The Care Quality Commission (CQC) has taken action to protect people at Cygnet Wast Hills in Bromsgrove and told the hospital to make improvements to ensure people’s safety.
CQC undertook an unannounced, focused inspection of the hospital in May, after receiving concerns from commissioners regarding patients being at risk of injury, poor communication from leaders and a lack of activities for patients.
Cygnet Wast Hills is an independent hospital providing assessment, treatment and care to people with a complex learning disability and autistic people.
Following the inspection the provider was told to submit an action plan within 24 hours that described how it was addressing the concerns found.
This inspection sees the overall rating for Cygnet Wast Hills move from good to inadequate. It is rated good for being caring and responsive, requires improvement for being effective and inadequate for being safe and well-led.
Deborah Ivanova, deputy chief inspector for people with a learning disability and autistic people, said:
“When we inspected Cygnet Wast Hills, we were not assured all reasonable steps were being taken to protect people from avoidable harm.
“Staff didn’t take the time to interact with patients during observation periods and we saw one patient sat alone in their room with the door closed.
“We were concerned that three patients had harmed themselves on more than one occasion whilst on high level observation, when staff should have been watching them closely.
“One person had been able to bang their head repeatedly in the bathroom for example and although staff increased their observations, care records showed this had already been recorded as happening three times previously, so staff weren’t learning how to intervene early and prevent this happening.
“These incidents weren’t always recorded either, which increased the chances of them reoccurring.
“We saw a lack of meaningful activities for patients with many just watching TV and lying on the sofa. However, managers had recognised this needed to change and were working on a project to improve this so patients could enjoy activities and live more fulfilling lives at the service.
"We spoke with Cygnet about addressing our findings as a priority and told leaders to submit a report detailing what action it will take to address the issues raised. “We will continue to closely monitor the service and will return shortly to check on progress.”
Inspectors found several areas of concern, including:
- Records were not always completed consistently or were missing which put patients at further risk of harm
- Some patients continued to harm themselves despite having completed risk assessments and during high level nursing observations
- The service had not always managed patient safety incidents well and staff did not always report incidents appropriately
- Not all staff had enough awareness of policies and procedures. For example, physical health policies such as rapid tranquilisation and neuro observations had not been followed correctly
- Governance processes did not operate effectively, and there was not enough oversight of the service to ensure performance and risk was well managed.
However, inspectors also found:
- Staff had the skills to develop and implement support plans to enable them to work with patients who displayed challenging behaviour
- Staff developed holistic, recovery-oriented care plans and provided a range of treatments to meet the needs of patients
- Most staff were knowledgeable about patient needs and could describe their likes and dislikes and knew how to care for them safely
- Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care
- Staff treated patients kindly and respected their dignity and privacy
- The provider promoted equality and diversity in its daily work and provided opportunities for career progression
- Staff felt able to raise concerns without fear of retribution.
Full details of the inspection are given in the report published on our website.
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