Cygnet Hospital Maidstone

On this page

• 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

We reviewed all 8 quality statements in the safe key question. This means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question Requires Improvement. At this assessment the rating has changed and is now rated as Good. This meant people were safe and protected from avoidable harm. 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.

We scored the service as 3. 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.

There were 12 incidents reported and resolved across both wards in the last 6 months.

Managers of both Roseacre and Bearstead wards promoted a proactive and positive culture of safety based on openness and honesty, in which concerns were listened to, and safety events were reported and investigated. Lessons learned were used as opportunities to support, mentor staff and implement good practices. We were confident that incidents were logged, reported appropriately, were discussed and reviewed in the morning risk meetings, handovers and clinical governance meetings.

Both wards used appropriate systems and governance processes, and we found that incidents and complaints were effectively managed to promote learning and improvement. For example, following an incident on Bearsted ward, where a patient’s depot injection was missed, the team had learned to deploy two nurses to check depot administration documents, so patients’ depot due dates were not missed. Staff attended a weekly meeting to share lessons learned and received emails with lessons learnt which included a weekly newsletter update. Staff on Roseacre ward also said that there was a poster in the handover room with lessons learnt displayed on it.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong.

Some Patients we spoke with told us that staff spent time with them following incidents, providing emotional support and ensuring they felt safe on the ward. Staff used lessons learned from incidents to inform and update care planning and risk assessments.

Staff on both wards were debriefed and received support after a serious incident.

We scored the service as 3. 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.

Managers of both Roseacre and Bearstead wards told us they reviewed and assessed patients’ referrals into the service in collaboration with members of the multi-disciplinary team to ensure the care and support available was suitable for the patient. Managers ensured only appropriate referrals were accepted to ensure patient and staff safety and well-being. 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.

Both wards had appropriate systems and governance processes that supported safe admissions, discharges and transfers of care. Staff had a good understanding of the processes and policies to ensure transitions between services were managed well.

Staff on both wards were aware of potential risks to people across their care journey and worked to ensure sufficient and appropriate information was shared during referral, admission and discharge processes. Staff worked together towards the best outcome for the patients. Roseacre ward had 5 successful discharges over the past year.

Patients we spoke with understood their care and treatment and reason for admission and staff were helpful in explaining information to patients who did not agree with their admission and worked with them towards discharge.

We scored the service as 3. 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.

Patients we spoke with on both Roseacre and Bearstead wards felt safe and told us they were supported to understand and manage risks on the wards. Staff we spoke with were knowledgeable about safeguarding and any potential safeguarding concerns were discussed in morning risk meetings, handovers, clinical governance and multidisciplinary meetings.

Staff demonstrated their understanding of how to recognise a safeguarding concern and how to protect patients and staff from abuse, including how and who they should report their concerns to.

The service had safeguarding leads who supported the management team by submitting safeguarding concerns, kept the team up to date with changes in policy and provided advice and support to staff. At the time of our assessment staff on both wards had a 100% completion rate for level 3 safeguarding training.

The wards did not have blanket restrictions in place, and staff regularly reviewed restrictions to ensure they were clinically justified. For example, we saw a restrictive a practice poster which was displayed on boards in the communal areas of the wards. However, even though it was stated there that patients had access to drinks, we did not find cups, tea, coffee or any healthy snacks available. We approached a staff member who agreed drinks should have been available for patients. This was feedback to the team.

The manager told us they engaged in a blanket restrictions audit and reviewed blanket restrictions every 6 months. The manager also reviewed the blanket restrictions list with information on reasons for the restrictions. The provider had a Psychiatric Intensive Care Unit (PICU) steering group that periodically discussed restrictive practice across Cygnet. Patients accessed outdoor areas and sensory rooms with staff supervision. Patients’ restrictions were kept to a minimum and appropriately care planned. Staff told us they worked closely with patients to manage their risks and used de-escalation techniques to support distressed patients instead of using restrictive interventions.

Bearstead ward had access to a seclusion room. Staff and management tried other means of support such as verbal de-escalation before placing a patient in seclusion.

Mental Capacity Act

Staff and managers on both wards had a clear understanding of safeguarding, the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS) with information about safeguarding and how to raise concerns on displayed in staff and patient areas.

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.

Staff received and kept up to date with training on the Mental Capacity Act and had a good understanding of the five principles. Training on the Mental Capacity Act was mandatory, and the compliance rate was 100% for all staff.

Staff knew where to get advice from the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions.

For patients who might have impaired mental capacity, staff assessed and recorded their capacity to consent appropriately staff members did this on a decision-specific basis regarding significant decisions. We saw evidence of this in patient records.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. We saw evidence of this in patient records.

Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies.

The service had arrangements to monitor adherence to the Mental Capacity Act.

Staff audited the application of the Mental Capacity Act and took action on any learning identified.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs that was safe, supportive and enabled patients 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 used restraint and seclusion only after attempts at de-escalation had failed. 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 on both wards told us they felt safe on the wards and were supported to understand and manage their risks.

We reviewed 10 patient records, and all records had an up-to-date risk assessment in place. Risk assessments covered key areas and captured relevant information to support the ongoing management of risk.

Staff involved patients in care planning and risk assessment shown by evidence in their care plans. Patients participated in multidisciplinary team reviews and had access to a copy of their care plan.

All patients we spoke with on both Roseacre and Bearstead wards felt safe and supported to manage their risks. Patients felt confident to raise concerns and felt involved in their care and treatment. Appropriate systems and governance processes were in place to promote and ensure good risk management.

All the wards had outside space that patients could access. Bearsted ward had a secure garden with benches, astroturf and gym equipment. Patients on Bearstead ward had access to their garden until midnight.

Staff were aware of the risks of each patient, and changes in risk were updated in patient records, care plans and risk assessments, and information shared during staff handovers.

Patients were involved in weekly community meetings which enabled patients to provide feedback about their care and were able to raise concerns with support from advocates.

We scored the service as 3. 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.

Staff we spoke with on both wards displayed a good understanding of environmental risks. Staff had received training and were aware of ligature risk assessments that had been completed and described how they used individual risk assessments, care planning and observations to manage environmental risk. New staff received ligature awareness training as part of their induction. Staff were aware of fire evacuation procedures and reported regular drills and alarm tests. Fire notices were displayed on the wards.

Seclusion rooms on Bearstead ward had mirrors and Closed-Circuit Television (CCTV) installed for monitoring blind spots, had a separate toilet and shower, and had a clock installed on the wall so patients could see the time. There was a screen for staff to check the shower room. The seclusion room also had a two-way intercom and a window to receive natural light. There was a board that staff posted information for patients to plan their day including their medical reviews.

No ligature anchor points were seen on the wards and in communal areas. For example, both wards had anti barricade doors, collapsible curtain rails and appropriate windows. Staff had easy access to alarms and patients had easy access to nurse call systems.

The layout of both wards allowed the nursing staff to have good lines of sight from the nurses’ office into the communal ward areas and into the bedroom corridors. The wards also had parabolic mirrors mounted at corners to ensure that all areas were clearly visible. CCTV was installed to monitor the communal areas on both wards. Staff did not continuously monitor the CCTV. CCTV was monitored only as needed. Staff told us CCTV was in place to safeguard patients and staff and to review incidents as part of their learning from incidents should an incident happen.

The ward mitigated ligature risks using mirrors and staff members were always present in specific areas.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We scored the service as 3. 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.

Managers had calculated the number and grade of nurses and healthcare assistants required and they matched this number on all shifts. Staff and patients told us that they felt there were always enough staff around to meet the needs of the patients.

The ward manager could adjust staffing levels daily to take account of case mix. Due to fluctuating levels of observations and changing needs of patients, staff were sometimes required at short notice; the managers utilised effective systems to ensure these staff were provided.

When necessary, managers used agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

Staffing levels allowed patients to have regular one-to-one time with their named nurse. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

There were enough staff to carry out physical interventions, for example, observations, restraint and seclusion safely. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had received and were up to date with appropriate mandatory training. Overall compliance with mandatory training was above 98%. The training was appropriate for the patient group using the service.

Staff received regular supervision monthly. Managers monitored compliance with supervision. Reasons for supervision not taking place were documented and mostly included staff members being off sick or on leave.

Staff were given a comprehensive induction to the service to ensure they were prepared for the role. Managers monitored staff competencies on an annual basis to ensure staff were competent to carry out their duties. The competencies monitored were medication (for registered nurses), seclusion and observations.

Leaders supported staff to develop through yearly, constructive appraisals of their work. All staff across the service were up to date with their appraisal at the time of the inspection.

We scored the service as 3. 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.

Staff and patients did not raise concerns in relation to infection prevention and control (IPC). Patients we spoke with on both Roseacre and Bearstead wards said facilities on the wards were clean and well maintained.

Staff had access to infection prevention and control resources including personal protective equipment, hand gel and cleaning materials. We observed staff following infection control principles including using handwash. Cleaning records were up-to-date, and clinical equipment was appropriately cleaned and maintained. Domestic staff were visible during the assessment.

The service completed infection prevention and control checks and audits to ensure required standards were met. Staff had access to an infection prevention and control policy and support and guidance was readily available. Compliance rates for infection prevention and control training was above 98% on both Roseacre and Bearstead wards.

We scored the service as 3. 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.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication.

The service had systems and processes in place to safely administer, and record medicines use. Prescription and administration records were regularly reviewed by a multi-disciplinary team.

Prescribed medicines were given in line with relevant Mental Health Act ‘consent to treatment’ authorisations where needed.

Medicines were stored safely and securely. There were robust and regular stock checks of controlled drugs and drugs liable to misuse.

The use of medicines to manage anxiety and agitation were low. Rapid tranquilisation (RT- the process of administering a medicine intramuscularly for rapid sedation) was used as a last resort and staff actively worked to use alternative person-centred ways to de-escalate without the need to administer RT. The service tried to limit the use of PRN (‘when required’) but when PRN medicines were used the reason for their use and what else had been tried first was clearly recorded on the daily electronic care records.

Patients who were prescribed medicines which required additional physical health monitoring had this completed. Staff created robust records to support this monitoring, and paper records were uploaded onto the electronic care record in a timely way.

Patients were supported to self-administer their own medicines to promote independence and understanding of their treatment. Staff completed risk assessments and checks to ensure people continued to take their medicines as prescribed.