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

Cygnet Hospital Clifton

Overall: Requires improvement read more about inspection ratings

Clifton Lane, Clifton, Nottingham, Nottinghamshire, NG11 8NB 0845 200 0465

Provided and run by:
Cygnet Clifton Limited

All Inspections

28 June 2021

During an inspection looking at part of the service

Cygnet Hospital Clifton is a specialist low secure mental health and rehabilitation service for men with a personality disorder.

Cygnet Hospital Clifton was placed into special measures by the CQC Chief Inspector of Hospitals in May 2020. This followed findings of significant concerns about the safety and leadership of the service. Since then the CQC has continued to monitor the service closely and has found some improvement. We judged that enough improvement was made following an inspection in May 2021 to remove the provider from special measures.

However, following urgent concerns raised by staff in relation to staffing, increased patient acuity and increasing patient numbers we inspected the hospital again on 28 June. The inspection focused on parts of the safe and well led domains, but we did not change the ratings from the previous inspection in May 2021.

We found the following issues the provider needs to improve:

  • Managers had not ensured that there were sufficient staff to ensure patient and staff safety across both wards in the hospital. Staffing levels had worsened since our inspection in May 2021.
  • We were not assured that all incidents were being recorded during periods where wards were extremely unsettled and where staffing numbers were low.
  • The service had not ensured that there were enough experienced staff to provide leadership to newly qualified nurses and to the rest of the nursing staff.
  • Staff did not feel supported and valued by senior managers in the hospital or feel able to raise concerns without fear of retribution. Staff knew how to use the whistle-blowing process but felt discouraged from raising issues or that their concerns were dismissed and nothing would change as a result.
  • Managers had not always ensured that damaged property had been repaired in a timely fashion to maintain safety.

4-6 May, 18 May

During a routine inspection

Cygnet Hospital Clifton is a specialist low secure mental health and rehabilitation service for men with a personality disorder.

Cygnet Hospital Clifton was placed into special measures by the CQC Chief Inspector of Hospitals in May 2020. This followed findings of significant concerns about the safety and leadership of the service. Since then the CQC has continued to monitor the service closely and has found some improvement. We have judged that enough improvement has been made to remove the provider from special measures.

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

  • Although we found the service largely performed well, it did not meet legal requirements relating to good governance and staff support, meaning we could not give it a rating higher than requires improvement.
  • The provider did not support newly qualified nurses through their preceptorship in line with their own policy. Preceptors did not have the required post qualification experience and preceptorship nurses did not receive regular supervision as stipulated.
  • The provider did not ensure all nursing staff received regular, constructive clinical supervision of their work.
  • Managers had not ensured preceptors had the skills and experience to manage preceptorship nurses effectively. Managers had not ensured these nurses had two years post qualifying experience, had a mentoring qualification or received robust supervision and specialist support from more experienced staff in order to undertake this task. When raised with them, managers did not ensure the whole group of preceptorship nurses received the support stipulated in the provider’s policy.
  • Staffing levels were not always at the level stipulated by the provider on both wards.
  • Patient risk was not always accurately handed between shifts. Staff had not completed risk assessment training consistently.
  • Staff did not always feel supported and valued by hospital managers. Managers had not ensured there were regular and effective team meetings for nursing staff. Staff were not always offered a debrief after incidents. There was no system for reviewing minor incidents and giving feedback to staff where appropriate. Learning from incidents and staff feedback was not applied consistently across the service.

However:

  • The service had addressed issues since the last inspection, including increased training for staff, increased staff competence for existing staff and improving patient safety. Staff now followed procedures when delivering care and treatment and protected the privacy and dignity of patients. They had ensured staff kept information confidential and maintained accurate records of patient care and treatment, including preparing advanced statements with patients, completing security checks and checking emergency equipment on the wards.
  • The service provided safe care. The ward environments were safe and clean. The wards generally had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • 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 audit to evaluate the quality of care they provided.
  • The ward teams included or 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 as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients in care decisions.
  • Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • Governance processes ensured that most ward procedures ran smoothly.

22 and 23 January 2020

During a routine inspection

Cygnet Hospital Clifton provides specialist low secure mental health and rehabilitation service for men with a personality disorder.

We rated Cygnet Hospital Clifton as inadequate because:

  • The service did not always provide safe care. Ward based staff did not always manage patient risks well and staff actions did not always protect patients from avoidable harm. This included incidents of harm to patients when staff failed to follow plans or procedures to keep patients safe and incidents when staff behaved poorly towards patients. For example, when harm occurred to patients during high level observations provided by staff. The provider used temporary staff to maintain ward staffing levels, but patients expressed greater concern about the attitude and behaviours of temporary staff towards them. The provider investigated incidents, but it was not always clear what ward based staff had learnt from incidents and how practice had changed to prevent reoccurrence. This meant risks were not always reduced and incidents happened again.

  • Staff were not always sufficiently trained or experienced to meet the needs of patients. The provider identified that the limited experience and competencies of some staff contributed to safety incidents and inconsistent standards of relational security practice. The standard of, and staff’s completion of specific training to meet the needs of patients was not always good. Staff did not always work together effectively to ensure care and treatment remained safe and effective for patients using the service.

  • Some staff did not always treat patients with kindness and compassion, and some did not always provide patients with support when they needed it. Patients sometimes believed staff failed to keep them safe and purposefully provoked them. Staff and patients reported concerns about the confidentiality of information in the service. It was not clear how staff managed and applied advance statements in the service.

  • The service was not always well led. Some concerns raised at the previous CQC inspection remained including the way staff treated patients and the way staff managed risks to keep patients safe. Positive and effective leadership was not embedded at all levels of the service. Governance processes did not always demonstrate that risks and staff deployment were managed well. Some staff at the service continued not to feel respected, supported and valued.

However:

  • The provider had introduced actions to address concerns at the hospital, but it was too early to measure the impact of these when we inspected. This included the introduction of ward managers to improve ward based leadership, improvements to the personality disorder training available to staff and changes to supervision practices that made discussions about security duties, relational security, learning from incidents and staff conduct mandatory between staff.

  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and ensured that patients had good access to physical healthcare. Therapy staff provided a range of treatments suitable to the needs of the patients, and in line with national guidance about best practice.

  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

  • Staff planned and managed discharge and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

15 & 16 August 2018

During a routine inspection

We rated Cygnet Hospital Clifton as requires improvement because:

  • Staff did not always treat patients with kindness and compassion. This was confirmed in interviews with patients and our review of hospital records. We frequently saw staff responding to patients requests for assistance, rather than approaching patients to initiate contact and support.
  • Staff practices did not ensure that risks to patients were always minimised. This was demonstrated in failures to maintain checks of emergency equipment, undertake prescribed observations, and monitor patients following the administration of rapid tranquilisation.
  • Communication practices were poor. This was confirmed in interviews with staff and patients. We saw an example of how information poorly communicated between staff led to gaps in care. Patients reported that staff did not keep them informed of changes occurring in the service and inform them of planned visitors to the wards.
  • Staff did not always keep accurate and complete records of the care and treatment provided to patients. This included patients being cared for in seclusion. 
  • Staff reported short staffing, low morale, and an unhappy staff team. Staff were concerned about high staff turnover rates, the suitability of training provided for their roles, and maintaining professional staff and patient boundaries. Patients reported experiencing delays when they required staff support to move around the hospital.
  • Staff completion rates for Mental Health Act and Mental Capacity Act training were low. Some staff identified a need to receive training in these areas, and others believed the training offered was not sufficient for their roles.
  • Management systems were not embedded to ensure that all staff were aware of, and understood lessons learned as the result of the investigation of incidents and complaints. Staff reported their experience of this was poor, and examples of good practice were not embedded in the service.
  • Despite the new providers improvement plan, transition to existing governance structures, and additional senior and multi-disciplinary staff, change at the service had not sufficiently embedded to demonstrate safe and effective care.

However:

  • There was evidence of investment into the service from the new provider. This included changes to the hospital environment to improve safety, establishing a new senior staff team, the recruitment of additional staff, and an overarching action plan of improvement in all clinical areas.
  • Staff completed risk assessments for the hospital environment and individual patients. Resulting plans from these assessments contributed to reducing restrictive practices for patients.
  • Staff assessed the physical and mental health of all patients on admission. Interviews with patients confirmed that staff supported them with their physical health and encouraged them to live healthier lives.
  • Staff supported patients to access activities inside and outside of the hospital. This included voluntary work, education, and community support for patients with protected characteristics. Patients could also contribute to decisions about the service by contributing to staff recruitment practices and a People’s Council.

16 November 2016

During an inspection looking at part of the service

We have rated services as good overall because:

  • The hospital acted to meet the requirement notices we issued after our inspection in April 2016.
  • We found the service had made changes to keeping their electrical equipment up to date with safety stickers and Cambian (the provider) had updated and published the Mental Health Act Code of Practice (2015) policies
  • We also found safe staffing levels that allowed staff to care for the patients.
  • The staff kept care plans that reflected the involvement of the patient and care records were up to date, well written and detailed.
  • Regular audits were taken in areas such as ligature risk, environmental risk and medicine management.
  • Staff used relevant guidance from the National Institute of Health and Care Excellence when providing therapies.
  • Specialised training was available to help staff understand the patient group better.
  • A local GP ran a well persons clinic weekly at the hospital.

25 and 26 April 2016

During a routine inspection

We rated the Ansel Clinic Nottingham as requires improvement because:

  • Clinic room equipment on Acorn ward was not consistently checked and some equipment had not been calibrated.
  • Not all electrical devices demonstrated safety checks were undertaken.
  • Staff had not always followed correct procedures for seclusion.
  • Cambian Mental Health Act (MHA) policies did not reflect the changes to the Code of Practice in April 2015.

However,

  • Managers undertook an assessment of ligature risks annually and then took appropriate steps to reduce risk. They participated in regular local and regional governance meetings. Staff knew who their managers were.
  • Staff had access to mandatory training and additional specialist training to ensure they were suitably skilled and qualified. Supervision of staff took place frequently and all staff had received an appraisal in the 12 months prior to our inspection. All support workers worked towards the care certificate.
  • There were effective working relationships with teams outside of the organisation such as local authority safeguarding teams and GPs as well as local voluntary organisations that supported patients to secure employment in the local community.
  • Staff used a recognised outcome measure to measure recovery.
  • Patients had access to psychological therapies and National Institute for Health and Care Excellence (NICE) guidance was informing care planning. A full range of mental health disciplines had input to patient care.
  • Patients’ care records contained up to date, personalised, holistic, recovery-oriented care plans and demonstrated comprehensive and timely assessments following admission. They showed patients being involved in their care planning and risk assessments. Patients told us staff were caring and provided them with practical and emotional support. We saw staff treating patients kindly and with compassion. Staff had undertaken physical health examinations of patients on admission to the service.
  • Patients could give feedback about the service in weekly community meetings and in patient surveys. Patients had advance statements in place detailing their preferences for care and treatment.
  • Patients were able to personalise their bedrooms to reflect their taste and preference and could make drinks and snacks 24 hours a day if they chose to do so. There was access to a full range of rooms to support treatment and care.
  • The hospital was fully accessible for people with disabilities.
  • Rotas demonstrated adequate safe staffing levels.
  • There were no delayed discharges from the service.

8 October 2013

During a routine inspection

We spoke with 14 patients who were detained in the hospital at the time of our inspection. We spoke with nine patients on the downstairs ward and five patients on the upstairs ward. Patients gave differing feedback about their involvement in the care planning process. Patients in the upstairs ward indicated they were given the opportunity to be involved in their care plan. However, the patients we spoke with on the downstairs ward reported that they did not have the opportunity to be involved in the care planning process.

We asked patients for their opinion of the care and treatment they received. One patient said, 'They have turned my life around.' Another patient told us, 'I am nearing the point where I can be discharged. I would never have thought that possible.' All of the patients we spoke with indicated they felt safe at the hospital.

The downstairs ward was not of an appropriate standard of cleanliness. There were not effective systems in place to ensure the cleanliness of the hospital.

There were not effective systems in place to regularly monitor the quality of the service being provided. The patients we spoke with were frustrated that they were repeatedly raising the same issues and did not always receive a response in a timely manner. One patient said, 'We are always raising the same issues. We never hear anything back so we don't know what's happening.'

Records relating to patient's care and treatment were not always of the required standard.

6 March 2013

During an inspection in response to concerns

There were 21 people living in the hospital. We looked at the medicine administration records for eight people and how the service stored and managed medicines.

We were told that improvements had been implemented to ensure medicines were stored securely. We found medicines were stored safely and securely in the two units with access restricted to the person in charge of the unit.

We spoke with one person who told us 'I don't get given my medicines on time." We found that the Medicine Administration Record (MAR) charts documented that people were given their medicines at the prescribed times. We observed nursing staff giving people their medicines at the times that they were prescribed. However, we also found that when a medicine was not given the reason was not always recorded.

We spoke with a pharmacist from the supplying pharmacy. They explained about the support provided to the service to ensure medicines were handled safely. We were shown a folder called 'Pharmacy Audit Medicine Management'. These contained medicine audits which were undertaken every week by the visiting pharmacist. The pharmacist detailed specific action points to improve medicine management. We found that some of these action points had not been undertaken by the service.

We found that appropriate arrangements were not always being undertaken in order to manage the risks associated with the unsafe use and management of medicines.

9, 10 October 2012

During a routine inspection

For the duration of our inspection the Mental Health Act Commissioner spoke with, observed and was based on the ward downstairs. The expert by experience and the compliance inspector looked at the care and treatment being provided for patients on the upstairs ward.

Patients on these two wards had different views on their experience of care and treatment. This is unsurprising as there were a number of factors affecting the experience of patients on the downstairs ward, including a situation which was challenging for patients and staff alike. Steps were being taken to address and resolve the issue but the experiences had unsettled some patients on the ward. Patients on this ward commented more negatively about the service than those upstairs who were all very happy about the care they received, and one patient commented, "I have been in secure units for over 30 years and this is the best one I've been in."

Although staff took action to identify the possibility of harm or abuse and to protect people they were not following locally agreed safeguarding procedures in place by reporting incidents. This meant they were not taking appropriate action when incidents occurred.

Staff were supported in their role and complaints were recorded and responded to effectively.

16 January 2012

During a routine inspection

We visited this service as we had not been since their registration under the Health and Social Care Act. We wanted to be sure the people detained at the service received good, safe care, treatment and support and to check that the service was compliant. Throughout this report we will refer to the people detained at the service as "service users" or "people using the service." This is because this is their preferred term.

We spoke with three people using the service. They said they had seen their care plan, and said that the staff went through this with them and agreed it. One person told us the plans were reviewed roughly every two months.

People told us that many of the staff who worked at the unit were good at their jobs. One person told us that their co-ordinator had helped them prepare for their Mental Health Review Tribunal and had written down what they wanted to say and the issues they wanted to discuss. A person using the service told us there had been improvements in the consistency of the staff group. The person said that the manager tried not to use agency staff. One person commented, "there's lot of good staff in here. Some are like family to me."

People told us that restraint and seclusion were not used very often. One person explained that restraint had never been used with him, "because the staff know how to calm me down."

One of the people we spoke with told us he (along with another service user) was a patient representative. He told us they spoke to the unit managers to bring about improvements to the service. People using the service also told us that an ex service user came in every week to advocate of behalf of the people who use the service. We were told he saw people individually or in groups. The advocate attended the weekly 'community meeting' on both units.

Another person told us that the new unit manager was very good and had made significant improvements to the service. He told us, "he has turned this place around and he's turned me around too. Everyone knows where they stand with him which is good. He's always gone out of his way to come and talk to me and find out what I think about this place."

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.