Cygnet Kidsgrove Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

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

Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

We reviewed 4 patient care records whilst on site. It was not always evident that staff had completed a mental health assessment for all patients at admission with 1 new patient having most of their paper file incomplete 4 days after admission. We saw that staff in most cases had assessed patients’ physical health needs in a timely manner. We saw evidence that staff had completed physical examinations on admission and tailored treatment in response to this.

Staff developed care plans that met patient needs identified during assessment. They were comprehensive and holistic. However, all 4 care plans did not consistently include the patient’s voice and were not written in first person. Staff discussed patient care and treatment regularly and updated care records following incidents and multidisciplinary ward rounds which were held for each patient once a month.

Most patients could not remember being offered a copy of their care plan. It was not recorded in care plans if they had been offered or provided to the patient. However, patients were involved in care planning through their ward rounds, and we saw that their views were recorded in ward round notes.

Following feedback from community meetings the ward was in the process of implementing a monthly review meeting of care plans in which patients were invited to attend a one to one meeting with staff. Prior to this meeting, patients would be given a printed copy of their care plans which patients would be encouraged to complete either individually or with their key nurse / worker. This would then be fed back into the care plan meeting, reviewed and changes agreed and made within the meeting with the patient and / or their carer as appropriate. This new process had not yet been implemented at the time of the inspection.

One family member told us that care plans were not effectively shared with them despite their loved one agreeing to full disclosure. They stated that it would be useful to have if their loved one was returning home on leave to help understand the level of support they were receiving.

One patient was supported to communicate using text on a mobile phone as they did not verbally communicate. Staff had considered ways to include patients in their care planning such as through 1 to 1 session template sheets which were made available on the ward. However, we did not see examples in the care records that these had been effectively used at that time by patients.

The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well

Staff provided a range of care and treatment interventions suitable for the patients in the service. The team included a full range of specialists required to meet the needs of patients. As well as doctors and nurses, there was a full complement of multi-disciplinary staff including occupational therapists, clinical psychologists, social workers, activity coordinators, advocate and an expert by experience.

There was an occupational therapy programme in place which offered a variety of recovery-based activities for patients. These included activities crafts sessions, coping skills, yoga, pamper sessions and walking groups. Family members stated that they thought the patients would benefit from more activities off the ward such as walking groups as they were not aware of any that had taken place.

The ward had started to introduce the diamond framework and were in the process of training staff in delivering this new approach when we visited. The Diamond Framework was developed by members of the Multi-Disciplinary Team at another Cygnet Hospital. This is an assessment tool that is psychologically and trauma informed, where all staff members provide support either through their communication or through psychological interventions to support patients. Staff received training on this framework with a 60% completion rate at the time of the inspection. Although, staff told us that it was hard to attend the 3-day training program due to staff being pulled back on the ward to cover staffing issues.

Despite staff wanting to engage in training they could not always access it due to the pressures on the ward. Therefore, patients and a staff member told us that knowledge of areas such as autism and dialectical behavior therapy (DBT) were lacking in some of the newer staff. This had an impact on communication and boundaries between some patients and with staff members. Staff told us that nurses and members of the MDT had to step in to de-escalate incidents.

The ward held monthly staff meetings which staff could attend in person or online. There had been good attendance when the hospital had opened but leaders recognised that there had been a reduction in staff being able to attend due to staffing pressures and the timing of the meeting. The minutes from the meeting were shared with all staff and the ward manager had changed the time and structure of the meeting to include as many staff as possible.

Staff participated in both managerial and clinical supervision. In the month prior to our visit, 100% of staff had received clinical supervision and 92% had received managerial supervision.

Mental Health Act

The provider reported 94% of staff had received training in Mental Health Act Awareness.

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

Patients had easy access to information about independent mental health advocacy which was displayed in communal areas and discussed in ward rounds.

Staff explained to patients their rights under the Mental Health Act although one patient told us that this was not in a way that they could understand. Care records showed that advocacy support was requested and the advocate told us that they ensured that patients understood their rights and would support them to appeal their section if they requested.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted. The service did not display a clear notice to tell informal patients that they could leave the ward freely. When speaking to patients who were informal, they were able to leave the ward upon request. Staff told us they were also considering the use of a key fob to allow informal patients to leave the ward without having to seek out a staff member.

Staff informed us that they did find it difficult to access timely Approved Mental Health Practitioner (AMHP) support for informal patients who need to be assessed under the Mental Health Act. This resulted in them having to utilise other Mental Health Act powers to detain a patient if they had concerns for their immediate safety. This concern had been raised by the relevant local authorities,

Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.

Staff requested input from a second opinion appointed doctor when necessary although we were told that there had at times been delays in this despite the hospital making timely requests.

The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held a morning meeting to discuss patients and improve their care. The morning meetings took place with a range of staff from the MDT including psychology, nursing and occupational therapy. These meetings were effective in discussing a range of issues including changes to clinical risk, incidents, changes in observation levels, leave, medication and patient views. We observed a morning meeting where staff were engaged and were able to discuss in detail each patient and any changes in their needs.

Each patient had a ward round every 4-weeks where their care was discussed in detail, and their relatives and all professionals involved in their care were invited. People could attend virtually if they could not attend in person. Two family members stated that the invite to wards round was not always consistent with one family member stating that their opinion was sometimes dismissed during meetings.

Leaders stated that they had good links with the local doctor’s surgery and all patients were registered with the local GP. The ward had an email address for the surgery so that they could make direct contact. The doctor’s surgery had previously sent staff to attend ward rounds but this had recently stopped when the Physical Health lead nurse had left.

Commissioners told us that there was good communication from the ward who were open and honest about incidents. They were receptive to feedback and implemented changes following discussion.

The evidence showed some shortfalls. The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Patients had access to healthy snacks and drinks. Health and wellbeing activities such as yoga and breathing meditation were also offered. Staff told us how some patients were following a healthy eating plan so were preparing some of the own meals independently. Patients were able to make their own food and drinks in the activities of daily living (ADL) kitchen on the ward. Two patients and a family member all said that an onsite gym would be beneficial. A family member stated that they had complained about the lack of physical activity available for their loved one on the ward and following this a personal trainer had been on the ward to see patients. However, another family member told us that they had had to prompt for the staff to reorder medication as nursing staff had forgotten. They felt that there was no encouragement around healthy lifestyles and that their family member had to take their own initiative.

The hospital promoted healthy eating by encouraging a healthy diet. Catering staff took onboard feedback and would provide an alternative for patients who did not like the first option.

It was not clear that staff understood the importance of consistently monitoring physical health needs. Patients had shared that they were not always listened to around physical health conditions and they struggled to find staff to speak to. The advocate told us that patients who had a headache had shared that they had waited hours for pain relief and that this was an ongoing issue. The same had been said about access to clean bandages with doctors being asked repeatedly before these were provided.

We saw in one care plan that bowel monitoring charts had not been consistently recorded for a patient. After investigation it was found that these had been completed but not stored in one accessible place so it was not clear to all staff that this had been completed. This had been rectified since our site visit.

The service was recruiting for an additional physical health nurse. It was unclear who had been taking on this role during the period of recruitment.

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff used recognised rating scales to assess and record severity and outcomes. Their main outcome measure was the fu MOHOST (MOHOST)assessment tool. They also used the Global Assessment of Progress tool (GAP).

Psychology outcome measures used include psychometrics which are considered with the patient. These included, Difficulties in Emotion Regulation Scale (DERS), the PTSD Checklist (PCL-5 a standardised measure of post-traumatic stress disorder (PTSD) symptoms that is based on the Diagnostic and Statistical Manual of Mental Disorders-5 criteria.), impact of event scale (IES-R) the Rosenberg self-esteem scale, Beck Hopelessness Scale (BHS), Beck Suicide Scale (BSS), Beck anxiety and depression scales, Eating Disorder Questionnaire, Fears of Compassion Scale, Self-compassion Scale, and Beliefs about voices Questionnaire. The ward used these as pre and post measures to monitor outcomes, and due to longer stays on the ward, as a mid-point progress review.

Leaders were monitoring the impact of Diamond Framework Training on incidents levels across the ward. The incident data collated in October and November showed a 44% reduction in incidents (66 incidents October, 37 November) and that PRN usage had reduced by 65%. Although they were aware of other factors which may also impact upon these figures.

Care notes, however, did not include clear information on outcomes that were accessible for the patient. Leaders told us that the psychometrics were scored and an interpretation made, which could then inform treatment planning. This was recorded on the daily notes and additionally shared with the patient. Most patients spoken to were not aware of these outcomes.

The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff had good awareness of patient’s rights around consent to care and treatment. Staff took all practical steps to support patients in making their own decisions. They ensured patients had the relevant information to fully understood what they were consenting to.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis regarding significant decisions.

Most patients were aware of their rights and remembered these being read to them. The advocate who visited the ward also ensured that patients understood their rights under the Mental Health Act and supported people to appeal in line with their wishes. An informal patient was clear around their right to leave the ward. However, information around informal patients’ rights to leave the ward was not clearly displayed.