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Psychiatric Intensive Care Unit at Cygnet Hospital Godden Green Requires Improvement, say CQC inspectors

8 January 2021
Cygnet Hospital Godden Green
  • Media

The Care Quality Commission (CQC) has told Cygnet Hospital Godden Green in Sevenoaks, Kent, that it must embed the improvements made to its Psychiatric Intensive Care Unit (PICU), following an inspection which took place in November.

CQC previously visited the hospital on 23 September to inspect the Knole and Riverhill wards, which provide Child and Adolescent Mental Health Services (CAMHS). Following this inspection, the provider, along with system partners, took the decision to close the CAHMS service permanently and reopen it as a female acute ward.

Inspectors returned on 2 October to review Castle ward, a PICU for adult women, following concerns raised about the safety and wellbeing of patients on the ward by members of the public, relatives and professionals. After this inspection, CQC issued a letter outlining improvements that needed to be made and asking Cygnet Hospital Godden Green to provide an action plan explaining how and when these improvements would be put in place and embedded.

The latest visit, on 10 November, was an unannounced inspection of the PICU ward. The service was rated Requires Improvement overall and for each of the key questions in relation to whether the services are safe, caring, responsive and well-led. The service was rated Good for its effectiveness.

Karen Bennet-Wilson, CQC’s head of hospital inspection for mental health, said:

“Following our latest inspection of Cygnet Hospital Godden Green’s Psychiatric Intensive Care Unit, we told the provider that although the service had made a number of improvements, there was still much to do to fully embed those, as well as a number of additional improvements that still needed to be made.

“This includes ensuring that all environmental and fixed ligature point risks are identified and removed or managed appropriately, and that dangerous items are stored securely. Personal evacuation plans must also be developed to ensure that patients can leave the ward safely during an emergency.

“In addition, the service must ensure that staff only ever use physical restraint as a last resort. Patients must be allowed to make private phone calls, be given access to toilet paper and provided with enough room to store their personal belongings. Staff must also knock before entering a patient’s bedroom, except in an emergency.

“We will continue to monitor the service and ensure that follow-up action is taken.”

During the visit, inspectors found that:

  • Although some improvements had been made since the previous inspection, the management team had not fully embedded the processes to ensure that ward procedures ran smoothly
  • Staff did not always know when it was appropriate to use physical restraint
  • The service had not identified all risks within the ward environment, such as ligature points
  • In the case of an emergency, there were no clear instructions for the emergency services explaining how to assist patients to leave the ward
  • Staff did not always respect the privacy and dignity of patients; they were not able to make private telephone calls on the ward, they did not have enough storage space in their bedrooms, and they were not allowed to keep toilet paper in their rooms
  • Patients and their families or carers were not actively involved in the planning of their care

However, the inspectors noted that there was a new leadership team in place at the hospital with the experience to manage the service. They also found that the wards were clean and had enough doctors and nurses. Patients were offered a range of treatments suited to their needs and in line with national guidance, and families were kept informed about their relative’s care.

Full details of the inspection are given in the report published on the CQC website here.


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Last updated:
08 January 2021

Notes to editors


About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.