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Inspection Summary


Overall summary & rating

Outstanding

Updated 29 May 2019

Our rating of this service stayed the same: We rated it as outstanding because:

Patients were protected by a strong and comprehensive safety system and a focus on openness, transparency and learning when things go wrong. Cygnet Cedars had a genuinely open culture in which safety concerns raised by staff and patients who use the service were highly valued as integral to learning and improvement.

Staff took a positive approach to risk management. Patients and those close to them were actively involved in managing risks. Positive risk taking and least restrictive practice was embedded within the culture of the unit. Patients were actively involved in managing their own risks using risk assessments, positive behavioural support plans and worked collaboratively with staff.

Staff understood and focussed on least restrictive practice. Cygnet Cedars had a least restrictive practice group, completed restrictive practice audits and sought to use the least restrictive approaches when managing challenging behaviour. Patients were involved in shaping least restrictive practice through governance and community groups. We found no evidence of blanket restrictions. The providers had a transparent policy on the use of restrictive interventions, with an overarching restrictive intervention reduction programme with a board-level lead.

Staff supported the national STOMP pledge to reduce the long-term use of anti-psychotic medicines without the use of appropriate clinical justification. All patients at the hospital who were on anti-psychotic medicines had a care plan in place with the prescribing rationale, reduction plan and side effect monitoring.

Staff used a truly holistic approach to assessing, planning and delivering care and treatment to patients. The staff were actively supported by management to use innovative approaches to care. The model of care promoted patients’ recovery, comfort and dignity. Staff worked with patients to create excellent care plans that were holistic, recovery focussed, and person centred. They wrote these care plans in the voice of the patient. Staff reproduced care plans and other documentation in easy read formats for each patient. The multidisciplinary team provided a clear care pathway through the service from admission to discharge. Care plans fully reflected individual circumstances and preferences.

Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients, families and carers in care decisions to make sure patients were active participants in their care and treatment. We saw positive, professional and respectful interactions between staff and patients during our inspection. Staff showed patience and warmth. Staff and patients shared humour and were relaxed with each other whilst maintaining professional boundaries. Patients knew the staff well and were complimentary about all the staff at Cygnet Cedars.

The continuing development of staff skills, competence and knowledge was recognised as being integral to ensuring high quality care. Staff were proactively supported to acquire new skills and share best practice. All staff engaged in clinical audits to evaluate the quality of care they provided and learned from these to improve their practice.

We saw evidence of best practice in the application of the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA). All staff we spoke with had a comprehensive understanding of the Mental Health Act, the Mental Capacity Act, Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice. Staff had excellent understanding of capacity. They fully involved patients in decisions about their care. All patients had a file that documented what reasonable adjustments to communication should be considered when assessing the patient’s capacity. This ensured staff undertaking the assessment clearly understood the patient’s communication needs and was aware of any communication tools needed to support the patient.

The staff team were committed to providing active support to patients. Staff helped patients to be actively, consistently and meaningfully engaged in their own lives regardless of their support needs. One example of this was staff supporting patients to exercise their civil rights to vote and become active members of society. They supported patients to get involved with projects at the hospital and in the wider community. For example, helping staff with clinical audits and undertaking voluntary work in the local community.

Staff empowered patients to have a voice and to realise their potential. They showed determination and creativity to overcome obstacles to delivering care. Staff ensured that patients’ individual preferences and needs were always reflected in how care was delivered.

There was a holistic approach to planning people’s discharge, transfer or transition to other services, which staff started on admission. 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 took patients that had already spent a long time in care and enabled them to move into lesser dependant services in a reasonable time frame. This is the aim of Transforming Care

Governance structures were clear, well documented, followed and reported accurately. There were controls for managers to assure themselves that the service was effective and being provided to a high standard. Managers and their teams were fully committed to making positive changes. We saw changes had been made to maintain improvements in quality using audits. The service had clear mechanisms for reporting incidents of harm or risk of harm and we saw evidence the service learnt from when things had gone wrong.

The staff team were committed to improving and taking part in innovative practice. We saw excellent evidence of learning and developing projects within the hospital and throughout the provider region, staff shared ideas and good practice across sister units. Staff were supported to undertake research and present findings at national conferences.

Inspection areas

Safe

Outstanding

Updated 29 May 2019

Our rating of safe improved. We rated safe as outstanding because:

  • There were comprehensive systems to keep people safe, which took into account current best practice. The whole team was engaged in reviewing and improving safety and safeguarding systems. People who used services were at the centre of safeguarding and protection from discrimination.

  • A proactive approach to anticipating and managing risks to people who used the service was embedded and was recognised as the responsibility of all staff. Risk management was everyone’s responsibility and patients and carers where appropriate were actively involved in managing their own risks. Staff were able to discuss risk effectively with people using the service. People who used the service and those close to them were actively involved in managing their own risks.

  • Staff managed medicines consistently and safely. Medicines were stored correctly and disposed of safely. Staff kept accurate records of medicine. Patients received the right medicine at the right time.

  • Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses and they were fully supported when they did so.

  • Learning was based on a thorough analysis and investigation of incidents. All staff were encouraged to participate in learning to improve safety as much as possible, including working with others in the system and where relevant, participating in local and national programmes.

  • The environment was safe, clean and well maintained. Equipment was kept in good working order.

  • The hospital had enough staff to meet the need of the patients. The staff had the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.

  • Staff understood and took a person centred, least restrictive approach in line with the Mental Health Code of Practice and the Department of Health guidance entitled Positive and Safe (2013). Staff and patients worked together to reduce restrictive interventions. We found no blanket restrictions. Any restrictions were individually assessed recorded and regularly reviewed. Staff took creative approaches and used modern technologies to be as least restrictive as possible.

  • Staff fully understood and took a person centred, least restrictive approach in line with the Mental Health Code of Practice and the Department of Health guidance entitled Positive and Safe (2013).

  • Staff knew 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.

Effective

Outstanding

Updated 29 May 2019

Our rating of effective stayed the same. We rated effective as outstanding because:

  • Staff undertook thorough and holistic assessments of the physical and mental health of all patients on admission. All care plans were excellent. They were comprehensive, personalised, holistic and recovery orientated. Patients we spoke with told us they were encouraged and empowered by staff to be to be fully involved in the planning of their care needs. All patients had a discharge plan in place which reflected individual circumstances and preferences. Each patient had a copy of their care plan drawn up in a way they could understand.
  • Staff provided a wide range of care and treatment interventions suitable for the patient group and consistent with national guidance on best practice. They ensured that patients had good access to physical healthcare and went above and beyond to support patients to live healthier lives through a range of initiatives that all staff were engaged in. Doctors sought to prescribe the least amount of medication necessary in line with STOMP. STOMP is a national NHS campaign which is aimed at stopping over medication of people with learning disabilities, autism or both.
  • The recovery approach taken by Cygnet Cedars was underpinned by the Department of Health ‘My Shared Pathway’. This meant patients and staff worked together to reduce the length of time the patient needed in hospital by working together, planning and following agreed goals, using outcome measures.
  • All staff used recognised rating scales to assess and record severity and outcomes. They also participated in clinical audit, benchmarking and quality improvement initiatives.
  • The staff team included or had access to the full range of specialists required to meet the needs of patients. Managers made sure they had staff with a range of skills needed to provide high quality care. The provider proactively supported staff with appraisals, supervision and opportunities to update and further develop their skills and share best practice. Staff were supported to access specialist training and to undertake health care apprenticeships.
  • 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 provider ensured that the systems to manage and share the information that was needed to deliver effective care were fully integrated and provided real-time information across teams and services.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Managers made sure that staff could explain patients’ rights to them. The provider actively monitored and reviewed consent practices and records to improve how patients were involved in making decisions about their care and treatment.
  • Staff supported patients to make decisions on their care for themselves. They understood the provider’s policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity. All patients had a file which documented what reasonable adjustments to communication should be considered when assessing the patients’ capacity. This ensured staff undertaking the assessment clearly understood the patients’ communication needs and was aware of any communication tools needed to support the patient in making a decision.

Caring

Outstanding

Updated 29 May 2019

Our rating of caring improved. We rated caring as outstanding because:

  • There was a strong culture of enablement and person-centred care. Patients were fully involved in planning and evaluating their care. Patients were active partners in their recovery and risk management. Patients were involved in developing and leading groups and activities. All care planning documents where appropriate were signed and agreed by the patients. Staff understood individual patients’ physical and emotional needs. Staff knew about patients’ likes and dislikes and their beliefs and values.
  • People who used the service were active partners in their care. Staff were fully committed to working in partnership with people and making this a reality for each person. Staff always empowered people who used the service to have a voice and to realise their potential.
  • People’s emotional and social needs were highly valued by staff and were embedded in their care and treatment. People’s individual preferences and needs were reflected in how care was delivered.
  • Staff treated patients with kindness, dignity and respect.
  • Relatives and carers were involved where appropriate. The hospital had arranged open days and completed carers’ surveys.
  • Staff introduced new patients to the hospital prior to admission. This involved visits, introductory/ buddy groups and information packs. Admissions were tailored to individual need.
  • Patients knew who the independent mental health advocate was. The advocate met with patients individually, as well as attending the weekly community meeting and patient reviews when needed. Staff supported patients to access the advocate service.
  • The staff team were committed to ensuring the patients actively participated in society beyond daily functional living. They were supported to exercise their civil rights to vote and become an active member of society.
  • Patients were involved in developing the service. This included patient representatives at the governance group, community groups within the hospital and at provider level.

Responsive

Outstanding

Updated 29 May 2019

Our rating of responsive stayed the same. We rated responsive as outstanding because:

  • The service was discharge oriented and committed to discharging patients to independent or support living. Proactive discharge planning took place from the point of admission. The service worked in conjunction with the patient and partner agencies to facilitate discharge as soon as was safely possible. The service enabled patients to be discharged to lesser dependent or independent living in a reasonable time frame. All partner agencies we spoke with gave positive feedback regarding Cygnet Cedars. They were described as transparent and responsive.

  • Staff ensured that patients’ individual needs and preferences were central to the delivery of tailored services. There were innovative approaches to providing integrated person-centred pathways of care, particularly for people with multiple and complex needs.

  • This service took patients that had already spent a long time in care and enabled them to move into lesser dependant services in a reasonable time frame.

  • There was a proactive approach to understanding the needs and preferences of different groups of patients and to delivering care in a way that meets these needs, which was accessible and promoted equality. This included patients with protected characteristics under the Equality Act 2010, and people who were in vulnerable circumstances or who had complex needs.

  • Patients who used the service and others were involved in regular reviews of how the service managed and responded to complaints. The management demonstrated where improvements had been made as a result of learning from reviews and the learning was shared with other hospitals. Investigations were comprehensive, and the hospital used innovative ways of looking into concerns, including using external people and professionals to make sure there was an independent and objective approach.

  • Therapeutic jobs were available to the patients. Jobs were advertised, and patients were interviewed for them. Patients supported staff with audits and tasks around the hospital, for example, a daily environment audit.

  • There was excellent accessible information in a variety of formats for both patients and carers. Staff worked creatively to support patients’ communication needs, taking a personalised approach to every patient and auditing the accessibility of the environment.

  • Staff and patients had access to a wide range of facilities to support treatment and care. For example, a gym, sensory room, games room, computers and multi faith room.
  • Patients had access to their own personal smart phones and Wi-Fi.
  • Patients always had access to a kitchen where they could make refreshments.
  • Staff supported patients to engage with the wider community ensuring access to education and work opportunities. Staff also supported patients to maintain and develop relationships that mattered to them, including pets.

Well-led

Outstanding

Updated 29 May 2019

Our rating of well led improved. We rated well-led as outstanding because:

  • There was a great commitment towards continual improvement and innovation.
  • The service was very responsive to feedback from patients, staff and external agencies.
  • Low morale amongst some staff had been recognised and the service had worked actively with staff to respond to their concerns and make changes that would benefit them. Staff we spoke with on inspection were highly motivated and reported that they were a strong supportive team and that morale was good.
  • All staff knew and understood the vision and values of Cygnet Cedars. It was evident throughout the inspection that staff agreed with them and incorporated them into their daily work.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Although the registered manager had only been in post for two months, staff stated he was supportive, visible and ‘got stuck in’ – indicating that he did not shy away from ‘hands-on’ clinical work.
  • Cygnet Cedars had robust governance structures in place which fed into the provider’s regional and national systems. This ensured that quality of patient care and safety were reviewed, performance measures monitored, lessons learnt and good practice shared. Governance arrangements were proactively reviewed and reflected best practice. A systematic approach was taken to working with other organisations to improve care outcomes.
  • There was a demonstrated commitment to best practice performance and risk management systems and processes. The service reviewed how they functioned and ensured staff at all levels had the skills and knowledge to use those systems and processes effectively. Problems were identified and addressed quickly and openly.
  • The service invested in innovative and best practice information systems and processes. The information used in reporting, performance management and delivering quality care was consistently found to be accurate, valid, reliable, timely and relevant. There was a demonstrated commitment at all levels to sharing data and information proactively to drive and support internal decision making as well as system-wide working and improvement.
  • There were consistently high levels of constructive engagement with staff and patients, including equality groups. Rigorous and constructive challenge from people who use services, the public and stakeholders was welcomed and seen as a vital way of holding services to account.
  • Safe innovation was celebrated. There was a clear, systematic and proactive approach to seeking out and embedding new and more sustainable models of care. There was a strong record of sharing work locally and nationally.

Checks on specific services

Wards for people with a learning disability or autism

Outstanding

Updated 29 May 2019