Cygnet Lodge Woking

Our rating of this service stayed the same. We rated it as requires improvement because:

• The ligature risk assessment for Marlowe ward did not accurately reflect the identified ligature risks of the bedroom environment. For example, although the bedrooms were suitably rated as high risk, there were identified ligature risks that were shown as low risk. The mitigation provided in the assessment for one of these risks was also not accurate with what was in place at the time. We fed this back during the inspection and have seen evidence that the provider addressed this for the bedrooms, as well as reassessing and developing new ligature forms for other areas of the ward, though these should be reviewed regularly to ensure they remain accurate.
• At the time of the inspection, the service did not have a maintenance log in place to record repairs that were needed, or that had been requested. This meant that they could not monitor and ensure that maintenance actions already reported were rectified in a timely way. We found maintenance issues on Marlowe ward including a broken fridge that was still being used, and a broken door handle, both of which had been reported but not addressed. Since inspection, the service has sent evidence of a new log which will monitor the progress of maintenance issues.
• Some staff raised concerns around the safety of staffing numbers on Milligan ward when it was expected that one support worker would be on the ward with four patients. Although, there had not been any reported incidents as a result of this lone working and staff confirmed that there was support from staff on Marlowe ward if an incident was to occur or if cover was needed for breaks. Management assured staff that they would review and increase the staffing numbers, yet this had not been done. Leaders told us that staffing was based on the ward acuity and the resources needed to escort community patients.
• Not all managers were visible within the service. Some staff told us that the ward manager was not always visible on the wards although the senior nurses and deputy manager were supportive and available when needed. The consultant psychiatrist was also not visible on the wards to both staff and patients other than during ward rounds, and some staff felt that a greater presence on the wards would have a positive impact for both patients and staff.
• Although the service had positive behaviour support (PBS) plans in place which identified triggers and described how to work with individuals diagnosed with autism, this information was not clear throughout the care plans. Given the use of agency staff on the wards who may not be familiar with these individuals, this could impact the care and appropriate risk management of these patients. Following initial feedback, the senior leaders and wider directors reviewed this and developed a more suitable template to ensure that this information is captured fully within the care plans.
• We saw discharge planning discussed as part of the ward round, although we only saw discharge plans outlined in one of the seven care records we reviewed and there was clearly still a need for this to be embedded fully. Leaders acknowledged that these needed to be captured in care plans.

However:

• The ward environments were clean and well furnished. Staff assessed 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.
• Staff provided a range of activities and treatments suitable to the needs of the patients and in line with national guidance about best practice. Patients told us that they engaged in regular activities including quiz nights, community skills, shopping/ cooking and breakfast groups, as well as therapy sessions, including both occupational therapy and psychology. Staff engaged in clinical audits to evaluate the quality of care they provided.
• We saw good practice around physical health monitoring including clozapine and stool monitoring.
• The ward teams had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together.
• We saw that each patient had their care team details on the front of their bedroom door, so they knew which staff were caring for them. Ward rounds were inclusive and patient feedback was respected.
• Staff understood and discharged their roles and responsibilities with the use of the Mental Health Act 1983 and the Mental Capacity Act 2005 safely.
• Patients reported that staff treated them with kindness and respect. Patients we spoke with felt safe and told us that they had access to nursing and care staff when they needed. They actively involved patients, families and carers in care decisions.
• The service worked to a recognised model of mental health rehabilitation. It was well led, and the governance processes ensured that ward procedures ran smoothly.