Cygnet Elms

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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.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

The service was safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines.

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.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

In the past 12 months, there had been no serious incidents or deaths at the service. When incidents, such as episodes of aggression occurred, staff responded promptly, documented the events accurately and updated the patient’s care plans and risk assessments.

The service identified, acted on and shared learning from incidents to improve patients experience and care. Staff received debriefs following incidents and patients were supported to discuss incidents where appropriate. Learning was discussed during morning meetings, handovers, regular team meetings and operational meetings to identify possible opportunities for improvement.

Staff understood what an incident was and how to report it. Incidents were reported appropriately. Staff understood the duty of candour. They knew how to be open and transparent, and gave patients and families a full explanation if things went wrong.

The service demonstrated effective learning from incidents. Staff participated in regular restrictive practice and lessons learned meetings where incidents, safeguarding concerns, restrictive practices, policies, training and care planning were reviewed to identify improvements.

We reviewed one moderate harm incident, where a patient sustained a minor burn to their hand following an unexpected seizure whilst they were preparing themselves a hot drink. Staff were reported to have responded promptly and arranged appropriate medical treatment for the patient. Lessons learned from the incident involved introducing a temperature-controlled kettle to the service to reduce any further risk and continue to promote independence.

Staff received feedback following incidents and had opportunities to discuss learning through team meetings, handovers and reflective discussions.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had effective systems in place to manage risks and support safe transitions. Staff worked with patients, their relatives and external partners to support safe transitions and discharge.

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.

The service used structured risk management processes, including regular review of care plans and risk assessments and Positive Behaviour Support (PBS) plans. PBS plans followed least restrictive principles and identified the individual’s triggers, early warning signs, proactive strategies and reactive approaches to support the patient when they were in crisis. PBS plans were informed by psychological assessment and formulation. They were regularly reviewed and audited. Audits provided opportunities to further improve each individual PBS plan.

The service had a strong multidisciplinary team including psychology, occupational therapy, speech and language therapy, nursing, medical and advocacy. The MDT worked well together to develop person-centred interventions and support safe care delivery to each individual patient.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff demonstrated a good understanding of their safeguarding responsibilities and knew how to identify and report safeguarding concerns. Any concerns staff had, were reported through the appropriate channels and investigated.

Safeguarding training compliance was 100% at the time of our assessment. Staff were able to describe different types of abuse and how they would recognise them and raise their concerns.

We reviewed safeguarding records and found appropriate governance arrangements were in place. Staff demonstrated an open culture where safeguarding concerns were raised without hesitation or fear of consequence.

Staff followed safe procedures relating to children visiting the service. We were told that children did not visit the service during our assessment period. However, where patients had contact with children in the community, staff supported this safely and in line with appropriate procedures and individual risk assessments.

The service had blanket restrictions in place to maintain the safety of patients and staff, in the way of restricted items, some of these included; lighters and plastic bags. These were clearly documented and communicated to patients using easy-read posters. They explained the restrictions that were in place, and why they were put in place. The poster also explained that other restrictions would be based on individual needs and patients could speak to staff about else.

Mental Capacity Act

All staff had received the mandatory Mental Capacity Act (MCA) training at the time of our assessment. Staff demonstrated a good understanding of the five statutory principles and understood that capacity should always be assessed on a decision-specific basis.

Staff took practical steps to support patients to make their own decision, where appropriate. They provided patients with information around decisions in accessible formats, meeting the patient’s individual communication needs.

We reviewed four care records during our assessment. One patient required a decision-specific capacity assessment in relation to managing their finances. The assessment had been completed and documented appropriately. When the patient was assessed to be lacking capacity, a best interest assessment had been undertaken in line with the MCA. The remaining records we looked at, demonstrated that patients were presumed to have capacity, meaning there was no need to further assess their capacity unless any concerns arose.

The provider had policies in place relating to the MCA and staff told us they were aware of how to gain advice and guidance should they need to.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff knew to attempt to de-escalate a situation before using restraint or seclusion. There had been no incidents of restraint or seclusion. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients were involved in discussions about risks relating to their care and treatment. Staff adapted their communication to meet patients’ individual needs, using accessible information such as easy-red documents and Talking Tiles.

We reviewed four care records during our assessment. These demonstrated comprehensive, individualised risk assessments that were regularly reviewed and updated, depending on the patient’s risk. Patient risk was also discussed at the service’s morning meeting, where changes in a patient’s presentation, incidents, section 17 leave and behaviour were discussed.

Patients had individualised positive behaviour support (PBS) plans that identified their triggers, early warning signs, coping strategies and support required when in crisis. PBS plans followed least restrictive principles and were informed by psychological assessments and formulations. We identified an opportunity for the provider to strengthen the PBS plans further, by consistently recording how patients had been involved in developing their PBS plans, as it was clear patients had been involved in creating their PBS plans.

Staff actively involved patients in care planning and multidisciplinary reviews where possible. Patients had access to advocacy services, with an independent advocate visiting the service twice weekly to support patients with understanding and exercising their rights.

Patients were encouraged to provide feedback about the service through regular community meetings.

There had been no incidents of restraint during the reporting period.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service completed environmental risk assessments, including ligature anchor point and blind spot assessments. Environmental risks were clearly identified, reviewed and managed through action plans on the services risk register.

Current environmental risks, including access to carrier bags and reliability of the patient lift, had appropriate mitigation measures in place. Staff understood the risks and took actions to reduce them where possible, with support from estates.

The service had appropriate procedures in place for searching patients where required. Staff completed individual risk assessments to determine if searches were necessary. At the time of our assessment, no patients required routine searches.

The service had appropriate business continuity plans in place, including an on-call system to support the smooth running of the service, outside of office hours.

Staff completed regular environmental risk assessments. The clinic room was clean, fully equipped and contained accessible resuscitation equipment and emergency medicines. Records confirmed that emergency equipment and medicines were checked regularly.

The service did not have a seclusion room.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service maintained safe staffing levels that reflected the needs of the patients using the service. Managers regularly reviewed staffing levels and adjusted them daily to reflect patients’ need and observation levels. Staff told us they were allocated to provide 1:1 support and therapeutic observations according to the patients’ needs and risks.

There were no registered nurse vacancies during our assessment. Staff turnover in the previous 12 months was 1.82%, with one member of staff leaving to attend university. Sickness absence remained consistently low throughout the previous 12 months, ranging from 0% to 2.5%. Where there were any staffing shortfalls, these were filled with bank staff who were familiar with the service. The provider did not use any agency staff at the time of our assessment.

The service had access to a full multidisciplinary team. Staff had access to medical cover at all times and a doctor could attend the service promptly in an emergency.

We reviewed mandatory training records and found no modules with a compliance rate below 75%. Mandatory training compliance was 92.2%, with most modules achieving 100% compliance. Staff had also completed learning and disability and autism training appropriate to their roles, with 100% compliance.

Staffing levels enabled patients to receive regular 1:1 time with their named nurse and to participate in planned activities. Staff told us cancellations of activities due to staff shortages were very rare.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Patients and their relatives told us that the environment was clean and well maintained. During our assessment, we observed the site to be clean and tidy throughout.

Staff ensured that equipment was appropriately maintained and cleaned. All ward areas were clean, well-furnished and in a good state of repair.

Staff adhered to infection prevention and control procedures, followed hand hygiene guidance, used personal protective equipment appropriately and cleaned equipment in line with guidance and best practice. Throughout our assessment, we observed staff adhering to infection prevention and control principles, including hand hygiene between interventions with patients.

The service had clear processes in place to assess and manage infection risks. The provider’s procedures aligned with current national guidance. Regular cleaning and infection prevention and control audits were undertaken to monitor compliance and identify areas for improvement. Cleaning records were up to date and demonstrated that ward areas were cleaned regularly.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had safe and effective systems in place for managing medicines. Staff followed national guidance for prescribing, administering, storing and disposing of medicines. Controlled drugs were managed securely, and staff completed all required checks and records accurately. We observed staff administering medicines safely to patients during our assessment.

Staff supported patients to be involved in decisions about their medicines. Where patients had capacity, staff ensured they understood what their medicines were for and were actively involved in discussions about any changes to their treatment plan. Where patients lacked capacity, staff followed processes in line with the Mental Capacity Act and the Mental Health Act 1983 (MHA). Patient care plans clearly documented their individual needs when being supported to take their prescribed medication safely.

Staff regularly reviewed the effects of medicines on patients’ physical health in line with National Institute for Health and Care Excellence (NICE) guidance. All medicines were managed within the appropriate legal frameworks. We found no evidence of medicines being used inappropriately to control behaviour.

The service administered medicines in line with Stopping Over-medication of People with a learning disability, autism, or both (STOMP). We reviewed all prescribing and medicines administration records and found no concerns.