Cygnet Hospital Oldbury

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated Requires improvement

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.

The service was in breach of regulation for safe care and treatment as the provider did not always detect and control potential risks in the care environment and did not always make sure the equipment and facilities supported the delivery of safe care

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 knew what incidents to report and how to report them. The hospital followed the provider's policy on incident reporting. We reviewed 3 incident reports that showed staff had taken appropriate action in each instance and records were completed fully and accurately.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Managers investigated incidents thoroughly and supported staff following incidents through debriefs and reflective practice. Staff told us that debriefs did not always take place after every incident but that leaders were supportive. Governance records showed that leaders recognised debriefs did not always take place and had taken action to ensure these occurred.

Staff received feedback from investigation of incidents, both internal and external to the service. We saw evidence that incidents were discussed in staff meetings and in governance meetings. Staff gave us examples of recent learning and changes made to the service following investigation and lessons learnt. This included changes in ward search protocols and increased training.

Staff met to discuss the feedback and look at improvements to patient care. Staff discussed individual incidents at handover and in the morning multi-disciplinary meeting.

Managers shared learning with their staff about never events that happened elsewhere. The manager shared learning from other services, ensuring that information was cascaded across the team.

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 had clear acceptance processes for admission and managers told us that they would only accept referrals if the service could clearly meet their needs and that they felt supported by senior leadership when making these judgements. Managers told us that they were honest with referrers and commissioners regarding their decisions for non-acceptance.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. External partners such as local mental health teams and other representatives within the patients care team were involved within the care plan and invited to multi-disciplinary meetings.

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.

All patients we spoke with told us that did not always feel safe on the wards due to the acuity of other patients but that they did feel able to discuss their concerns with staff. Leaders were aware that patient conflict was an area of concern and were taking action to address this.

Staff we spoke with had good knowledge about safeguarding and any potential safeguarding concerns were discussed in morning risk meetings, handovers, clinical governance and multidisciplinary meetings.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff kept up to date with their safeguarding training. They were 100% compliant in mandatory safeguarding training.

All staff that we spoke to knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns.

The hospital had a designated safeguarding lead who met weekly with other safeguarding leads within the organisation. Staff told us that they had good relationships with local safeguarding structures and had regular engagement with the local authority safeguarding teams.

Staff followed clear procedures to keep children visiting the ward safe. Staff assessed potential risk and considered any child protection issues. A visiting room was available outside of the ward and staff were available if needed.

Staff explained the safeguarding procedures to patients on admission and patients had access to relevant information.

The hospital monitored the use of restraint and restrictive interventions and worked closely with staff to ensure they were appropriately trained and up to date with relevant practice and policy.

Staff regularly reviewed blanket restrictions and when in place were clinically justified. We saw that audits were completed on a 3 monthly basis.

All the wards had outside space that patients could access. On Rosa ward the garden was easily accessed via the communal area and during our inspection we noted the doors to always be unlocked and staff within the area observing. However, patients on Emmeline ward did not have direct, unrestricted access to outside space as the ward was located on the first floor of the building. Staff told us they mitigated this by ensuring that they supported patients to go into the garden on request.

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 6 electronic care records. Staff completed risk assessments on admission, reviewed them during monthly ward rounds and updated them after incidents. Staff discussed incidents during handovers and the morning meeting.

Most patients we spoke with said they felt supported to understand their risks and keep themselves safe although some said they were not always fully involved with their care and treatment and felt that treatment was done to them as opposed to with them. We did observe that some patients had chosen to display how they wished to be supported on their bedroom doors.

We spoke with 3 carers. All carers we spoke with felt involved in care plans and treatment with their relative's consent, and most said they had been invited to attend ward rounds and other meetings about their relative's care.

Staff told us that they were committed to reducing restrictive practices. Members of the multi-disciplinary team attended weekly regional consultant peer group meetings to promote learning across sites and generated shared strategies to further reduce restrictive interventions.

Staff told us they made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe.

Patients told us that they had been restrained. Some patients told us that they understood why these had occurred and that they believed they had been carried out correctly by staff. Two patients told us that they did not like being restrained by male staff.

In the 3 months prior to our assessment there were a total of 125 restraints: 30 restraints on Emmeline and 90 restraints on Rosa. Of these restraints 0 were in the prone position, 12 were in supine and the remaining restraints were low level. Restraints were reviewed by managers and discussed monthly within clinical governance. Leaders discussed themes and regular occurring issues. Leaders were aware of staff reporting incorrectly and not always documenting debriefs that had taken place with patients.

In the 3 months prior to our assessment there 4 episodes of seclusion. These were all below 12 hours.

All patients we spoke to on Emmeline ward told us that they were not given the opportunity to give feedback. However, we did see evidence of weekly community meetings that were well attended by patients and detailed feedback was given. The meeting minutes did not always reflect what actions had been taken by staff however the hospital had implemented monthly "You said, we did" posters that summarised the feedback given and what action had been taken or was being taken.

Staff ensured that patients could access advocacy. All patients told us that they knew who advocates were and that they visited regularly. An advocate was visiting the wards when we inspected.

We do not always detect and control potential risks in the care environment and do not always make sure that the equipment, facilities and technology support the delivery of safe care.

Although staff completed and regularly updated environmental and ligature risk assessments, staff had not identified potential environmental risk and risk items in some areas. On the day of our inspection a patient informed us that there were items of risk within the Emmeline garden area that could be used to self-harm. We informed senior staff who removed the items immediately and performed an additional examination of the area. As the hospital was newly opened, significant building and renovation work had been completed within the grounds. Items of risk, including a small wire coil and small pieces of glass and ceramic had been embedded within the soil. Staff told us that prior to opening, extensive assessments of the grounds had taken place both visually and with metal detectors and that they completed security sweeps on a regular basis.

Within the garden area we also noted that there was a blind spot not covered by CCTV cameras. We informed the manager who immediately took action and requested an additional camera to rectify this issue.

Fire extinguishers were located within locked cupboards however there were no signs to indicate where they were kept. Staff told us that signs had been removed by patients and that new stickers had been purchased that could not be removed easily.

The service assessed and managed ligature risks well. The service had completed a ligature risk assessment for the whole building which was detailed and had clear actions. Staff were aware of ligature anchor points on the ward and mitigated the risks to keep people safe. Patients' bedrooms were fitted out to a high standard with anti-barricade doors and anti-ligature features.

All communal ward areas were clean, well maintained, well-furnished and most items were fit for purpose. The garden seating furniture was hard plastic and dipped in the middle and so gathered rain water which made them unusable. The service was aware that this was an issue and had requested new furniture.

We did see that store cupboards used to keep patients belongings were untidy and over filled. One patient told us that they were aware of this and they worried their belongings were not being kept safe due to the disorganisation of the storage. When advised of this the manager took immediate action was to rectify this and all areas were cleaned by the following day.

The ward layout did not allow staff to observe all parts of the ward, but this was mitigated through convex mirrors and staff observations. The nurse station on Emmeline ward was located on a corridor away from the communal areas. At the time of our inspection the window had been damaged by a patient and was boarded up. This meant that there was no visibility of patients on this corridor. Patients told us during the days prior to the inspection, staff were not as accessible as the board prevented them from speaking or making eye contact with staff through the window. The manager informed us that a new window had been requested and hoped this would be fitted within a week.

Staff had easy access to alarms and patients had easy access to nurse call systems. Following feedback from patients that alarms were too noisy, the hospital had reviewed the alarm system and had implemented silent alarms which vibrated instead. Patients told us that this had been a success and had a positive impact on their wellbeing. Staff told us that they had no issues with the alarms and that response time had not been affected.

A seclusion room was situated on Rosa ward. The room allowed clear observation and two-way communication and had toilet facilities and a clock. We saw some issues with the environment within the seclusion room including part of the smoke detector had been removed and not replaced, a chair did not have a cover and the privacy screen to the bathroom was not functional. We informed the manager about our concerns who immediately decommissioned the room until actions were rectified. These had been actioned by the third day of our inspection.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. We found that all equipment was in place, and most were in date or had check stickers on them. During the inspection we found some that the sharp bin on Emmeline ward had not been labelled and there was 1 expired blood bottle. Staff actioned these issues when informed on the day of inspection.

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 looked at the staffing figures for the service. At the time of the inspection the service employed 52 staff. The vacancy rate was low. There was 1 vacancy for a registered nurse and 3 vacancies for healthcare assistants. The multi-disciplinary team was fully staffed.

Managers had calculated the number and grade of nurses and healthcare assistants required. Agreed staffing levels varied dependent on the ward. We reviewed staffing rotas for the 6 weeks prior to our assessment. No shifts were short of staff and were generally over the agreed established numbers due to ward activity and acuity.

Ward managers could adjust staffing levels to take account of levels of acuity on the wards. When necessary, managers deployed bank staff to maintain safe staffing levels and they received an induction and were familiar with the ward. The service did not use any agency staff.

During our inspection we observed staff were present in the communal areas of the ward at all times. Patients told us that staff were not always visible or available and they often felt that some staff hid away in the nursing station. Managers told us that they were aware of this concern and had been proactive in monitoring this.

Staff said shortages rarely resulted in staff cancelling escorted leave or ward activities. Staff told us that leave would be rearranged. There were enough staff to carry out physical interventions safely such as observations and restraint and staff had been trained to do so.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had received and were up to date with appropriate mandatory training. At the time of our inspection overall mandatory training compliance was 96% The course with the lowest compliance was Safety Intervention Training at 87% however we saw evidence that staff outstanding had been booked onto specific dates. The training was appropriate for the patient group using the service and managers told us of specialist training that had been implemented to meet the needs of patients such as Emotionally Unstable Personality Disorder (EUPD) training and the development of specialist activity training to be used as means of de-escalation and distraction.

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

All ward areas were clean, had good furnishings and were well-maintained. All patients were very complimentary about domestic staff and told us that cleaning took place very regularly and effectively.

Staff ensured that cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

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.

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.

Staff followed good practice in medicines management. They followed systems and processes and safely stored, prescribed, dispensed, administered and recorded medicines in line with national guidance. All clinic rooms were clean and staff had access to all appropriate equipment. We saw staff administer medicines safely to patients and complete relevant documentation. Staff reviewed each patient's medicines regularly and provided advice to patients and carers about their medicines.

Staff completed medicines records accurately and kept them up to date. We reviewed 9 patient's medication and physical health records. Staff completed them fully and accurately.

Staff stored and managed all medicines and most prescribing documents safely. We saw that Consent to Treatment Certificates were not always stored appropriately. On Emmeline ward we saw that all previous and current certificates were stored together. Staff actioned this immediately and archived previous certificates and ensured only the current certificates were stored with the prescribing documentation.

Staff followed national practice to check patients had the correct medicines when they were admitted, or they moved between services.

Staff reviewed the effects of medication on patients' physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of anti-psychotic medication.

Staff learned from safety alerts and incidents to improve practice. We saw that medication errors were discussed in daily meetings, within clinical governance and lessons learned cascaded.