The Care Quality Commission
  • Mental Health
  • Independent mental health service

Archived: Cygnet Thors Park

Overall: Inadequate read more about inspection ratings

Thors Farm Road, Brightlingsea Road, Thorrington, Essex, CO7 8JJ (01206) 306166

Provided and run by:
Cygnet (OE) Limited

Important: The provider of this service changed. See old profile

All Inspections

23 June to 24 July 2020

During an inspection looking at part of the service

Cygnet Thors Park is a 14-bed hospital, which provided care and treatment for men aged 18 years and above who have a learning disability, autism and complex needs. The provider has taken the decision to close the hospital: there have been no patients at the hospital since 18 June 2020.

We rated the provider ‘inadequate’ overall at our inspection in September 2019. We rated the safe and well led domains as ‘inadequate. We rated the responsive domain as ‘requires improvement’ and the effective and caring domains as ‘good’.

At our most recent inspection, we did not change amend our previous ratings.

The Care Quality Commission (CQC) placed the hospital in special measures following an inspection in 5 February 2019 and imposed conditions on the provider’s registration at this hospital. These included not admitting any new patients; ensuring there were sufficient competent, skilled staff and ensuring observations of patients were carried out appropriately. As a result of placing the provider in special measures we commenced a programme of enhanced monitoring. During this period of enhanced monitoring both the CQC and the provider identified significant areas of ongoing concern.

On 16 June 2020 the provider took the decision to transfer all patients out of this hospital. On 9 July 2020, the provider submitted a notification to the CQC to cancel the registration of this location and has since deregistered.

We undertook a focused, short notice site inspection on 1 and 7 July 2020 because we had concerns about the safety of patients prior to their transfer to new services and concerns about how the provider had undertaken the transfer of patients.

At this inspection we found:

  • The provider did not manage the hospital in order to deliver safe, good quality care to patients. They had not provided effective leadership and did not have robust governance processes in place to ensure that the hospital operated appropriately. They did not have oversight of the way staff assessed and managed risks relating to the patients.
  • The provider had not ensured they had taken all the necessary action we told it that it must following our September 2019 inspection. They had not acted to ensure staff undertaking observations, did so in line with the provider’s engagement and observation policy and protocol. They had not acted to ensure there were always sufficiently skilled and competent staff to support patients .
  • The provider had not implemented effective monitoring systems to check that staff were observing patients as specified in their care plans. We considered that patients and others were placed at risk of harm and that there was a risk that patients were not getting the care they needed. Hospital managers informed us of multiple incidents (between April to May 2020) where they had found staff were not observing a patient as per their care plan at night. The provider was investigating a number of night staff (support workers and registered nurses) to determine if they had failed in their duties. We viewed samples of closed-circuit television footage where staff had not observed three patients as their care plans specified. We saw that staff had falsified patient notes stating that they had observed one patient when they had not. Hospital managers informed us on 17 July 2020 that they were now investigating 27 staff; mostly night staff but also some day staff.
  • We found an example where the provider had not checked that hospital managers ensured staff followed identified learning and recommendations from an incident investigation. The recommendation was to ensure female staff were not allocated to a specific patient due to identified risks but this was not followed. Some staff told us they had raised concerns about patient’s continuous observation levels with hospital managers. They said hospital managers had not acted to address their concerns.
  • The provider did not have a system of assurance to check that hospital managers had ensured that staff received adequate training, supervision and appraisal. They had not ensured that staff worked well together as a team. They had not ensured that there were sufficient numbers of suitably qualified, skilled, competent and experienced staff at all times to meet the needs of patients. For example, we checked personnel files for 24 staff (of 27) under investigation and found poor pre employment screening and post employment screening of competency. This related particularly to clinical support worker staff.
  • The provider had not ensured there was adequate and consistent leadership at the hospital. There had been six different hospital managers (or senior staff) since our last inspection in September 2019. The Care Quality Commission had taken enforcement action in 2019 to ensure the hospital had a registered manager in post. Over the period covered by the last three inspections, the risks identified at the hospital had increased. We found evidence that a culture of poor care had developed particularly during night shifts , where staff did not follow the instructions contained in patient care plans, or the provider’s observation policy.

At this inspection we found the following relating to patients transfers out of the hospital:

  • Provider staff told us they were closing the service and transferring patients as they could not provide safe care.The provider had not treated patients with respect compassion and kindness, when they transferred patients out of the hospital within 24 to 48 hours. Whilst CQC does not disagree with the provider’s decision to close this service for this reason, we were concerned about the extreme short notice period within which these transfers were completed, the difficulties commissioners would have in considering alternative and appropriate placements, the complex needs of the patients and the length of time patients had been within this service.
  • There were no apparent individualised plans detailing how staff should best support patients for their transfer to minimise the impact of the sudden move. The provider had not actively involved patients and families and carers in the decision or plans/preparation for the transfer. They had not given sufficient notice to patients, carers and commissioners about the transfer of patients out of the hospital. Some patients had received care and treatment at the hospital from between 15 months to 17 years and no consideration had been given to the impact and considerable distress the move would cause for them. Patients’ care plans showed they all had differing levels of capacity to understand information and differing communication needs and many would not be able to comprehend what was happening or why it was happening at such short notice. One patient had only been given two hour's notice.
  • The provider had not ensured that staff developed care plans informed by a comprehensive assessment to support patients transfer. This was not in line with national guidance about best practice. The provider had not planned and managed patient’s transfers well and liaised with services that would provide ongoing care and support this includes commissioners and community teams.
  • Additionally, the provider had not effectively communicated with their staff, commissioners and the CQC about the transfers. They had not ensured that staff assessed patients’ individual needs and developed support plans to give them the support they needed when moving.

However:

  • Hospital managers had ensured staff had reviewed all patients’ observation records to ensure that the level of observations prescribed were individualised, detailed specifically when levels of observations should reduce or increase and were based on individual risk assessments, including mitigation of risks identified.
  • Hospital managers had ensured there was documentation to inform staff of the current observation level of all patients. This included details of any changes to their observation levels. All documentation was accessible to relevant staff.

24 and 30 September 2019

During a routine inspection

We rated Cygnet Thors park as inadequate because:

  • The service did not provide safe care. Staff were unable to call for help when they or a patient needed protection from violence or aggression. Staff personal alarms did not work when we tested them and the display panel which helped staff to find the emergency, displayed an inaccurate location.
  • The provider had not identified or sufficiently mitigated blind spots in the ward environment. This meant that staff and patients were unable to observe all parts of the ward to ensure their safety.
  • Managers failed to ensure there were enough staff on duty to provide the required levels of patient observations in a safe way. Staff were completing patient high level observations from two to 12 hours continuously (on rotation) without a change of activity or alternative task. The provider did have a protocol in place which stated that staff should not undertake close observations for longer than two hours without a break but this protocol was not adhered to during the inspection. The records for the patient’s care plan, their daily risk assessment, and their observation plans did not always match.
  • Managers failed to complete bi weekly CCTV reviews for three weeks during September 2019. The CCTV was not working effectively during this time and was not identified by the provider. This was an action from the November 2018 inspection. We found the closed-circuit television (CCTV) system was not working and the manager was not aware of this until the inspection.
  • Staff did not plan sufficiently for patient discharge. Patients stayed at the service for longer than they needed to with the average stay being 1423 days. One transition plan for a patient’s discharge had action points which staff had not completed and it was not clear why their discharge was delayed.
  • The registered manager did not have enough oversight of all the safety concerns and risks at the service and had not acted to correct all the concerns raised at previous inspections or from enforcement action.

However;

  • The ward environments were clean. Staff assessed patient risks regularly, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
  • 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 cared for in a ward for people with a learning disability and autism and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • 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.

05 February 2019

During a routine inspection

We rated Thors Park as inadequate because:

  • Safety was not a priority. The provider did not have sufficient oversight to ensure the clinic room was maintained safely. Staff did not ensure the clinic room was organised, clean or tidy. Staff did not manage medications appropriately, dispose of expired medications and numerous miscellaneous items or replace equipment. The provider had not ensured the replacement of an oxygen cylinder despite being aware that it had remained empty since November 2018 or an ambu bag (a manual resuscitation bag) that had expired in 2011. The provider had not ensured the repair of the clinic room door. This compromised the security of the clinic room which led to a patient forcibly accessing the room during our inspection. As the clinic room door remained faulty and no temporary solution had been put in place, this remained a risk to patients and staff. The provider did not ensure the timely maintenance of the alarm systems. Staff were unable to know the location of a raised alarm without viewing the alarm panel in the nursing office as the panel in the ward area was inaccurate. Not all staff responded to the alarm when it was pulled. Staff reported personal alarms as faulty since August 2018. Although the provider had repaired and replaced staff personal alarms, staff continued to raise concerns that their alarms did not always work effectively. We were not assured of the provider’s oversight and responsiveness to the safety of staff and patients. There were no effective system for identifying, capturing and managing issues and risks.

  • Staff did not manage risks to people who use the services. Managers and staff missed opportunities to prevent or minimise harm. During the inspection, staff did not maintain enhanced observation levels for two patients as specified in their care plans and in line with the provider’s observation policy. This issue had been identified in a recent focused inspection but the provider had not addressed our concern. We were therefore not assured that the provider had managed the risks posed by or to people using the service. Staff did not intervene in situations of challenging behaviour towards the inspection staff during the inspection. Managers were aware of staff’s reluctance to intervene during incidents involving one patient and said they were providing training on this patient’s positive behaviour support plans and provided training on how to maintain boundaries. Restraint records were not accurate. The provider had not ensured that staff were recording physical restraints used during incidents. We found three incidents where staff did not record the type of physical restraints used during an incident. Managers were unable to know the type and frequency of physical restraints used.

  • The provider had not ensured they maintained parts of the environment adequately. Some parts of the environment were dull and required re-painting. Two patients’ bedrooms had damaged radiator covers that had not been repaired and one bedroom was very worn and damaged. The activity room was bare, required redecoration and was not conducive to therapeutic activities.

  • The provider had not ensured that staff were up to date with all mandatory training including safeguarding children training which 74% of staff had completed and Mental Health Act training which 67% of staff had completed. The provider had not ensured their staff had met their target of 80%. Managers did not provide staff with regular supervision or appraisals. Data showed that 50% of staff received supervision and 21% of eligible staff received an appraisal in the twelve months prior to the inspection.

  • The service did not always meet people’s needs. Staff did not ensure they had records of care and treatment reviews. This meant they had limited records of actions required to support patients’ discharge. When people complained about the service, the response was poor and the quality of investigations into complaints were poor. The provider did not always use their terms of reference for investigating. We reviewed four investigation reports, they lacked clarity about what was being investigated and investigators had not used all evidence available to form a judgement.

  • Managers had no oversight of significant issues that threatened the delivery of safe and effective care. Issues were not always identified and adequate action to manage them was not always taken. Managers had not identified issues in the clinic room and staff continued to report personal alarms as faulty despite the provider repairing these. Staff continued to leave patients who required constant enhanced observations despite this being raised in a recent focused inspection. These issues compromised staff and patient safety.

11 October 2018 and 1 November 2018

During an inspection looking at part of the service

We did not rate the provider during this focused inspection as we did not cover all aspects of each domain. CQC last rated the provider at the comprehensive inspection, published 16 January 2018, when the service was rated as ‘good.'

We found the following issues that the provider needs to improve:

  • The provider had not ensured that there were sufficient staff on duty for safe care and treatment of patients. There were insufficient staff on duty and staff were not always able to take breaks during their shift. Information provided about staff allocations showed that the provider often used staff intended to relieve others for activities such as driving.
  • Staff did not always complete enhanced observations correctly. They did not follow observations in accordance with patients’ care plans, the provider’s policy or the strategies identified in positive behavioural support plans. Staff did not always engage with patients whilst on observation and did not always use physical intervention techniques in line with their training.
  • Staff did not ensure that they updated care plans and risk assessments according to their own procedure. The provider had not ensured that best interest decisions made for patients who lacked capacity under the Mental Capacity Act were decision specific.
  • The provider did not complete investigations according to their agreed procedure. Descriptions on incident report forms did not always match closed circuit television footage. Two closed circuit television cameras were not working correctly. The provider did not always respond to complaints in a timely manner and the provider did not always apologise when their own investigation found them to be at fault.
  • Staff did not always ensure that they monitored patients’ physical health. We found that staff completed physical health monitoring of patients on admission however, they did not always update this.
  • Three of the eight staff we spoke with stated that they would not feel comfortable to raise concerns without fear of victimisation, and did not feel listened to.

However, we found the following areas of good practice:

  • We observed some positive interactions with patients. Staff used several different methods to communicate with patients. Patients had access to advocacy services. Patients had access to activities, escorted leave and could keep in contact with their families.
  • Staff completed a two-week induction period, including shadowing other staff members, prior to working directly with patients on the wards.

16 January 2018

During a routine inspection

We rated Thors Park as good because:

  • The provider ensured there were sufficient staff on duty for safe care and treatment of patients. The provider had significant vacancies for support workers; however, agency staff were block booked, where possible, to ensure continuity of care for patients. Data provided showed no shifts were left unfilled. New staff, including agency staff, received an induction to the service before working with patients. Staff were in receipt of mandatory training, clinical supervision and appraisals. The manager had introduced a new supervision model.
  • We observed kind and compassionate interactions between staff and patients. Staff showed a good understanding of the individual needs of the patients and treated them with respect and dignity. Staff showed passion for their work with patients.
  • Patients had access to advocacy services and staff involved families and carers in discussions around care and treatment. Staff supported patients to access information about local services, patients’ rights and how to complain.
  • Staff were aware of safeguarding procedures and made referrals when necessary for the protection of patients. Patients told us they felt safe in the service. Staff completed holistic and recovery focused care plans and positive behaviour support plans. Staff completed risk assessments on admission and updated regularly and after incidents. Staff knew how to report incidents and managers completed investigations. Staff were aware of their responsibilities under duty of candour and we saw evidence that these principals were followed, when required.
  • Staff prescribed medication in accordance with National Institute for Health and Care Excellence guidelines. Medication was stored and administered appropriately and in accordance with the appropriate legal authority. Staff completed and stored Mental Health Act paperwork correctly.
  • Staff completed capacity assessments in accordance with the Mental Capacity Act 2005 and held best interest decision meetings for significant decisions.
  • The provider had a full range of rooms and equipment to support care and treatment for patients. Patients were able to personalise their bedrooms if they wished and had access to lockable storage within their bedrooms. The provider had a seven day activity programme displayed in ward areas and in patient notes. Patients had access to outside activities, such as a climbing wall and swimming. Work placements were also available.
  • The service was well led at local and regional level. Senior managers demonstrated a commitment towards continual improvement and innovation and had worked hard to improve the culture of the hospital and morale of staff. The provider had a robust rolling audit programme to monitor the effectiveness of the service. The provider had ongoing plans for refurbishment at the hospital to improve the quality of the estate.

However:

  • The provider had not fully completed the services ligature risk assessment. Staff did not have all the detail for the safe management of patients at risk of self-harm.
  • The provider had not ensured the emergency equipment was fully accessible. The sink in the clinic room was stained and did not meet infection protection and control guidance. The provider had not ensured all emergency equipment was in good working order. One defibrillator did not have the required pads and the suction machine was broken.
  • Staff had not ensured all areas of the hospital were clean and some damaged areas had not been repaired.
  • Staff did not always fully complete records of physical health care monitoring for patients.
  • Patients remained in the service for long periods. The provider reported an average length of stay for patients of 1825 days.
  • The provider did not always ensure all staff received feedback of outcomes of investigations from within the service or from other sites.

13 December 2016

During a routine inspection

We rated Thors Park as requires improvement because:

  • There was little evidence seen in regional meeting minutes regarding lessons learned from incidents or complaints.
  • The window handles in the conservatories were not anti-ligature and there were some exposed wires by the fascias in the garden on Thorrington ward.
  • The provider used a large number of agency staff and from 01 June 2016 to 31 August 2016; 29 shifts had not been covered. This meant that the wards did not have safe staffing levels on these days.
  • Patients had not signed their care plans. Staff and not recorded whether a copy had been given to the patient.
  • Staff had not recognised or recorded two episodes of seclusion in accordance with the Mental Health Act Code of Practice.
  • The provider had not ensured that when a patient lacked capacity to make decisions, decisions made on their behalf were not documented appropriately.
  • Staff compliance with mandatory training was low at 64% of staff up to date with mandatory training. The providers target was 80%.

However:

  • Since the last inspection Thorrington ward had been renovated; the bedrooms, lounge, dining area and corridors had been decorated and there was new furniture and sanitary ware. The provider was due to bring Brightlingsea ward up to a similar standard, although no date was given when the works would be completed.
  • The provider held staff profiles on agency staff members that worked on the wards. These contained qualifications, disclosure and barring service (DBS) records, references and training records.
  • The provider used an electronic recording system to update patient records in the weekly multi-disciplinary team meeting.
  • Staff showed a good understanding of the individual needs of the patients, and we observed good interactions between staff and patients.
  • The provider provided easy read multi-disciplinary meeting forms for patients to complete prior to them attending the meeting to give feedback to the team.
  • We saw good evidence of patient involvement in the recruitment of staff, for example being a part of the interview panel.
  • We observed proactive discharge planning in the multi-disciplinary meeting. The provider ensured patients’ beds remained available following return from periods of leave.
  • The provider was a member of the Award Scheme Development and Accreditation Network, which was designed to develop alternative education provision.
  • Notes were observed to be patient centred and holistic.
  • We saw six medication charts which all had consent to treatment forms attached.

17 and 18 September 2015

During a routine inspection

We rated Thors Park as good because:

  • Risk assessments were comprehensive and reviewed regularly and if patients risk levels changed.
  • Care plans were up to date, risk related, holistic and recovery focused.
  • Staff appropriately reported all incidents.
  • There were no episodes of prone restraint used on patients. Managers staffed shifts to the established levels of nurses: although these levels were at times achieved by using agency or bank staff.
  • Senior staff had an active recruitment process in place.
  • Staff interacted with patients in a caring and respectful manner. They told us they wanted to provided good quality care for patients.
  • Weekly activity programmes were available to patients.
  • The provider supported and trained patients to become experts by experience so that they could work with staff to complete audits.
  • The service had a range of rooms and equipment – including a dedicated occupational therapy suite with a sensory room.
  • Staff participated in clinical audits and used information from these audits to improve the service and outcomes for patients.
  • Managers had access to key performance indicators to gauge team performance and compare against other services.
  • Managers held debrief sessions and staff meetings to share outcomes of incidents, complaints and patient feedback.

However:

  • Ligature and environmental risk assessments were conducted, but no action was taken to minimise assessed risks to patients.
  • Cleaning records were not fully completed.
  • Ensuite bathrooms were dirty, stained and had a musty odour.
  • The paintwork looked tired and worn and the conservatory had missing window handles.
  • Patients on Brightlingsea ward spent long periods of time in isolation for significant periods. This practice constituted long-term segregation.
  • Nurses did not complete seclusion reviews and checks to safeguard patients in line with the Mental Health Act code of practice.
  • Forty-two percent of staff were not up to date with mandatory training.
  • The service had 28 staff vacancies.
  • Staff supervision records were not fully completed and showed that not all staff received monthly supervision.

18 December 2013

During an inspection in response to concerns

We saw that people were actively encouraged to participate in their individual treatment programme and that they accessed specialist therapies and other support from staff. This demonstrated to us that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Staff reported that there were good opportunities for training and career development. This demonstrated to us that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

There were appropriate arrangements in place for ensuring that people were safeguarded against harm or abuse.

There were appropriate arrangements in place to ensure that people were protected from the risks associated with receiving mediciation.

The provider had effective systems in place to monitor the quality and safety of service that people received.

13 June 2013

During an inspection in response to concerns

People told us that the care they receive is generally good and told us that they liked the staff and thought that they understood their needs well. We saw that the rapport between the people and staff was positive. We saw people laughing and joking around, all of the interactions we saw looked to be completely genuine.