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Inspection carried out on 21 April 2021 to 22 April 2021

During a routine inspection

Cygnet Acer Clinic provides care and treatment to female patients. Most patients have a diagnosis of emotionally unstable personality disorder and present with challenging behaviours including self-harm.

Cygnet Acer clinic was placed into special measures by the CQC Chief Inspector of Hospitals in August 2019. 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 through inspection and engagement meetings and has found sustained improvement in the safety of the service. 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 good because:

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed ligature risk as well as other risks including the proper use of fire registers. 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 cared for in a mental health rehabilitation ward and in line with national guidance about best practice. The service uses the global assessment of progress and daily living skills observation scale. Staff used a model of care called ‘Enabling environments’ which has five principles for the patients to achieve successful discharge. This is used within the Cygnet hospital group.
  • 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 community teams 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.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The service worked to a model of mental health rehabilitation specific for patients with emotionally unstable personality disorders. It was well led, and the governance processes ensured that ward procedures ran smoothly.

However

  • Staff reported that there was a lack of dedicated, non-bedroom space, available to facilitate de-escalation of a patient in distress.
  • When speaking with carers they have found staff didn’t communicate with them as often as they would like.

Inspection carried out on 25-27 August 2020

During an inspection looking at part of the service

Cygnet Acer Clinic provides care and treatment to female patients. Most patients have a diagnosis of emotionally unstable personality disorder and present with challenging behaviours including self-harm.

This was a focussed inspection in response to a serious incident and other safety concerns at the hospital. We did not look at all key lines of enquiry in each of the domains. The overall rating remains requires improvement and the hospital remains in special measures.

 The hospital did not have a good track record of serious ligature incidents that resulted in severe harm to patients or death. It was not always clear from staff discussion how they developed and reviewed actions to better manage incidents at the hospital. The electronic incident management system required further development to ensure incidents were recorded and managed correctly.

 It was not always clear that governance processes maintained oversight of actions to ensure they improved quality and safety at the hospital. We identified a number of areas where the provider still needed to make improvements.

Staff practice to complete the fire register remained poor. This meant the fire register did not always provide an accurate record of where and when staff were on duty or the staffs whereabouts in the event of an emergency.

Patients raised concerns about staff engagement with them and the way staff provided support, particularly during incidents or periods of distress.

However:

Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.  The provider assessed and managed risks associated with the COVID-19 pandemic well.

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 cared for in a mental health rehabilitation ward and in line with national guidance about best practice.

Staff 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 and supervision. Staff worked well together as a multidisciplinary team and with those outside the hospital who would have a role in providing aftercare.

Staff understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

Staff planned and managed discharge well and liaised well with services that would provide aftercare.

Inspection carried out on 18 and 19 March 2020

During an inspection looking at part of the service

  • Due to Covid 19 it was not possible to inspect the hospital on site. However, information was gathered remotely to see whether the service had made improvements since our last comprehensive inspection in October 2019. We focused on the areas highlighted as requiring improvement from our last inspection as outlined in the warning notice we issued to the provider, and other areas of concern that had been raised since our last inspection. We did not inspect all areas and so the ratings have not been changed. The hospital remains in special measures.

  • The service had made the required improvements outlined in our warning notice, issued following our last comprehensive inspection. However, some further work was still needed.
  • The wards 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 cared for in a mental health rehabilitation ward 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. The ward staff worked well together as a multidisciplinary team and with those outside the ward who had a role in providing aftercare.
  • Records demonstrated patients were involved in the development and review of their care plans.
  • The service was well led, and the governance processes ensured that ward procedures ran smoothly.

However:

  • Whilst there had been improvements in how staff carried out the observation of patients, there was still more to do.
  • Patients gave us mixed feedback about staff attitude towards patients. Not all patients said that staff understood the individual needs of patients or supported patients to understand and manage their care, treatment or condition.
  • Staff did not always inform and involve families and carers appropriately.

Inspection carried out on 11 and 14 October 2019

During a routine inspection

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

  • The service did not consistently provide safe care. Staff did not always maintain complete records of clinical cleaning and equipment maintenance checks. This included cleaning of portable physical healthcare equipment and checks of emergency equipment.
  • There were discrepancies between the systems used to monitor staff attendance within the service. This made it difficult to confirm the exact number of staff on duty to maintain safe staffing levels.
  • Staff did not always follow the provider’s observation policy and procedures to ensure patients risks were safely managed. This included missed observations and inaccurate records of observations.

  • Staff did not always keep complete records of medicines management. This included records of drugs liable for misuse and medicine self-administration records.
  • Staff treated patients with compassion and kindness, but did not always respect their privacy and dignity, Patients raised concerns about staff attitudes towards them and engagement with them. We saw staff did not always maintain the confidentiality of patient information.
  • The governance of the record keeping in the hospital was not effective. Although the service had made improvements in the safety of the service since our previous inspection, the systems used to accurately identify, understand, monitor and reduce or eliminate risks required improvement.

However:

  • Safety risks were being addressed. The service had addressed safety issues identified in the last inspection and the wards had been subject to a thorough Manchester ligature risk assessment and remedial works to reduce identified risks.
  • Staffing levels for qualified nurses had increased since the last inspection.
  • Staff provided a range of treatment and care for patients based on national guidance and best practice. This included access to psychological therapies, support for self-care and the development of everyday living skills and meaningful occupation. Staff supported patients with their physical health and encouraged them to live healthier lives. Staff used recognised rating scales to assess and record severity and outcomes.
  • 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 well and liaised effectively with services that would provide aftercare. As a result, discharge was rarely delayed. The service worked to a recognised model of mental health rehabilitation.

Inspection carried out on 19, 20 and 28 August 2019

During a routine inspection

We undertook a focused inspection of Cygnet Acer Clinic, looking at only the safe and well-led key questions. This inspection was undertaken following a serious incident and other information of concern we received.

We rated safe and well-led at this service as inadequate. This means the service is now rated as inadequate overall. The rating for these key questions is limited to inadequate due to the enforcement action we have taken. During this inspection we served notice on the provider under section 31 of the Health and Social Care Act 2008 to urgently impose conditions on the registration of this service. This was due to the serious concerns we found that affected the safety of patients and placed patients at risk of avoidable harm. The urgent conditions included stopping the service admitting any new patients.

We found:

  • The service was not safe. The number of incidents of self harm by patients had increased significantly in the three months before the inspection. Almost half of the incidents during that time had involved patients using a ligature. The ligature risk assessments for the wards was too generalised and unstructured and did not include all ligature anchor points on the wards. Service leaders and staff had not effectively minimised the risk of serious harm to patients.

  • Over 75% of nursing staff were unqualified. This was not an acceptable skill mix of staff to provide care and treatment to up to 28 patients with complex needs and behaviours. On 60% of shifts there was only one registered nurse on each ward. Senior nursing staff did not recognise that having only one registered nurse on shift, particularly in Upper House, did not provide the skills mix required to support the complex needs of patients.

  • On at least four occasions during the inspection patients congregated on the ward, in front of the reception area, banging on windows to attract the attention of staff who were not on the ward. Staff were not available to support patients when they needed them.

  • When patients’ risks increased this was not always communicated clearly and documents contained different information. The clinical team did not always respond appropriately when patient risks were escalating. Patient risks was not always managed well, particularly on Upper House which had seen a dramatic increase in incidents of self harm.

  • When staff observed patients intermittently, this was undertaken at fixed times. This meant patients could predict when staff would check on them. This increased the risk of self harm by patients in between those fixed times.

  • The wards were large and spread over two floors. With bedrooms on both floors, the layout of Upper House hindered staff observations of patients. Senior staff had not reviewed the environment to identify ways to increase the observation of patients whilst also maintaining their privacy and dignity.

  • Staff worked shifts of 12 or more hours per day or night, in some cases, working up to seven days without a day off. Working these hours for four or more days and nights, without a day off, was not best practice, particularly with a patient group with such complex needs and risk behaviours.

  • At least two staff who had worked in the service for two or more years had not undertaken face-to-face training on working with people with personality disorders. There was a risk that staff did not have a good understanding of how to work effectively with patients with personality disorders. There was a risk that long-standing staff who had not undertaken this face-to-face training would not be able to fully support newly appointed support workers.

  • Leaders in the service did not consistently demonstrate that they had all of the skills and knowledge to manage the service safely. Following a patient death and feedback from a visit by the local clinical commissioning group, the June 2019 ligature risk assessment had a short addendum highlighting one further type of ligature risk. Other ligature risks were not identified or risk assessed. Investigations and reviews of incidents by senior staff had not always maximised the opportunity for learning from these incidents. Important areas of learning were missed.

  • There had been no analysis of themes or trends of self harm incidents in the service. These were the most frequent type of incident in the service and such an anaylsis should have been in place.

  • A staff whistleblower had contacted the Care Quality Commission in May 2019. Two further whistleblowers contacted us during the inspection. They reported low staffing levels, a lack of support from managers, and a lack of action by managers when they raised concerns.

However:

  • There were clear processes for dealing with complaints, monitoring safeguarding referrals and making statutory notifications to the Care Quality Commission.

  • Although staff restrained patients 91 times in the three months before the inspection, none of these restraints were in the prone position. This followed best practice guidance due to the risks to patients when restrained in the prone position.

  • Patients were able to progress to self medicate on Upper House and Lower House. This involved a clear system of multidisciplinary reviews to ensure any risks to patients were minimised.

  • Following the imposition of conditions on the provider they conducted an analysis of self harm incidents including themes and trends. When we returned to the service on 28 August for the last day of this inspection we saw that the provider was acting on this information to minimise incidents when they were most frequent. The provider also took other immediate action concerning staffing levels, staff training, the environment and the risk management of patients.

Inspection carried out on 1 and 2 October 2018

During a routine inspection

We rated Cygnet Acer Clinic as good as because:

  • Staff completed and updated risk assessments for each patient and used these to understand and manage risks individually. Staff supported patients to make their own decisions about their care and staff assessed and recorded capacity clearly. Care plans were personalised, holistic, recovery orientated and up to date. Patients had been involved with writing them.
  • Staff understood their roles and responsibilities under the Mental Health Act (1983) and the Mental Capacity Act. The completion rates for training were 100%. Staff used restraint as a last resort and had positive behavioural plans in place to help patients develop strategies to manage their challenging behaviour.
  • The hospital was visibly clean, and furniture was in good order. Domestic staff cleaned all areas of the ward regularly and both clinic rooms were clean. Staff stored medication correctly and they carried out daily checks on equipment.
  • Staff understood what abuse was and how to report it. Safeguarding training was 95%.
  • Patients accessed independent advocacy services and staff supported and encouraged them to access services in line with the Mental Health Act Code of Practice.
  • The team included a good range of specialists to help meet the needs of the patients.
  • Patients had rooms with ensuite facilities which they were able to personalise.
  • Staff worked with individual patients to maximise the amount of time they could spend in the community accessing various groups including educational facilities, animal help groups, personal support groups and charities.

However:

  • Staff had not updated the current ligature risk assessment since access to two areas had changed, and staff had not changed the risk assessment to reflect the change.
  • There was a raised level of complaints and concerns about staffing levels and staff attitudes towards patients.
  • We observed in two out of 10 patient notes staff had identified concerns but no care plans written to action or support the concerns..

  • No all appropriate information was displayed in patient areas to inform patients of the complaints procedure, how to contact the CQC, provide information on mental health. Nor information for informal patients about their right to leave,the manager rectified this once informed

  • The provider should improve the engagement of staff in knowing the vison and values of the organisation.
  • The provider should ensure there is sufficient staff on the wards to facilitate patient activities including one to one sessions and planned leaves.
  • The provider should ensure that SOAD is requested when required in order to ensure the correct authorisation for treatment is in place.

Inspection carried out on 19 July 2017

During an inspection looking at part of the service

  • The manager and head of care were visible on the ward, were accessible to staff and were proactive in providing support.
  • The culture on the wards was open and encouraged staff to bring forward ideas for improving care.
  • Staff carried out a risk assessment of every patient before and on admission. Staff updated the assessments daily and reviewed them after an incident.
  • Observation of the ward and patients was good.
  • Staff were caring and treated patients with dignity.
  • All staff had completed mandatory training and had access to further specialised training.
  • Staff updated patient care plans regularly. Patient care plans showed staff engaged with patients.
  • Staff understood the safeguarding process and took appropriate action when necessary.
  • The manager completed a ligature risk assessment yearly which outlined plans and actions to reduce the ligature points. However, the ligature points had not been clearly identified.

Inspection carried out on 4-5 May 2016

During an inspection looking at part of the service

We rated Acer Clinic as good because:

  • Patients told us it was good. Patients told us staff were kind and supportive and helped them get better.
  • Staff assessed risks using recognised risk assessment tools.
  • Care plans were recovery-focused and acknowledged patients’ strengths.
  • Patients were involved in their care plans.
  • Staff measured patients’ progress using a recognised outcome measure called Health of the Nation Outcome Scores (HoNOS).
  • Patients had input from a psychologist who provided them with psychological therapies.
  • Staff managed and stored medicines safely.
  • Medicines charts had the appropriate authorisations including consent to treatment certificates.
  • Staff undertook clinical audits.
  • Managers consistently maintained staffing levels.
  • Staff received clinical supervision regularly.
  • Staff made safeguarding alerts appropriately and in a timely manner.
  • Staff reported and recorded risk incidents accurately. The provider had governance systems for analysis of risk incidents. The risk register was up-to-date and accurately reflected the risks present.
  • The provider mitigated blind spots for observation with convex mirrors.
  • Mental Health Act 1983 documentation was accurate.
  • Mental Capacity Act assessments were taking place regularly.
  • Staff compliance with mandatory training was high.
  • Staff commitment to continuous improvement was evident.
  • Staff effectively balanced positive risk-taking with identified potential risks.
  • There was clear learning from complaints and risk incidents.
  • The provider had satisfactorily addressed all the issues highlighted in our inspection in November 2015.