patients’ needs and the planning of their care was thorough, individualised and had a focus on recovery. Staff considered the needs of patients at all times. Physical healthcare assessments and associated plans of care were thorough and consistently delivered to a high standard.
  • Patients had access to a variety of psychological therapies described as best practice in The National Institute for Health and Care Excellence guidance. This therapy was delivered either on a one-to-one basis or in a group setting, as part of the treatment programme. There was a varied, strong and recovery-orientated programme of therapeutic activities and treatment groups available every week.
  • There was evidence of best practice in, and all staff had a good understanding of, the Mental Health Act 1983 (MHA), the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice.
  • There were many examples of initiatives implemented to involve patients in their care and treatment. Patients told us that the staff consistently asked them for feedback about the service and how improvements could be made. Patients were appointed as ward representatives and a ‘people’s council’ met regularly and ensured good communication between patients, staff and managers. The service was responsive to listening to concerns or ideas made by patients and their relatives to improve services. Staff considered these ideas and used them when they could. Staff had developed pamphlets for children to explain why their parents had been admitted to a psychiatric ward. The pamphlets were presented as stories, were age appropriate and used pictures to get the information across.
  • The service had clear guidance in place to report incidents and support staff learning when things had gone wrong.
  • Ward staff provided clinical quality audits, human resource management data and data on incidents and complaints. The information was summarised, updated daily and presented in a key performance indicator dashboard. Staff had good access to robust governance systems, which enabled them to monitor and manage the wards effectively and provide information to senior staff in the organisation and in a timely manner.
  • All staff had good morale and said they felt well supported and engaged with a visible and strong leadership team, which included both clinicians and managers. Staff were motivated to ensure they achieved organisational objectives. Without exception, staff spoke highly about the senior management team.

However:

  • The senior management team had only been in post for four months and staff had concerns about the stability of this team, given the hospital had 11 managers over a ten-year period.

13-15 June 2017

During a routine inspection

We rated Cygnet Hospital Woking as Inadequate because:

  • Young people had repeatedly self-harmed when on enhanced observation levels and staff had been slow to respond to incidents of self-harm.
  • There were a high number of incidents reported in CAMHS and a high use of restraint, of which 10% of restraints were carried out in the prone position.
  • Staff in the CAMHS did not possess the experience, skills and competencies to safely manage the complex behaviours of young people in their care.
  • Physical health care conditions, including significant weight gain, were not managed effectively on the CAMHS ward.
  • Risk assessments in the CAMHS ward did not contain the latest risk factors and the care plan progress was not measured.
  • Safeguarding alerts were not always made to the locality authority or CQC when young people were assaulted by other patients.
  • Staff on the CAMHS ward did not always log, report or review adverse events. Staff did not manage complaints and issues of concern according to hospital policy. Staff therefore did not always take opportunities to learn from the investigation of incidents and complaints.
  • Collectively, the young people felt frustrated, said they were not listened to and felt that staff did not read or follow care plans.
  • Lengths of stay on the CAMHS psychiatric intensive care unit ward were not in line with NHS England service specification guidance (no longer than eight weeks). Two young people had been resident for eight months due to delays in transfer to adult services once they had reached eighteen.
  • Staff reported that calls for assistance were not always responded to.

However:

  • Staff working within the low secure service rarely used physical restraint.
  • Staff on the low secure wards, used nationally recognised tools to support their assessment of patients and were actively involved in clinical audit.
  • There had been only one delayed discharge in the low secure service in the six months period prior to the inspection.

We found a number of concerns during our visit to CAMHS on Park View First ward. However, the provider was responsive to the issues we raised and took immediate action to address them. The provider has continued to engage with the Care Quality Commission and NHS England to resolve issues and ensure that in the future patients will receive care that is in line with the standards expected.  The provider closed the ward in question and has undertaken a significant review of staffing and workforce.

13-16 October 2015

During a routine inspection

We rated Cygnet Hospital Woking as good because:

All patients had risk assessments. Risk information was reviewed regularly and documented. We saw that the reviews of risk were part of the multi-disciplinary care review process. There were appropriate systems embedded with regards to safeguarding vulnerable adults and children. De-briefing for both staff and patients took place after incidents.

  • Patients’ needs were assessed and care was delivered in line with their individual care plans.
  • Records showed that all patients received a physical health assessment and that risks to physical health were identified and managed effectively. Staff followed best practice in treatment and care. Staff participated in a wide range of clinical audits to monitor the effectiveness of services provided. Staff received appropriate mandatory and statutory training, supervision and appraisals.
  • Most patients spoke highly of the daily and weekly therapeutic activities that were offered across the wards. Staff respected patients’ diversity and human rights. Attempts were made to meet people’s individual needs including cultural, language and religious needs.
  • Complaints were appropriately reviewed and responded to.
  • Patients we spoke with were positive about the staff. The interactions we observed between patients and staff were friendly and respectful. Feedback received from families and external stakeholders was good.
  • The service had good governance processes in place to monitor performance and trends.

However:

  • The seclusion facilities across the wards did not meet current guidelines as per the Mental Health Act Code of Practice 2015, to ensure safety and patients dignity was maintained. This was a breach of regulation at the previous inspection visit.
  • On Acorn and Parkview Ground ward the use of the Extra Care Area (ECA) was not in line with the Mental Health Act code of practice.
  • Staff did not clearly document when restraint was used in seclusion records and correct terminology was not used to help identify this.
  • Not all ligature points had been identified on audits and for some of those identified staff could not explain the reason why it was considered a ligature risk.

9, 10, 11 February 2015

During an inspection in response to concerns

We looked at 17 personal care and treatment records of patients and young people, who used the service, carried out a visit on 09, 10 and 11 February 2015, observed how people were being cared for and talked to patients and young people.

During our inspection we spoke with 22 patients and young people who used the service, 39 staff, eight relatives, nine external health and social care professionals and three senior management representatives, including the chief executive officer, the hospital director and the medical director. We considered all the evidence we had gathered under the outcomes we inspected.

The inspection was undertaken by a team of 11 which included three inspectors, an expert by experience, two Mental Health Act reviewers, two specialist advisors, a pharmacist, a psychiatrist and the head of hospital inspections for the South East.

During our inspection we visited three wards. Green acre was a male low secure ward with a bed capacity of 17, with 16 patients admitted at the time of our visit. Oak tree was a female low secure ward with a bed capacity of 11, with nine patients admitted during our visit. Park view (ground) was a female child and adolescent mental health service (CAMHS) psychiatric intensive care unit (PICU) with eight young people admitted at the time of our visit. Alpha Hospital - Woking had another closed ward (Acorn ward) which had provided a male CAMHS. At the time of our inspection no CAMHS patients were being admitted into the hospital under the instruction of NHS England.

This is a summary of what we found.

Is the service safe?

Patients told us they felt safe. Safeguarding vulnerable adults from abuse procedures were robust and staff understood how to safeguard patients they cared for.

Systems were in place to make sure that managers and staff learnt from events such as accidents, incidents, complaints and whistleblowing investigations. This reduced the risks to patients and helped the service to continually improve.

We found staffing levels were sufficient to meet patients' needs to a good standard. We noted some inconsistencies in the pre-employment checks for prospective staff.

We found risk formulations were consistently strong on Green acre and Oak tree wards and used a recognised method which staff had been trained to use. We found some inconsistencies with risk formulations on Park view (ground) ward.

We found evidence of good medicines management on all three wards.

We found that patients were not protected against risks associated with unsafe premises in regards to the three seclusion rooms.

Is the service effective?

We found that there was evidence of best practice being used in most cases. We found that the interaction between all members of the multi-disciplinary teams facilitated good communication and ensured delivery of effective care and treatment for patients. All contributions from the multi-disciplinary team members were considered equally valuable.

We looked at all detained patients' care records and found that all detentions appeared legal and that all statutory forms had been completed appropriately.

Is the service caring?

Patients were treated with respect and dignity by the staff. Patients were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting patients. Patients' preferences, interests, aspirations and diverse needs had been recorded and care and treatment had been provided with their involvement.

Is the service responsive?

We found detailed assessments of patients and that they had been actively involved in both the planning and review of care and treatment.

The system for managing and responding to complaints was well embedded and learning from such events was evident through the 'You said and we did' initiative.

We found a good selection of therapeutic activities available for patients.

Is the service well-led?

We found staff groups on all three wards who were highly motivated and had a positive approach to their work. We found overall good morale on Green acre and Oak tree wards without undue stress. We found morale on park view (ground) was improving although stress levels remained concerning.

We found a strong and developing senior management team which included consultant psychiatrists and other senior representatives from the multi-disciplinary team who were fully involved in all aspects of the service.

We found several examples of innovative practice.

18, 21 November 2014

During an inspection in response to concerns

Is the service safe?

The safeguarding policies and procedures were up to date. Staff demonstrated a clear understanding of the types of abuse and the responsibilities they had to report safeguarding concerns. Medicines were prescribed, administered and stored appropriately. The risk of cross contamination was increased due to poor infection control practices.

Is the service effective?

There was a multi-disciplinary team of staff working within the service. Audits had been carried out and some changes implemented as a result.

Is the service caring?

Some of the care we observed was positive. Capacity to consent to decisions was routinely assessed and recorded. Care plans showed involvement and acknowledgement of the person's needs and what action was needed to support them. Blanket rules and restrictions were implemented on some wards.

Is the service responsive?

All the people using the service had a care plan. In some cases this was tailored to the needs of the person, but in others it did not reflect their individual needs or risk assessment.

Is the service well led?

The service had up to date policies and these were accessible to all staff. There were processes in place for monitoring the service. However, there was limited evidence to demonstrate action taken or required, and timescales when this would be achieved.

19 February 2014

During a routine inspection

This inspection was undertaken by a pharmacist from the Care Quality Commission. The purpose was to follow up on the compliance action that was made in relation to medicines during the inspection of December 2013.

We looked at the processes, and records held by the service relating to the use and management of medicines.

We reviewed the supply process, supporting information and administration records. Medicines were obtained in a timely manner. Staff showed us where and how medicines were stored and the expiry date and temperature records they kept. Therefore we were assured that the medicines were safe to be administered.

We reviewed the prescribing and administration records including additional monitoring records that were required when a few medicines were administered. These records were complete.

We spoke to four people using the service. They explained to us how they were given their medicines, the written information they were given prior to stating medicines and if they had questions about their medicines the staff find the answers. The service users also told us how their medicines were looked after by the staff, parents or guardians when they were they went out or stayed away from the service.

29 January and 13 February 2014

During an inspection looking at part of the service

We undertook a follow up visit to the service to check they had become compliant with three warning notices and a compliance action from the inspection of November and December 2013. Two compliance inspectors undertook these visits and were accompanied by a Mental Health Act operations commissioner and a specialist advisor on the first day of our visit. The second day of our visit was undertaken by two compliance inspectors.

Our visit focussed on the adolescent wards as this was where we had found evidence of non-compliance at our previous inspection.

We spoke with seven members of staff, the registered manager and the chief executive officer. We had limited conversations with three people who used the service.

We found that people had been cared for appropriately when in seclusion and that all relevant observations had been made.

People we spoke with told us that they had not been moved on the stairs whilst they were in a restraint hold. One person told us that staff had monitored them when they had been in seclusion. For example, they told us that their blood pressure was taken.

We found that the provider had put systems in place to monitor and assess the delivery of care to people.

We saw that people's records were correct and up to date, and that all monitoring of people's care had been completed and recorded in a timely way.

26, 29 November and 2, 4 December 2013

During an inspection looking at part of the service

We undertook a follow up visit to the service to check they had become compliant with the compliance actions from our planned review on the 24 and 25 June 2013. Two compliance inspectors undertook these visits and were accompanied by a Mental Health Act Operations Manager, an expert by experience and a specialist advisor. The Care Quality Commission pharmacist undertook a visit to the service on the 4 December 2013 to look at how medicines were being managed. Mental Health Act commissioners also undertook a visit on 2 December 2013.

Our visit focussed on the adolescent wards as this was where we had found evidence of non-compliance at our previous inspection.

We spoke with six people who used the service, six members of staff and the registered manager.

People who used the service told us that they could make telephone calls and had a mobile telephone they could use when their education and therapeutic activities had ended.

One person described the range of educational and therapeutic activities they participated in. They told us that a 'Bill of rights' for the ward was developed from one of these meetings. This focussed on the rights of young people living on the ward.

People told us that they felt safe with staff who were on the wards. One person told us staff were "brilliant."

We found the service had made improvements in relation to ensuring that the gaps between the identified doors of bedrooms and bathrooms had been repaired. However, we found the service to be non-compliant with the care and welfare of people who use services, safeguarding people who use services from abuse, management of medicines, assessing and monitoring the quality of service provision and records.

24, 25 June 2013

During a routine inspection

We undertook a two day inspection of the service on the 24 and 25 June 2013. Our visit focussed on the adolescent wards as this was where we had found evidence of non-compliance at our previous inspection. Four compliance inspectors undertook these visits and were accompanied by a Mental Health Act Operations Manager.

We spoke with eight adolescent patients who were receiving care, treatment and support at the time of our inspection. We saw that other adolescent patients were undertaking their exams at the time of our visit. We spoke to 12 members of staff and the registered manager.

Patients told us that recent improvements had been made and they were happy with the changes made. One patient told us, "It is much better now our bedrooms are unlocked as we have more freedom." Another patient told us, 'I can call my family anytime through the nursing station.'

Patients told us that staff used de-escalation techniques and that the use of security clothing had been stopped. They told us they felt safe with staff that looked after them and they had been offered and attended more external activities.

We acknowledge that changes in practice had been made since our last inspection that ensured patients experienced safe and effective care, treatment and support. These changes need to be embedded in practice over a period.

7, 26 February 2013

During a routine inspection

We undertook two visits to Alpha Hospital Woking. One visit was on the 7 February 2013 with the Mental Health Act Commission that was a thematic visit to look at the seclusion and restrictive practices at the service within the adolescent units. The second visit on the 26 February 2013 was a planned review of the service. Three compliance inspectors undertook this visit and were accompanied by a specialist advisor from the Child and Adolescent Mental Health Service (CAMHs).

The hospital consists of five wards. Greenacre is a ward for adult male patients. Oaktree is for adult female patients. Parkview first floor and Acorn wards are for adolescent female patients and Parkview ground floor is for adolescent male patients.

During these visits we spoke with six people patients, five of whom were adolescent patients. We had discussions with the manager, deputy manager, one Psychiatrist and five members of staff. The adolescents we spoke with told us that they could not make choices they would like to make. They told us that they were not able to access their bedrooms during the day which they did not like and had set specific times when they could use the telephone to receive or make telephone calls. Some patients told us they had a care plan and they had seen them.

We have made eight compliance actions as a result of this review.

13 July 2011

During an inspection in response to concerns

People who use the service told us that staff look after them well, and that they feel safe living at the hospital. We were told that an external advocate group that are specific to females visit the hospital on a weekly basis, and other advocacies visit for all people who use the service.

They said they always received their medication on time and staff and the Doctors explained to them what their medication was for. They told us that they were consulted each time their medication is changed, and the reason for the change is explained to them.

People who used the service told us that they had been asked their views about the service, and they had recently completed a questionnaire for the hospital. They told us that staff often asked them for their views about the service.

9 December 2010

During an inspection in response to concerns

People who use the service told us that staff look after them well, and although staff are generally busy, they do take time to talk to them. Staff are generally good listeners, and some are better than others. They stated that they would talk to certain staff if they felt unsafe, in particular health care assistants and psychology staff. They said that most staff will talk to them in a polite manner; however, some staff can appear to be rude.

They agreed that there are enough staff on duty, and they now have regular day staff on duty. There are quite a few agency staff working at night, but there are always two permanent staff on duty at this time.

Some people who use the service had made complaints and that these were addressed. They stated that it would be good if staff could support people through the whole process when they make a complaint.

During discussions staff told us that they knew what Safeguarding meant (their rights and responsibilities to protect people from harm and abuse), and they would not hesitate in reporting Safeguarding issues. They stated that they had received all the mandatory training as required in their induction, and regular refresher training is provided by the service. They thought their recruitment was fair, and that they considered that there was always enough staff on duty. We were told that there are some senior staff who have 'attitude' issues, and that some senior staff appear to be bullying the more junior staff.

We observed good interaction between people who use the service and staff who were on duty on the day of the site visit. Staff were observed supporting people in a calm manner and using preferred names to address them.

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.