Cygnet Brunel

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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

At our last assessment we rated this key question good. At this assessment the rating has remained good.

All wards were 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. The service managed patient safety incidents well.

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 all events rated moderate or above are investigated through an after-action review process. A new monthly forum that includes the compliance leads from four local Cygnet services had been established to share lessons learnt and continually identify and embed good practice. The service had had no serious incidents in the last 12 months. All staff knew what incidents to report and how to report them. Staff understood the duty of candour and were open and transparent and gave patients and families a full explanation when things went wrong. Ward managers compiled a ‘lessons learned’ document that was shared across all wards and staff received regular feedback from investigation of incidents at other Cygnet services as a fixed agenda item during monthly staff meetings.

The evidence in care plans across all four wards showed an exceptional standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

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. The care plans contained an exceptional level of detail. The service doctor was responsible for weekly health checks and the GP service conveniently located nearby worked closely together, including on-site visits by the GP as required.

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 and all incidents were documented in a safeguarding log.

All staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. The Local Authority safeguarding team worked with the service to deliver some staff training. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. A recent safeguarding case at the service evidenced thorough investigation of CCTV and witness statements, a clinical review, a service user body map and appropriate steps taken to suspend, investigate and discipline the staff member involved.

93% of staff have had training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. There were 5 deprivation of liberty safeguards applications made in the last 12 months to protect people without capacity to make decisions about their own care. The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

The service has an on-site Mental Health Act and Mental Capacity Act administrator and a regional Mental Capacity Act lead that support the review of our documentation and provide training and guidance for staff. A corporate lead at national level supports escalation if required.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards. Care records demonstrated that staff took all practical steps to enable patients to make their own decisions and where patients had impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis regarding significant decisions. Managers audited the application of the Mental Capacity Act monthly and acted on any learning that resulted from it.

The evidence showed a good standard. The service worked well with people to fully understand and manage risks by thinking holistically. They provided care that met people’s needs and was safe, supportive and enabled people to do the things that mattered to them. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff had not used restraint or seclusion in the last twelve months. All staff have participated in the provider’s restrictive interventions reduction programme and there is a named lead for reducing restrictive practice.

We examined four care records on each ward (sixteen in total). Every record was up to date and contained detailed, multidisciplinary assessments and risk management plans. Each risk management plan demonstrated patient involvement to the degree possible. Staff clearly communicated with patients so that they understood their care and treatment, and every patient had been offered a copy of their care plan.

We visited every ward at the service. Ward fittings and fixtures were clean, serviceable and in good condition. Electrical Portable Appliance Testing (PAT) checks had been conducted and evidenced by stickers that were in date in all wards. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The ward layout did not allow staff to observe all parts of ward and staff mitigated this risk by being out of the office and visible in all parts of the ward. Staff were aware of the highlighted map of potential ligature anchor points displayed in each ward office, and ligature cutters were located beside these. Staff had easy access to alarms and patients had easy access to nurse call systems.

Ward managers conducted weekly risk assessments of the care environment and medical equipment and oxygen. Defibrillators are checked daily. All blood monitoring machines were calibrated monthly and all audit logs examined were current and up to date.

93% of staff were fully up to date with appropriate mandatory training for the patient group using the service. Staff reported full management support and protected time to complete required training. The service was fully staffed with no current vacancies and a broad multidisciplinary team that included psychiatry, psychology, physical health, occupational health, physical therapy, nursing and speech and language therapy.

Managers use the E-census and hours per patient per day (HPPD) tools to calculate the number and grade of nurses and healthcare assistants required for each shift and the number of nurses and healthcare assistants matched this number on all shifts. The ward manager could adjust staffing levels daily to take account of case mix, preferring to use a bank system with known and trained staff than agency staff in most cases. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

There were enough staff to carry out physical interventions (for example, observations and restraint) safely and staff had been trained to do so. Staffing levels allowed patients to have regular one-to-one time with their named nurse and staff shortages rarely resulted in staff cancelling escorted leave or ward activities. Half of the staff we spoke to complained of cliques, favouritism and a perceived divide between clinical and care staff. Management demonstrated awareness of these issues and had recently moved individual staff members to teams in other wards and invited nurses and support workers into weekly MDT meetings to capture their views.

All ward areas were clean, had good furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Ward managers did daily walk arounds to check the cleanliness of the environment and cleaning records are checked daily and weekly. All staff including cleaning staff had up to date infection control training and adhered to infection control principles, including handwashing. There have been no reportable infections at the service in the past year.

However, the evidence showed some shortfalls. The service did not always detect or manage the potential risk of infection. On the first day of our inspection, we saw a sharps bin that was full of used needles left open and unsecured on the floor of the physical health clinic room. Though patients had no access to this locked room unless accompanied by a nurse for the purpose of conducting physical health checks and bloodwork, it was clear from speaking to staff that this sharps bin had been stored on the floor for months despite the pharmacist and the named infection control lead raising this concern and requesting a sharps bin holder on the wall (as seen on the wards) to the clinical manager and to maintenance manager numerous times.

On the second day of inspection the sharps bin had been moved to a locked cupboard in the physical health clinic room, which made the sharps bin temporarily secure, but this was not the recommended practice. The current sharps disposal process involved carrying the yellow bag in one gloved hand while trying to exit the building using the fob with an ungloved hand to reach the medical waste area just outside the building. This was not safe. The service needs to mount the sharps bin on the wall near the point of use to make storage and disposal of sharps safer.

We examined the medication records for twenty patients across all four wards. The evidence showed an exceptional standard of completeness for all records. Staff followed good practice in medicines management including transport by secure courier, appropriate and secure storage with daily fridge and room temperature records completed, weekly checks and counter-signed records by nurse and pharmacists for dispensing, administration, medicines and reconciliation. All prescriptions are checked weekly by the pharmacist and medical doctor. Medication disposal records were complete and there had been no reportable controlled drug incidents or use of rapid tranquilisation in the last twelve months.

Medical staff reviewed the effects of medication on patients’ physical health weekly and monthly and in line with NICE guidance and employed the Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS) to capture patient perceptions of any antipsychotic medication side-effects monthly. Pharmacy team participated in monthly clinical audit and discussed medication with patients directly when requested.

Treatment authorisations were in place. Medication prescribed was legally authorised and the responsible clinician had completed capacity assessments prior to requesting a second opinion appointed doctor (SOAD). Treatment certificates were organised and available to view for the prescribing nurses. Staff told us that a pharmacist audited treatment authorisations weekly against any dispensed medication.

Care records demonstrated contemporaneous and accurate records of medicine administration and paperwork, evidenced patient involvement and choice in medication choice and medication change and document provision of easy read medicine information to patients. Medication was dispensed at the hatch with no queues to maintain patient dignity and timely supply of medication for periods of leave or discharge was evidenced in the records.