Cygnet Victoria House

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s needs were met through good organisation and delivery.

The service met the needs of all patients including those with a protected characteristic. Staff were committed to offering person-centred care to the patients. Staff helped patients with communication, advocacy, and cultural and spiritual support. Staff supported patients with activities outside the service, such as work, education, and family relationships. The design, layout, and furnishings of the ward supported patients’ treatment, privacy, and dignity. Staff raised concerns that the admissions process did not always ensure that people who were admitted were suitable for the service provision. They mitigated this through assessments and multi-disciplinary meetings but felt this was an area the service could improve on. Whilst the service had a high number of patients placed outside of their home area, we found patients were not moved between wards except for their benefit and were discharged in a timely manner once well enough to do so. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Patients and their carers told us treatment had been arranged around individual needs and preferences. Staff told us they received a good level of information prior to admission and that the assessments at admission helped them with gaps.

Staff supported, informed and involved people using the service and their families or carers. There was a social worker within the hospital who supported carers and also sought to facilitate smooth transitions to other placements when the patient was ready to be discharged.

During our tour of the wards, we saw evidence patients could personalise their bedrooms. Patients had lockers in which to securely store their possessions.

We saw evidence in care records that decisions around care and treatment were created collaboratively with the patient, and their carers where appropriate. We saw evidence of robust discharge planning and that patients were supported to move on with the next steps of their recovery journey.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff supported patients to maintain contact with their families and carers. Staff provided patients with telephones to call their loved ones and gave patients access to computers so they could contact them using video link.

We observed patients being supported to engage in educational courses online and engage in activities that were important to them.

We saw evidence that a patient’s faith was considered and included in their treatment.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed. We saw evidence of staff reporting incidents to both CQC and Local Authority safeguarding teams where needed.

Information governance systems included confidentiality of patient records. The provider’s electronic systems required staff to use a login name and password which needed to be made up of lower-case and upper-case letters, numbers and special characters. Staff received information governance training which highlighted the need to maintain patient confidentiality and safeguard patients’ data.

Staff ensured that patients could obtain information on treatments, local services, patients’ rights, how to complain and other useful information. Patient noticeboards on the wards contained a good level of information about the ward, the local community and services available to them. The information provided was in a form accessible to the patient group such as easy read for people with a learning disability or in other languages.

Staff ensured carers, families and commissioners were regularly updated about the patient’s progress.

The service complied with the Accessible Information Standard. The Accessible Information Standard (AIS) is a UK law requiring health and social care providers to ensure people with disabilities or sensory loss get information they can understand and communication support they need, through steps like asking about needs, recording them, flagging them for staff, sharing details across services, and meeting them.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

In the last 12 months the provider had received a total of 7 complaints comprising 6 formal complaints and 1 informal. Of those, 3 had been partially upheld, 3 had been unsubstantiated and 1 had been withdrawn. There were no instances where complaints had been referred to the ombudsman. There were no themes or trends to the complaints submitted.

Patients, and their families knew how to complain or raise concerns. Where patients did raise complaints, they were investigated and they received feedback. Learning from complaints was identified and disseminated through a variety of communications methods.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

Staff made reasonable adjustments for patients. For example, people with mobility issues were provided with walking aids, shower chairs etc.

There was adequate medical cover day and night, a doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital.

Staff ensured patients had access to post-discharge care such as Section 117 aftercare, community mental health services and crisis services.

Staff planned for patients’ discharge, including good liaison with care managers/co-ordinators. There were some delayed discharges however, these were due to external factors beyond the wards control, and where they occurred, the MDT worked hard to support people, and external organisations to manage this.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

Staff were trained in equality, diversity, inclusion and human rights.

The provider had a number of staff networks and groups including Equity, Diversity and Inclusion group, LGBTQ+ network, Cygnet Staff Carers network, Multicultural network, Disability network, Women's network and Men’s Health network. The most recent Staff Survey showed that staff had a good level of awareness of these groups and felt the provider recognised the challenges and inequalities faced by individuals. Staff reported the provider acted fairly with regards to suspensions and/or disciplinary procedures regardless of Age, Disability, Gender Reassignment, Sexual Orientation, Marriage or Civil Partnership, Pregnancy and Maternity, Race, Religion or Belief, Sex.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff supported patients to make decisions about their care and treatment and their future. We observed MDTs and reviews where this was discussed and reviewed, and we saw evidence of it documented in care records.

Staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs.

Staff planned for patients’ discharge from the service. Any plans for discharge were made in collaboration with other interested parties such as home teams, community mental health teams, housing services, social services and GPs.