Cygnet Hospital Woking

Ratings

• Overall

  Requires improvement

• Safe

  Requires improvement

• Effective

  Good

• Caring

  Good

• Responsive

  Good

• Well-led

  Requires improvement

Our view of the service

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.