Cygnet Hospital Woking

On this page

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

We reviewed all 8 quality statements in the safe key question. This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Because of this, we have found the provider to be in breach of regulation 12, Safe care and treatment.

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 have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

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

Managers investigated incidents thoroughly. They reviewed closed-circuit television (CCTV) recordings of incidents as part of their investigations.

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

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

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

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

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

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

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

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

Staff engaged with patients in a caring and meaningful way and showed a genuine interest in the patients. We observed staff interactions with patients and regularly saw they approached patients in a compassionate and caring manner. Relevant safeguarding information was displayed on the ward information boards.

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

Appropriate systems and governance processes were in place to ensure people were safeguarded. There was a database of safeguarding incidents to enable oversight and effective management. Senior managers and clinicians had oversight of all the safeguarding incidents, and these were discussed during the daily morning meeting which we observed, with actions assigned and follow up completed.

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

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We reviewed 16 patient records and all of them had an up-to-date risk assessment in place. Risk assessments covered key areas and captured relevant information to support the ongoing management of risk.

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

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

Staff followed policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. Staff conducted room searches when they suspected that a patient had prohibited items. Staff searched patients when they returned from leave. Staff ensured all risk items were stored securely. Patients’ items that were deemed to pose a risk and were not allowed on the ward were locked securely in individual lockers outside of the ward entrance.

On each ward there was a member of staff allocated as security lead. They ensured items that could pose a risk to the security of the ward were working effectively, such as radios, keys and alarm fobs, and other items such as ligature cutters and cutlery were all accounted for.

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

All the wards had outside space that patients could access. On Acorn ward the garden was easily accessed via the communal area and during our inspection, we noted the doors to be open and staff within the area observing. However, patients on Kahlo and Picasso ward did not have direct, unrestricted access to outside space as the wards were not located on the ground floor of the building. However, staff facilitated regular access to the garden during each shift and none of the patients we spoke with raised this as a concern.

Environmental risks that had been identified were discussed and reviewed by the senior management team daily so oversight of environmental safety could be maintained.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Staff did not always complete thorough risk assessments of all the wards and communal areas and therefore did not always remove or reduced any risks that should have been identified. For example, in the patients’ bedrooms, the convex mirrors and the door window did not allow for staff to maintain a clear line of sight when a patient was in their bed. This meant, particularly at night, staff had to regularly open patients’ bedroom doors and shine a torch light so they could check for signs of life because there was a blind spot that the mirrors did not cover and clear line of sight was further hindered by the door window covering. This was not recorded anywhere on the ward environment risk assessment. However, when we spoke with staff, they were aware it was a concern and told us they had to always open each patient’s bedroom door and shine a torch. Staff told us they did not know if this was common practice amongst all staff.

The service had completed a ligature anchor point risk assessment. This included a form for recording risks and an associated action plan, covering all areas of the ward and external areas. Staff we spoke with were aware of the ligature risk assessment that had been completed and were able to describe how they used individual risk assessments, care planning and observations to manage environmental risk. Patients’ bedrooms and communal areas were fitted out to a high standard with anti-barricade doors and anti-ligature features.

Staff had easy access to personal alarms which they carried on them and patients had easy access to nurse call systems in their bedrooms. Apart from in patients’ bedrooms, there were CCTV cameras on the wards and outside areas, such as garden areas as well as in communal stairways and corridors that were accessible by the patients off the wards. The CCTV cameras were not constantly monitored but could be used as part of any incident review and investigation.

The service had access to a seclusion room on Acorn ward. The seclusion room allowed for clear observation and included a two-way intercom. Patients in seclusion had access to toilet and showering facilities. A clock was in place to allow orientation to time and day. The lighting and temperature of the room was controlled by staff. Picasso and Kahlo ward had a quiet room which had seating should a patient need space for some quiet time or to be deescalated with support from staff.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

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

There were high levels of staff required on Acorn ward due to the acuity of the patient group and the number of patients on enhanced visual observations, which made the ward feel extremely busy. However, staff we spoke with told us they were aware of this, and they tried to ensure communal space was well used for activities, so the ward did not feel overcrowded or chaotic for the patients.

We observed a daily morning meeting where managers and staff discussed staffing across the hospital. They discussed the immediate staffing levels for that day and night, and the next few days and they adjusted and made changes where necessary. They identified factors that impacted on staffing levels such as how busy the wards were, enhanced observations, patients having leave off the ward, and other activities. When needed, staff could be moved between wards to support safety and therapeutic engagement with patients.

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

Staff completed mandatory training. Staff we spoke with also described additional specialist training they had completed. For example, emotional wellbeing and personality disorder training. Staff received regular supervision. There was a policy and guidance documents to support the supervision process and promote individual development, including management opportunities. At the time of our assessment, supervision compliance for Acorn and Picasso ward was 100% and Kahlo ward was 92%.

Managers monitored mandatory training and alerted staff when they needed to update their training. Managers received a regular report showing compliance with mandatory training. Compliance with mandatory training was also discussed every day in the morning flash meeting. This meant the senior management team had oversight with any concerns about access to and completion of training.

At the time of our assessment, the service had a short-term sickness rate of 3.9% and a long-term sickness rate of 1.7%. Staff had access to support services including human resources and occupational health.

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

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

The service did not assess or manage the risk of infection effectively.

The ward environments were not always clean and well maintained. On each of the three wards, we found examples where ensuites and bedroom spaces were either in need of repair and redecoration due to chipped and flaking paint or stained walls. We found the ensuites to be dirty, including the flooring and build-up of limescale and saw mould around the shower sealant and broken flooring seals between the ensuite and bedroom floor. These concerns had not been identified by staff on the daily environment check they completed and therefore no action had been taken to address the concerns.

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

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

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen

Medicines were not always managed in line with national guidance or legislation. Patients own prescribed medicines and stock medicines were not always stored separately. This had been previously highlighted internally; however, it was unclear what actions had been taken to reduce risk. The service was supported by an external pharmacy for clinical support and auditing. We saw input from the visiting pharmacists in patients’ records. However, we saw delays in medicines from the pharmacy supplier. We observed instances where patients had not received some medicines because of this. Staff told us that this had improved recently. Staff were provided medicines management training, and their competencies were assessed. Patient’s physical health was monitored in line with guidance which was overseen by a nurse practitioner. This included when patients were prescribed high risk medicines. For example, bowel monitoring was completed for patients prescribed clozapine. The service completed regular audits of medicines management. We saw evidence of learning and improvements being made as a result of the audits.

Patient’s behaviour was not inappropriately controlled by the use of medicines. We saw positive behaviour support plans to help staff support patients.

Patients were given rapid tranquilisation (RT) medicines intramuscularly to help reduce agitation and aggression. Physical health monitoring post dose was completed in line with policy. The service reviewed instances of RT daily. However, the service did not always record which RT was to be used first when multiple RT medicines were prescribed.

We saw medicines were generally administered in line with Mental Health Act consent to treatment authorisations. We reviewed 10 records and saw that one consent to treatment forms did not reflect the persons current medication.