All inspections: Cygnet Joyce Parker Hospital

We did not rate this service.

We carried out this inspection in response to concerning information received through our monitoring processes.

We found the following areas of good practice:

Staff involved children, young people and their families in risk assessment, risk management and care planning. Staff made sure the children and young people could access advocacy services when they needed to.
Staff supported, informed and involved families or carers.
Staff continually assessed the physical and mental health needs of all children and young people during their admission. They developed individual care plans, which the multidisciplinary team reviewed regularly and updated as needs changed. Young people reported staff used medication to sedate them less than in previous hospitals.
The ward had enough nursing and medical staff, who knew the children and young people. Staff completed and kept up to date with their mandatory training.
The provider’s governance processes were effective in identifying when staff had not reported and completed incident reports accurately.

However:

Young people did not always understand their restraint reduction risk management plans. This resulted in some feeling that staff did not care about them because they did not respond with immediate restraint techniques when the young people were attempting to harm themselves.
Not all young people felt staff treated them with kindness and compassion. Young people felt their privacy and dignity was compromised because there were often more male support workers than females working on the ward.

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

Not all staff were discreet, respectful, and responsive when caring for children and young people. We identified one incident of staff not treating a young person with dignity and respect on Pixie ward. Children and young people said staff did not always treat them well and behave kindly. Six young people across Mermaid and Pixie wards raised concerns about how staff treated them.
Staff did not always follow best practice in managing distressed and agitated behaviours. We were concerned about the frequency of use of rapid tranquillisation for one young person which meant the young person was being sedated on an almost daily basis. When a child or young person was placed in seclusion, staff kept clear records but did not always follow best practice guidelines. We reviewed six seclusion records across Mermaid and Dragon wards and identified three concerns in relation to the use of seclusion.
Not all wards were safe. We identified potentially risky items on Pixie ward and issues with the seclusion rooms on Dragon and Mermaid wards. Staff on Dragon ward did not always complete weekly emergency bag checks and did not always complete cleaning records for the clinic room.
Our findings from the other key questions demonstrated that governance processes did not always operate effectively. Service governance systems failed to identify one concern relating to prolonged seclusion. Managers had not applied sufficient scrutiny, sought external assurance or a second opinion to support the care and treatment of a young person with complex needs who was frequently administered rapid tranquilisation medication.

However:

Staff involved children, young people and their families in care planning and risk assessment. Staff made sure children and young people could access advocacy services. We observed effective advocacy involvement on all wards. Staff supported, informed and involved families or carers.
Staff assessed the physical and mental health of all children and young people on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed.
The service had enough nursing and medical staff, who knew the children and young people. Staff completed and kept up-to-date with their mandatory training.

Cygnet Joyce Parker hospital is provided by Cygnet Healthcare Ltd. The hospital provides care and treatment for children and adolescents between the ages of 12 and 18. This was a planned comprehensive inspection to follow up on our previous inspection and enforcement activity.

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

Two of the three seclusion rooms were out of use due to damage. Maintenance staff informed us the materials that were needed to repair these areas were on order and that they would be repaired as soon as they arrived. We were informed shortly after the inspection that the rooms had been repaired and were able to be used.
Not all care plans contained input from the young person and were not always written in collaboration with the individual. Every young person had a range of care plans covering all aspects of their care. As part of the care plan package for each young person, all positive behavioural support care plans had been created in collaboration with the young person, however other care plans had not.
We identified some blanket restrictions across the unit. Children and young people could not make their own hot drinks and snacks on Mermaid and Pixie wards which meant they were dependent on staff. We also found young people were not given keys to their bedrooms which meant they could not access them without a member of staff. We were told that this was due to risk management factors.
The provider had not addressed breaches in regulations, around blanket restrictions, from previous inspections. At our previous inspections we also found that there were blanket restrictions in place concerning access to bedrooms.

However:

All staff were given a complete induction before they started working with young people. In cases where new starters had not worked in healthcare or with young people before, they were given formal independent training with an external education provider.
The service provided a range of care and treatment options. There were regular multi-disciplinary team meetings and review meetings to ensure that care and treatment plans fully met the needs of the young person.
We observed that staff were caring, discreet and respectful. We saw high levels of positive staff interaction with young people. Young people were supported to understand and have input into their own care. People were encouraged to give feedback on their carer and the service in general. Carers and young people we interviewed were complimentary of the service and spoke highly of staff and management.
Staff and young people we spoke with were complimentary of senior managers and stated that they were visible and approachable. They also stated that they felt that they were listened to by managers.

We rated this location as requires improvement because:

The service did not always provide a safe care environment. Staff assessed risk well, but it was not always managed well. The structure of the ward environment on Mermaid ward was not always safe for all patients and there was not a clearly designated female only lounge area on either ward. Staff did not always complete and record physical health observations properly. We saw staff had left keys and alarms unattended and not secure in the reception area. There were still a number of incidents taking place, although moderate incidents had reduced. Staff continued to tell us that not all staff were confident in managing incidents. There had been two incidents take place after our inspection that the service had not notified us about without delay.
Not all staff had significant experience in working with young people in a hospital environment. The service had identified and planned extra training to support staff, but this needed to be completed.
Not all staff understood competency and capacity issues relevant to the patient group they worked with. There were blanket restrictions in place, where restrictions not been assessed individually for each patient.
The design, layout, and furnishings of the wards did not always ensure the hospital met all of the patients’ needs.
Our findings from the other key questions did not always demonstrate that governance processes operated as effectively as they should have done, and this sometimes affected the quality of treatment and safety of patients.
Not all families and carers felt the hospital staff communicated with them as well as they could do and did not always provide them with all the information they required.

However

The ward environments were clean. Staff followed policies and procedures to keep patients safe in the Covid-19 pandemic.
The wards had enough nurses and doctors. Staff managed medicines safely and followed good practice in respect of safeguarding. Staff reported incidents and there was shared learning and debriefs after these.
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.
Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. The ward team had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.
Staff understood their roles and responsibilities under the Mental Health Act 1983 and had received training in this. Staff supported patients to make decisions about their care for themselves. Staff assessed and recorded consent and capacity.
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 could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

We carried out a focused inspection of Mermaid ward after staff raised concerns with us. At the time of our inspection the service had made some improvements in respect of these concerns.

We did not rate this service at this inspection.

The service did not always have enough staff to ensure there were the right number according to the hospital’s staffing requirement.

Staff were new to their roles and not all staff were confident they had enough staff or experience to respond to emergencies or incidents. There was a period of increased incidents on the ward where the ward was chaotic. This resulted in an increase of assaults on staff, a rise in patients self-harming, and security breaches took place.

The ward environment was not always robust enough. There were patients who had damaged aspects of the ward and had caused harm as a result of this.

There were some effective governance processes, but these were not consistent. For example, there were lapses in management of the staff rota and staff inductions had not always covered all key areas. This meant not all staff were well prepared for their roles.

However:

The ward environments were clean, and staff followed policies and processes to keep staff and patients safe from COVID-19. Staff regularly assessed patients’ risk and recorded this, they minimised the use of restrictive practices and followed good practice with respect to safeguarding. Staff reported incidents and learned from these.

Senior leaders understood the service. Senior leaders acted following the increase in incidents and whistle blowing concerns. Staff were able to give feedback and knew how to raise concerns.

We did not change the ratings of Cygnet Hospital Coventry at this inspection because this was an unannounced focused inspection to check specific concerns that staff had raised with the CQC. The ratings of the previous inspection therefore remain in place.

At the time of this inspection the hospital had conditions in place on the providers registration which were previously imposed after the CQC comprehensive inspection in July and August 2019. The conditions we placed upon the provider’s registration in 2019 required the provider to close one ward and cap admissions to existing wards. Following the inspection in March 2020 and further enforcement action, the provider voluntarily closed another ward. They also made the decision prior to this inspection in June 2020 to temporarily close the hospital by the end of July 2020. The provider was hoping that the temporary closure of the hospital would enable them to address the culture of the hospital and to develop a staff team which worked well together to meet the needs of the patients.

At this inspection we inspected specific areas of the safe, effective, responsive and well led domains. We wanted to check that patients were being cared for safely during the run up to the temporary closure of the hospital and were largely assured this was the case although there was more to do. This is what we found:

Documentation for patient observations was not fully completed, although we were assured that patients were being observed correctly and safely.

Staff completing risk management plans had not documented all identified patient risks and how they were to be managed. This meant staff might not know of appropriate interventions to use to keep patients safe and minimise risk.

However:

The service had enough nursing and medical staff to keep patients safe from avoidable harm. This was because staff had been temporarily redeployed from other Cygnet hospitals after the decision to temporarily close the hospital. However, there was still a high use of agency staff.
Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The provider had good arrangements in place to identify and deal with safeguarding.
The ward team had access to the full range of specialists required to meet the needs of patients on the ward. Managers made sure they had staff with a range of skills needed to provide good safe care. Managers provided an induction programme for new staff.
The provider was working closely with clinical commissioning groups and other relevant stakeholders in preparation for the hospital closing to ensure patients were transferred to appropriate placements that met their individual needs.
The service had had a high turnover of managers in the last 12 months and the provider had decided to close due to long standing issues regarding the culture of the service. However, at the time of this inspection the manager and senior team had the skills, knowledge and experience to perform their roles, had a good understanding of the service they managed, and were visible in the service and approachable for patients and staff.

We did not rate Cygnet Hospital Coventry at this inspection because this was an unannounced focused inspection to check specific concerns that patients and relatives had raised with the CQC.

Due to the concerns we found during this inspection, we used our powers under section 31 of the Health and Social Care Act 2008 to take immediate enforcement action and placed additional conditions on the provider’s registration. Following work the provider did to provide assurances about the safety of the service, the conditions were reduced to those which were previously imposed after the comprehensive inspection in July and August 2019. The conditions we placed upon the provider’s registration in 2019 required the provider to close one ward and cap admissions to another. Following this inspection in March 2020, the provider voluntarily closed another ward.

We inspected specific areas of the safe key question to look at areas of concern that patients and relatives had told us about. We did not inspect all areas or rate the key question of safe at this inspection. This is what we found:

The service did not have enough nursing and medical staff who knew the patients well enough to keep patients safe from avoidable harm. Staff received basic training to keep patients safe from avoidable harm but not all staff implemented it well. Patients reported there were not enough staff to meet their needs. The hospital remained heavily reliant on bank and agency registered nurses
Staff did not always assess and manage risks to patients and themselves well and did not follow best practice in anticipating, de-escalating and managing challenging behaviour.
The service did not always manage patient safety incidents well.

However:

Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Apart from one significant incident, the provider had good arrangements in place to identify and deal with safeguarding.

We did not rate Cygnet Hospital Coventry at this inspection because it was an unannounced focussed inspection to check if staff were supported to observe patients safely.

We found that new processes and practice had been introduced to reduce the time staff spent observing patients that meant they were less tired and staff took breaks from observing. The allocation of staff to observe patients was well planned and staff were positive about the changes.

However, the nurse in charge on both wards could not take a break as there was no night co-ordinator. Managers who had introduced the change on observing patients needed to monitor the impact on staff and the quality of care provided.

Due to the concerns we found during this inspection, we used our powers under section 31 of the Health and Social Care Act to take immediate enforcement action and placed conditions on the provider’s registration. The conditions we placed upon the provider’s registration have closed Dunsmore ward and capped admissions to the other wards.

Our rating of this service went down. We rated it as inadequate because:

The service did not provide safe care on Dunsmore ward. There were high levels of patient self-harm, even for patients on close observation levels. The wards did not have enough nurses and support workers who knew patients well enough to keep them safe. Staff assessed and managed risk on Dunsmore ward by increasing restrictive practices. Dunsmore ward was loud, chaotic and not a therapeutic environment. Managers had introduced a new patient observation and engagement form across the hospital but not all staff were undertaking observation robustly or completing the documentation correctly. The ward environment on Dunsmore was dirty, unhygienic and poorly maintained; the seclusion room on Dunsmore ward particularly dirty with stains on the walls and ceiling and an offensive smell coming from the shower drain. Middlemarch ward was also dirty but was better maintained. Ariel ward was clean and well maintained. Emergency alarms went unheeded because there were not enough staff to respond to them.

Staff did not always protect patients’ dignity when providing care or protect their privacy when discussing them. Patients, who were all female, did not feel that staff always respected their privacy and dignity. A number of them did not feel safe at the hospital because the majority of staff were male, who had little knowledge of the patients’ individual needs. There was limited access to meaningful activities during the evenings and weekends. Accessing a hot drink was only possible with staff support, which was difficult at times due to limited staff availability. Accessing the toilet was also difficult for some patients due to limited staff availability. Patients had complained for a number of months that temporary staff did not know them or their needs well enough, referring to them by room number and not by their name.

The service was not well led in all areas. Dunsmore ward was chaotic, noisy and staff were not able to maintain a calm environment. Leaders of the service were out of touch with what was happening on the front line, and they could not identify or did not understand the risks and issues described by staff. Staff and patients had been telling managers for more than five months that a lack of regular staff was a problem, but no effective action had been taken. Since opening, staff turnover had been high and was not being effectively addressed. Internal audits showed that the ward environments were in need of cleaning and maintenance, but nothing had been done to address it. Staff engaged in clinical audit to evaluate the quality of care they provided but findings to bring about improvement were not always implemented.

There was little acknowledgement by managers that staff and patients were experiencing the negative consequences of having a large number of temporary staff and a high turnover of permanent staff. Many of the permanent staff were relatively new to the service. Staff used terms such as “burn out” and “firefighting” to describe their experience of working at the hospital. Some patients expressed their concern for staff.

However:

The service had enough doctors and patients had access to a range of staff. Staff followed good practice with respect to safeguarding.

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. On Middlemarch and Ariel wards a range of treatments suitable to the needs of the patients was provided in line with national guidance and best practice.

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

Most permanent staff treated patients with compassion and kindness. They generally involved patients and families and carers in care decisions.

The service managed beds well and patients were discharged promptly once their condition warranted this.

The ward had a blind spot behind the manager’s office created by changes to the ward. Staff were aware of this but could not monitor this area easily on a busy ward. Although there were no ligature points in this area and it was covered by close circuit television, this was not routinely monitored. There had been an incident on the day of the inspection where a patient had tied clothing around their neck to self-harm. Staff who informed us of this later issued a statement with a different version of how this happened. During a second visit to the ward to view close circuit television we found this incident was not responded to for a significant period and paperwork relating to this incident such as the incident form, handover notes and the daily risk forms for patients had not been completed for the day it occurred. We raised our concern regarding the blind spot at the inspection and formally wrote to the provider following inspection about our concern. The provider acted quickly to fix a convex mirror that supported observation of the corridor.
Staff did not complete observations in line with Cygnet Healthcare’s observation and engagement policy. In particular, intermittent 15-minute observations were carried out at the same time pattern throughout the day allowing patients to know when these would happen. Paperwork used to record observations had not been updated since the changes to the ward had been made so it was difficult to know which area of the ward staff were referring to when recording information. The sheets had been photocopied many times which made it difficult for staff to read the print on them.
The ward had a higher number of beds than was recommended in the National Association of Psychiatric Intensive Care Units (NAPICU) Design Guidance for Psychiatric Intensive Care Units, published in 2017. This meant that staffing levels were also high, and the ward was extremely busy with very few quiet areas for patients.
Due to the high level of complex needs of patients on the ward, staff completing observations of patients were often reacting to incidents rather than engaging with patients.

However:

The ward environment was clean. The ward had enough nurses and doctors. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

We rated Cygnet Hospital Coventry as good because:

Staff completed comprehensive risk assessments for patients and updated these regularly. Staff attended a daily risk meeting for updates and this was also discussed in the ward handovers so all staff knew if risk had changed for individual patients. Staff had received training in safeguarding and knew how to report this. The hospital had good medicines management and clinic rooms were well equipped and fit for purpose.
The hospital provided patients with access to a wide range of healthcare professionals including doctors, nurses, healthcare assistants, psychologists, occupational therapists, and social workers. Patients were also supported to see a local GP and access the optician and dentist in the community and the hospital had a practice nurse who managed patients’ physical healthcare. Patients had access to a range of therapies including dialectical behaviour therapy.
Staff knew their patients well and engaged with them in a way which was caring, discreet and respectful. They put patient care first and listened to patients concerns. Patients had access to advocacy support on a weekly basis and could raise concerns in the ward community meetings or through the people’s council.
The hospital provided patients with an extensive activity programme which was continually being developed and improved. They had an excellent suite of activity rooms off the wards as well as areas such as kitchens for patients use on the wards. Patients baked cakes to be sold in the hospital shop which was run by patients.
The governance of the hospital had improved significantly with managers putting in a range of support to improve staff morale and the retention of staff. This included a much-improved induction process and role related training. Staff received a range of supervision and an annual appraisal to support them in their roles and to identify career progression. The introduction of a practice development lead had further strengthened support for staff.

However:

Managers did not always follow the organisation’s policy for observations and in one case a member of staff had completed continuous observations for longer than the two-hour period specified in the policy.
Families and carers felt the system for booking visits and the amount of space for visitors needed to be improved.
The hospital had a high staff turnover and staff on Dunsmore PICU raised concerns about staffing levels and whether these were adequate to meet the needs of patients.

We rated Cygnet Hospital Coventry as requires improvement because:

There had been some issues with governance at the hospital, which will require actions to be taken at a senior level. The hospital had been open for six months. The senior management team had action plans in place but these had not been properly embedded at the time of the inspection. The issues included recruitment and retention of staff, lack of clinical audits, training, lack of signed and dated cleaning records in clinic rooms, following up on the audits completed by the external pharmacist, and a lack of communication with carers.
The hospital had an issue with patients leaving the hospital without permission during an incident when the fire alarm had been activated. This was unsafe for patients. The hospital had reviewed its fire evacuation plan and put in a new door but needed to continue to review its fire evacuation plan and ensure it met the needs of all individuals.
The visitor’s room on Dunsmore psychiatric intensive care unit was at the entrance to the ward and carers found that once in the room it was difficult to attract the attention of staff if they needed support or to be able to leave the ward to use the facilities.
The wards reported 457 episodes of restraint for the five months from April 2017 to August 2017. We found these numbers to be high for a five month period. Ward managers had been working with staff to reduce the number of times restraint was used through training and de-escalation techniques which had started to show some improvement in the numbers.
The wards had not always recorded the physical health checks following rapid tranquilisation and one clinic room had some items which were no longer in their packaging making it difficult to determine what they were for or if they were still in date.

However

The wards provided a clean and well-maintained environment for patients. Clinic rooms were well equipped and each ward had a separate room for dispensing medication. Access to doctors was good with each ward having a consultant and a specialist doctor. Serious incidents had been investigated and staff received feedback from managers as to the actions that were needed to reduce the risks in the future.
Patient records and Mental Health Act paperwork was in good order. Care plans included patients’ views and were holistic and person centred. Physical health care was a key focus for staff and included the use of a specialist eating disorder nurse and a dietician.
Staff behaved in a way that was caring and respectful to patients. They demonstrated a good knowledge of the patient group on each ward. Patients had access to advocacy and staff supported them to use this service.
The hospital was purpose built and had a full range of rooms and facilities for patients to use including a gym, a beauty salon and a library. Patients had access to outside space and communal areas for relaxing. Wards had good access for people with disabilities and displayed a wide range of leaflets and information for patients to use.

Cygnet Joyce Parker Hospital

All Inspections

12, 13, 18, 24 and 26 April 2023

During an inspection looking at part of the service

17, 18, 23 January, 1 and 10 February 2023

During an inspection looking at part of the service

14th 15th and 16th February 2022

During a routine inspection

15 March 2021

During a routine inspection

24 February 2021

During an inspection looking at part of the service

24 June 2020

During an inspection looking at part of the service

12 March 2020

During an inspection looking at part of the service

18 February 2020

During a routine inspection

27, 29, 30 July and 2 August 2019

During a routine inspection

04 June and 18 June 2019

During an inspection looking at part of the service

4/5 June 2018

During a routine inspection

30 and 31 October 2017

During a routine inspection