Cygnet Grange

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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 patients’ care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last inspection we rated this key question requires improvement. The service was in breach of legal regulation in relation to safe care and treatment (regulation 12). At this assessment, the rating has changed to good. The service made improvements and was no longer in breach of regulations in relation to physical health observations. Patients’ needs were assessed using a range of assessment tools. The service worked well across teams and services to support patients. The service supported patients to manage their health and wellbeing. There were effective approaches to monitor patients’ care and treatment and their outcomes. Patients’ capacity and ability to consent were taken into account.

However, patients did not always receive care, treatment and support in line with good practice standards. Risks relating to patients’ physical health were not consistently monitored or reviewed.

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 a good standard. The service made sure patients’ care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Patients’ needs were assessed using a range of assessment tools to ensure their needs were reflected and understood. Pre‑admission processes were thorough and ensured that the service could meet each patient’s needs effectively. Information gathered prior to admission included clinical history, behavioural presentation, physical health needs, and environmental considerations. We reviewed 3 care records, and all demonstrated staff completed comprehensive assessments of patients’ needs. Staff used a range of assessment tools including HoNOS and Waterlow scores.

Nurses and HCA’s worked together with patients and their families to complete detailed, personalised care plans that reflected patients’ individual needs and preferences.

Patients did not always receive care, treatment and support in line with recognised good practice standards. Risks relating to patients’ physical health were not consistently assessed, monitored or reviewed, placing patients at risk of avoidable harm.

We identified gaps and omissions in physical health records, with missing or incomplete information. For example, 1 patient’s records did not contain sufficient documentation to demonstrate that their risk of falls had been appropriately assessed or managed. In another case, a patient who was predominantly wheelchair-bound did not have a venous thromboembolism (VTE) risk assessment in place, despite presenting with known risk factors.

These omissions meant there was a risk that changes in patients’ health needs might not be recognised or responded to in a timely way.

Patients’ nutrition and hydration needs were met in line with current guidance. We saw the menu offered a good choice of options and was presented like a restaurant menu. Patients could access additional food throughout the day and drinks at any time. We saw food and fluid charts were in place for patients, where required. These were reviewed in the morning meeting we observed.

Mental Health Act

• The provider reported 100% of staff received training in the Mental Health Act.
• 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.
• The provider had relevant policies and procedures that reflected the most recent guidance.
• Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.
• Patients had easy access to information about independent mental health advocacy.
• Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.
• Staff requested an opinion from a second opinion appointed doctor when necessary.
• 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.
• The service displayed a notice to tell informal patients that they could leave the ward freely.
• The Mental Health Act team did regular audits to ensure that the Mental Health Act was being applied correctly.

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

Staff had access to the information they needed to appropriately assess, plan and deliver patients’ care, treatment and support. We observed a morning meeting during our site visit. These meetings took place every weekday morning. Attendees included head of care, psychologist, SaLT, forensic psychologist, and a nurse. Items discussed included staffing, incidents, risks, observation levels, personal care, food and fluid charts and planned activities for the day.

When patients received care from a range of different staff, teams or services, it was co-ordinated effectively. All patients were registered with a local GP practice. Staff supported patients to attend external appointments from referrals made by the GP. Patients had access to a community dentist.

The evidence showed a good standard. The service supported patients to manage their health and wellbeing to maximise their independence, choice and control. The service supported patients to live healthier lives and where possible, reduce their future needs for care and support.

Patients were encouraged and supported to make healthier choices to promote and maintain their health and wellbeing. A five-week rolling menu was displayed in the dining area, offering a wide variety of options, including vegetarian and gluten‑free choices. Information promoting healthy living and healthy eating was also clearly displayed.

Staff provided examples of how they supported patients to improve their physical health and re-engage in meaningful activities, such as bowling, going to the gym and swimming. The service implemented measures to support patients to re-engage in these activities, promoting both their physical health and social wellbeing.

We also saw evidence of a person‑centred approach to supporting patients’ development and independence. For example, 1 patient had been supported to enrol on an IT course delivered through a university, arranged by the occupational therapy team. Staff had adapted the patient’s bedroom environment to support their learning by providing a desk for study.

Quality Statement Score: 3

The evidence showed a good standard. The service routinely monitored patients’ 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 patients themselves.

There were effective and well-embedded approaches in place to monitor patients’ care, treatment and outcomes. The provider used a range of recognised and evidence-based outcome measures to assess patient progress and inform care planning. These included a wellbeing tool used during monthly ward rounds, safety formulations, the Model of Human Occupation Screening Tool (MOHOST), and the Allen Cognitive Level Screen (ACLS-5), which enabled staff to comprehensively assess patients’ functional abilities, cognition, and engagement in daily activities.

Staff also used the JAYS Observational Assessment of Dysphagia to proactively identify and manage risks associated with swallowing difficulties. In addition, staff routinely completed evaluation records to assess patients’ levels of engagement and their responses to therapeutic activities.

These processes were used consistently to monitor outcomes, inform clinical decision-making, and adapt care to meet individual needs.

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

Patients’ capacity and ability to consent was taken into account, and they, or a person lawfully acting on their behalf, were involved in planning, managing and reviewing their care and treatment. We reviewed patients medicine records. Staff completed an assessment of each patient’s capacity and made a best interest decision in relation to the patient’s treatment, with T3 forms in place where required. Under the Mental Health Act, a T3 Form (Certificate of Second Opinion) is the legal document required to medicate a detained patient who either lacks the capacity to consent to treatment or refuses it.