Cygnet Hospital Harrow

Updated 17 April 2025

Date of assessment: 4 December to 11 December 2024.

Cygnet Hospital Harrow provides a range of diagnostic, assessment, treatment and inpatient services for men with mental health needs and who also have a dual diagnosis of autism. The hospital recently underwent a full refurbishment and reorganisation of its services. This involved some wards closing and some re-opening under new ward names.

This assessment was a comprehensive unannounced assessment of all wards currently open. This included: West Ward, the acute mental health ward for adults of working age; and Springs Service (Springs Wing and Springs Centre), which are wards for people with learning disabilities or autism. The psychiatric intensive care unit, named Roxeth Ward, was not yet open at the time of our assessment. The overall rating of Cygnet Hospital Harrow has improved to Good.

Action the provider MUST take is necessary to comply with its legal obligations. 

Action the service MUST take to improve wards for people with learning disabilities or autism:

• The provider must ensure that rooms used for seclusion are fit for purpose, as detailed in the Mental Health Act (MHA) Code of Practice 2015. 

Updated 20 December 2024

This assessment of West Ward took place on 4 December 2024. West Ward is an acute mental health ward for adults of working age. The ward has capacity for up to 18 patients. On the day of our inspection, there were 11 patients on the ward. The ward only admitted male patients. West Ward had opened on 16 October 2024. The service replaced the acute service for adults of working age that had been provided on Byron Ward. Data presented in this report covers both Byron Ward and West Ward. We conducted this inspection to follow up concerns raised at our last inspection in May 2023. At that inspection, we rated the service as inadequate. At this inspection we found that the service had made considerable improvements. During this inspection we found no breaches of regulation.

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff anticipated and managed risks to patients. They minimised the use of restrictive practices and followed good practice with respect to safeguarding. All staff reported incidents and near misses. However, there was some scope for improvement in the management of some medicines and in recording the action taken after patients received rapid tranquilisation.

The service took a holistic approach to assessing, planning and delivering care and treatment to all people who use services. This included addressing, where relevant, physical health needs. Staff developed appropriate care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. All staff were actively engaged in activities to monitor and improve quality and outcomes.

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. Most patients gave positive feedback about the staff. The service had a pro-active ‘experts by experience’ programme to engage patients in developing the service.

The service provided person-centred care. Staff planned patients’ discharge, collaboratively with each patient’s local service. Staff responded to the religious and cultural needs of patients. The service displayed information about how patients and carers could make a complaint and ensured that complaints were investigated.

Leaders at all levels demonstrated appropriate experience, capacity and capability needed to deliver care. Staff held a shared purpose. Governance arrangements enabled senior staff to have a good oversight of the service. Staff felt confident that they could raise concerns if they became aware of poor practice. They were working on initiatives to improve specific aspects of service delivery. However, the daily tasks of the ward manager tended to focus on administration and oversight. The service may benefit from ward managers engaging more with staff and patients.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

The service admitted patients under the Mental Health Act 1983. At the time of the inspection, five patients were detained in hospital for assessment and three patients were detained for treatment. Three patients were not detained under the Act.

Staff received and kept up-to-date with training on the Mental Health Act and the Mental Health Act Code of Practice and could describe the Code of Practice guiding principles. Training on the Mental Health Act was mandatory for staff and the compliance rate was 91%.

Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice. Staff received assistance from the Mental Health Act manager, based at the hospital.

The service had clear, accessible, relevant and up-to-date policies and procedures that reflected all relevant legislation and the Mental Health Act Code of Practice. For example, the pharmacist’s weekly audit of medicines included checks to ensure that medicines prescribed to patients detained under the Mental Health Act had the appropriate certification. When the pharmacist found medicines that were not included in the certification, this was reported to the ward manager.

Staff explained to each patient their rights under the Mental Health Act in a way that they could understand, repeated as necessary and recorded it clearly in the patient’s notes each time. This was recorded in the patient's record. The multidisciplinary team explained patients’ rights to them during ward rounds. This included discussions about the right to appeal against detention.

Staff made sure patients could take section 17 leave (permission to leave the hospital) when this was agreed with the responsible clinician. The use of leave from the ward was agreed by the multidisciplinary team. Arrangements for leave were made at the daily planning meeting.

Staff requested an opinion from a Second Opinion Appointed Doctor (SOAD) when they needed to, although at the time of the inspection, none of the patients fell in scope of this requirement.

Staff stored copies of patients’ detention papers and associated records correctly and staff could access them when needed. The original copies of detention papers were held in locked filing cabinets in the Mental Health Act office. Copies of these documents were held on the ward.

Mental Capacity Act

Staff received and kept up-to-date with training in the Mental Capacity Act and had a good understanding of the five principles. Training on the Mental Capacity Act was mandatory for staff. This training was provided as part of the induction process.

Staff assessed and recorded capacity to consent clearly each time a patient needed to make an important decision. Staff completed an assessment of each patient’s capacity to consent to admission and treatment on admission. Further assessments took place during reviews by the multidisciplinary team.

Updated 20 December 2024

The assessment of Springs Service took place on 4 December to 11 December 2024. Springs Servicecomprised of two wards: Springs Wing and Springs Centre, which are wards for people with learning disabilities or autism who may also have a co-existing mental health condition. Springs Wing had capacity for 10 patients, and Springs Centre had capacity for 14 patients. On the day of our inspection, there were 7 patients on each ward. Springs Service only admitted male patients.

We conducted this comprehensive assessment to follow up concerns raised at an inspection in May 2023. The overall rating for the service is nowgood, with notable improvements since the inspection in May 2023, which identified multiple breaches of regulations. These improvements reflect significant efforts by the service to address identified gaps and enhance care quality. During this inspection we found one breach of regulation.Springs Centre was using a vacant bedroom for the seclusion of one patient, that did not meet seclusion room specification. The provider must ensure that rooms used for seclusion are fit for purpose, as detailed in the Mental Health Act (MHA) Code of Practice 2015. We have asked the provider for immediate assurances around how they will ensure this room is fit for purpose.

Springs Service mostly provided safe care.The ward environments were safe and clean. The wards had enough nurses and doctors. Staff anticipated and managed risks to patients. Improvements were noted in incident reporting, staff training and safeguarding practices. However, the use of a vacant bedroom as a seclusion room on Springs Centre did not comply with national guidance and posed safety risks. Site refurbishment noise also impacted the atmosphere of the wards, though some mitigation efforts were in place.

The service provided personalised care plans, regular multidisciplinary reviews, and tailored therapeutic interventions. Staff compliance with mandatory training, including autism-specific modules, was high, supporting better patient outcomes. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.

Staff treated patients with compassion, empathy and respect, promoting positive interactions and person-centred support. Patients reported feeling understood and supported by staff, who provided tailored activities and communication aids. The service had a pro-active ‘experts by experience’ programme to engage patients in developing the service.

The service provided person-centred care. Patients benefited from co-produced care plans, meaningful activities, and efforts to maintain family connections. Staff supported patients to meet their religious and cultural needs. Some challenges remained in evening activity engagement and reducing blanket restrictions, such as the locked kitchen in Springs Centre.

Leaders at all levels were knowledgeable, experienced and capable. Leaders had a clear vision for quality improvement and a proactive governance framework, enabling senior leaders to have good oversight of the service. Staff reported improved morale and confidence in senior management, reflecting a positive cultural shift.

We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

The service admitted patients under the Mental Health Act 1983. At the time of the inspection, all 14 patients in Springs Service were detained in hospital for treatment. Patient’s observation levels by staff varied from general observations, one-to-one, two-to-one and four-to-one.

Staff received and kept up to date with training on the Mental Health Act and the Mental Health Act Code of Practice. Staff could describe the Code of Practice guiding principles. This training was initially provided as part of the induction process and thereafter staff had regular refreshers. In Springs Service, 94% of staff were compliant with their training in the Mental Health Act.

Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice. Staff received assistance from the Mental Health Act manager, based at the hospital.During the morning staff huddle, we saw that the Mental Health Act Manager identified actions or paperwork that was required for specific patients on different days. This included flagging important upcoming meetings such as patient tribunals.

The service had clear, accessible, relevant and up-to-date policies and procedures that reflected all relevant legislation and the Mental Health Act Code of Practice. Staff explained to each patient their rights under the Mental Health Act in a way that they could understand, repeated as necessary and recorded it clearly in the patient’s notes each time. This was recorded in the patient's record. The multidisciplinary team explained patients’ rights to them during ward rounds. This included discussions about the right to appeal against detention.Information on the Mental Health Act and independent mental health advocacy was available in easy read formats on the ward notice boards.

Staff stored patients’ detention papers and associated records correctly and staff could access them when needed. The original copies of detention papers were held in locked filing cabinets in the Mental Health Act office. Copies of these documents were held on the ward.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave the ward or hospital) when this has been granted. The use of leave from the ward or hospital was discussed and agreed with the multidisciplinary team. Arrangements for leave were made at the wards’ daily planning meeting.

Mental Capacity Act

Staff received and kept up to date with training in the Mental Capacity Act. Staff had a good understanding of the five principles. Training on the Mental Capacity Act was mandatory for staff. This training was initially provided as part of the induction process and thereafter staff had regular refreshers. In Springs Service, 94% of staff were compliant with their training in the Mental Capacity Act.

Springs Service had a dedicated hospital social worker. Their role involved reviewing patients’ mental capacity assessments and legal status prior to discharge. They could detail upcoming discharges, and who would require a deprivation of liberty safeguards application for their new placement.

Staff assessed and recorded capacity to consent clearly each time a patient needed to make an important decision. Staff took all practical steps to enable patients to make their own decisions. Staff completed an assessment on admission of each patient’s capacity to consent to admission and treatment. Further assessments took place during reviews by the multidisciplinary team.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards. Staff told us that they found the social worker and safeguarding leads to be approachable and responsive.

Updated 18 October 2023

Our rating of this service went down. We rated it as inadequate because:

• Springs Unit is described as being a specialised service for men with a diagnosis of autism spectrum disorder. However, our inspection found that the service was not meeting the needs of autistic people using this service.
• Nursing and care staff were not adequately trained to communicate effectively with people using the service. This meant that while people felt safe, they did not feel treated with compassion and kindness. Some people said they did not have a positive rapport with the staff. The approach of the nursing and care staff was at times custodial and threatening rather than supportive. Staff did not communicate consistently with the people which caused them to be distressed.
• The environment was not suitable for autistic people. The environment was institutional, noisy with alarms ringing, the lighting was too harsh. There were no plans in place with clear timescales for improvements to take place.
• Restrictions were not always recognised or reviewed on a regular basis. One person was wearing handcuffs (a mechanical restraint) when travelling to appointments at the acute hospital and this restraint had not been reviewed by the clinical team.
• People were living on the units for lengthy periods of time but were not having health checks such as appointments with the optician or dentist or an annual health check with their GP.
• People were not being offered sufficient therapeutic activities at the weekend which meant they did not have a structure which met their individual needs.
• Some basic safety measures were not in place. Checks of equipment used for resuscitation were not taking place regularly which was outstanding from the previous inspection. People were not recorded as having the correct monitoring after receiving rapid tranquilisation. Controlled drugs were not always being administered correctly.
• The ward was not kept adequately clean. One person was in seclusion for 17 hours before smeared faeces was cleaned up.
• Incidents were not always reported so there was not sufficient management oversight.
• Care records including seclusion records were poorly organised and badly filed.
• The provider recognised that the food was not always of good quality. Some relatives said people were gaining weight.
• Governance processes were not sufficiently robust and had not identified many of the issues found in the inspection.
• Carers were not adequately informed and engaged in the operation of the service.

However:

• Some person-centred work was taking placed by the allied health professionals and psychologists to promote positive care.
• Therapeutic activities took place during the week including some community-based activities.
• Staff had a good understanding of safeguarding processes.
• Staff supervision had improved since the previous inspection.
• Staff understood the risks for people using the service and carried out thorough handovers between shifts.
• Staff worked well with external stakeholders and professionals to support people’s discharge plans.
• The provider had improved the level of mandatory training compliance since our most recent inspection.

Updated 18 October 2023

Our rating of this service went down. We rated it as requires improvement because:

• Springs Wing is described as being a specialised service for men with a diagnosis of autism spectrum disorder. Whilst our inspection found that the service was generally meeting people’s day to day care needs, staff did not receive specialist communication training to be able to effectively communicate with autistic people who used the service. Staff only had access to basic awareness training which meant they would not be appropriately trained in how to communicate with people using the service and how to use a range of communication aids.
• Restrictions were not always recognised or reviewed on a regular basis. The provider was unable to evidence that restrictions on the ward was routinely reviewed in between the hospital’s restriction audit that took place every 6 months.
• The ward had not ensured that they had become fully compliant with the requirement notice that the CQC issued following our most recent inspection in 2018 that related to the calibration of physical health equipment. During our latest inspection in May 2023, we identified physical health equipment that had not been appropriately calibrated, increasing the risks to people’s health and wellbeing.
• The hospital induction checklist record did not include a prompt to ensure the staff member was shown the ward ligature points and how they were managed. At the time of inspection, a few members of staff we spoke with were not aware of the environmental risks and management plan in place.
• People were living on the rehabilitation ward for autistic people for lengthy periods of time but were not having routine health checks such as appointments with the optician or dentist or an annual health check with the GP. Autistic people have a shorter life expectancy as their physical health needs are often not met and so it is important these health care appointments take place. Some carers said people were gaining weight and they did not feel as though the service was supporting them to reduce it.
• Governance processes were not sufficiently robust and had not identified some of the issues found in the inspection.
• People did not always receive a copy of their care plan.
• The care record system in place was not easy to follow. Information and people’s care and treatment was stored across two separate electronic care record systems as well as in paper folders.
• Carers were not adequately informed and engaged in the operation of the service.

However:

• Person-centred work was taking placed by the allied health professionals and psychologists to promote positive care.
• People were encouraged to attend therapeutic activities and leave the ward to visit the community. Some people took part in community-based activities such as swimming and voluntary work.
• Staff had a good understanding of safeguarding processes.
• Staff supervision had improved since the previous inspection.
• Staff understood the risks for people using the service and carried out thorough handovers between shifts.
• Staff worked well with external stakeholders and professionals to support people’s discharge plans.
• The provider had improved the level of mandatory training compliance since our most recent inspection.