Cygnet Nield House

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 patients were protected from abuse and avoidable harm. At our last inspection we rated this key question as Requires Improvement. At this assessment the rating has changed to Good.

There were effective systems and processes to protect patients from abuse and neglect. Staff understood how to protect patients from abuse. Staff completed risk assessments for patients.

Environments were clean, well-maintained and fit for purpose. Ligature risk assessments were up to date and staff managed environmental risks effectively.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients said they generally felt safe in the hospital, although sometimes they felt scared when an incident was happening on the ward. Patients and carers knew how to raise their concerns, or seek out help from staff.

Staff understood what type of incidents to report and were able to describe the process for reporting, reviewing and responding to incidents. Staff gave examples of learning and improvements that had been made following incident investigations. Staff understood the processes for managing and investigating complaints and supported patients and carers to raise concerns.

Managers described examples of incidents that had occurred, and the action that had been taken to remove or reduce the risk of them happening again.

The provider had systems and governance processes to support the effective management of incidents and complaints, and to promote learning and improvement following them.

Staff had access to a range of policies and procedures for additional guidance. There was a clear process for staff whistleblowing and access to a Freedom to Speak Up Guardian.

Patient and carer feedback was mixed about their experience of planning for discharge. Most patients and carers were positive about this and felt they had been involved in make decisions and developing their discharge plans. However, some patients had come up against barriers in the process, though it was not clear if this was from staff at the hospital, or with services in the community.

Staff worked collaboratively with each other and external stakeholders to promote joined-up care and ensure transitions between services were manged well. Staff had a good understanding of the processes and policies relating to referral, admission, transfer and discharge. Staff felt able to support patients along these pathways and were able to give examples of when they had done so. Staff were aware of the risks to patients across their care journey and worked to ensure sufficient and appropriate information was shared throughout the process.

The local host commissioners requested feedback from commissioners for each patient on the ward, in order to any identify any themes and trends, or areas of positive or concerning practice. The hospital managers and local host commissioners met every 3 months, and reviewed information submitted by the managers. No issues were raised about this quality statement.

The service had systems and governance processes in place to support safe admissions, discharges and transfers of care. The ward had a model of care which included clear admission criteria for patients. Staff sought comprehensive information about people as part of their pre-admission assessment. This information was discussed within the multidisciplinary team, so that they could ensure they were able to meet the needs of the person. Each patient’s discharge was discussed throughout their stay on the ward, and staff worked with representatives from the patient’s home care team towards this.

Patients said they generally felt safe in the hospital, although sometimes they felt scared when an incident was happening on the ward. Patients and carers knew how to raise their concerns, or seek out help from staff.

Staff and managers had a clear understanding of safeguarding and the Mental Capacity Act (MCA).

Staff we spoke with described what constituted a safeguarding concern and how they would protect patients from abuse. Staff knew how to report any safeguarding concerns. Staff knew where to seek further support or advice when required. The service had safeguarding leads that were able to provide advice and support to staff.

Staff were aware of the principles of least restrictive practice, and could describe the restrictions on the ward for individuals or everyone, and the rationale for these.

Information about safeguarding and how to raise concerns was on display in staff and patient areas.

We observed a daily morning meeting, where managers and staff discussed potential safeguarding concerns, and the actions that needed to be taken to keep patients safe.

There was a family visiting room outside the main ward area, where patients could meet with their visitors including children.

The service had appropriate systems and policies to ensure patients were safeguarded. Staff had receive training in safeguarding, the Mental Capacity Act and least restrictive practice. 94% of staff in the hospital had completed online safeguarding training, and 71% face-to-face training. 97% of staff had completed Mental Capacity Act training.

Restrictions on the ward were reviewed for individuals during multidisciplinary team meetings, and for the ward overall during community meetings and as part of the governance process.

Patient feedback was mixed about how involved they felt in the care. Most patients felt involved in the development of their care and risk plans, but some patients felt that decisions were made about them and not explained. Patients routinely attended the multidisciplinary team meeting and could easily contact their consultant. Some patients had a positive behavioural support plan that described for staff how the person wanted to be supported if they were unhappy or in distress.

Staff understood the restrictions placed on patients and the reasons for them. They were also aware of the principles of least restrictive practices, and were mindful that they were working towards patients moving onto a less controlled environment, such as their own homes. Staff were aware of patient’s positive behavioural support plans, that were developed with patients.

Staff attended a documented handover meeting at the beginning of each shift. This included key information about each patient, including any changes and their current level of risk.

Staff had received training on how to physically restrain a person in as safe a way as possible when this was required, as well as positive holds and de-escalation techniques.

The service had systems and governance processes in place to promote and ensure good risk management.

We reviewed 5 patients’ records and all of them 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. They used a recognised assessment tool.

The service had a reducing restrictive practice policy. Managers monitored and reviewed the use of restrictive interventions through the daily morning meeting, and through the governance process. This included the use of enhanced observations, physical interventions or restraint, and rapid tranquilisation.

Patient and carer feedback was mostly positive about the environment. It was usually clean and tidy, and a welcoming space. Patients liked the sensory room, and had been involved in its design. Patients liked the new patients’ kitchen, but were disappointed that it had only been open briefly and had then been closed for repair. Patients told us that the dining room could be cramped when lots of people were eating and being supported by staff at the same time. Patients had controlled access to the garden, which was shared with the other ward in the hospital. Some patients used the garden for smoking or vaping, which other patients did not like.

Staff were aware of environmental risks and how these were mitigated. They knew that some patients had supervised or unsupervised access to certain areas of the ward because of their assessed risk.

Managers had oversight of environmental risks, and had taken actions to remove or reduce these. Staff carried out routine checks of the environment, and reported any areas that presented a risk to patients or required maintenance.

The ward was generally clean and well-maintained. Patients had been involved in putting decorations and information on the walls. This included a recovery/discharge tree and positive messages.

All bedrooms were single with an ensuite shower and toilet. There was limited communal space on the ward in relation to the number of beds. Patients could use the sensory room which was open at all times. Patient had access to a kitchen to support them with food preparation, however this was closed for essential repairs.

Patients and staff had access to alarms to call for urgent assistance. The emergency alarms had been changed to silent alarms, which reduced the impact on patients, particularly those with sensory needs.

Staff could not easily observe patients in all areas of the ward, but this had been partially mitigated by the use of mirrors and CCTV, and routine observation by staff.

Emergency equipment was stored safely, but was still easily accessible by staff.

Managers used a standard framework to assess environmental risks, which had been updated to reflect national guidance. Following the risk assessment, action was taken to remove or reduce any risks identified.

Routine maintenance and inspection was carried out and any necessary remedial work undertaken. This included of gas, electricity and water supplies, and of equipment in the building such as electrical appliances, emergency lighting and the lift.

Patient and carer feedback was positive about staff, who they generally found kind and supportive. Patients said that there were not enough staff, and this sometimes stopped them having leisure leave or going shopping, or made it difficult to talk to staff particularly if there was an incident. Patients said there were usually more temporary staff at night, who they found less supportive.

Staff told us there had been staffing challenges on the ward, but this was generally described as being better at the moment. Bank and agency staff were used, and this could be difficult having new staff, but many of them were familiar with the ward and patients. New bank staff had the standard staff induction which included a shadow shift. New agency staff were shown around the ward and introduced to patients. There was usually more agency staff usage at night.

Staffing was discussed at the daily morning meeting, and staff were moved between wards if necessary. High levels of one-to-one observations could lead to difficulties in staffing.

Staff told us they received supervision and appraisal, and were up to date with their mandatory training. Staff also had access to additional training.

We observed sufficient numbers of staff on the wards to facilitate the delivery of safe care and treatment. Staff were a visible presence in communal areas. We observed therapeutic engagement between staff and patients. There were sufficient staffing levels to meet the required level of observations.

We observed a daily morning meeting where managers and staff discussed staffing across the hospital. They discussed the immediate staffing levels for today, and the next few days, and made adjustments and changes where necessary. They identified factors that impacted on staffing levels such as how busy the wards were, enhanced observations, patients having leave off the ward, and other activities. They took account of the number of staff, but also whether staff were permanent or temporary, new or experienced, and male or female. Vacancies and recruitment of nurses and support workers, as well as medical staff and allied health professions was also discussed.

Managers monitored staffing levels through daily meetings and governance processes. The service had had vacancies across all professions including doctors, nurses, support workers, psychology and occupational therapy, but most of these had now been recruited to or were waiting for staff to start.

The recruitment process was carried out centrally by the provider, but interviews and decisions about the appointment of staff remained with the local manager. There had been problems with information being shared with managers following the introduction of a new IT system, but staff were now managing this.

97% of ward staff had completed all their mandatory training. Staff had completed other essential training for working on the ward, which included awareness of self harm and suicide, personality disorder, and nasogastric feeding.

Staff received regular supervision. There was a policy and guidance documents to support the supervision process and promote development. At the time of our assessment supervision compliance for qualified nurses was 58%. Supervision compliance for health care support workers was 72%.

Patients told us the ward was usually clean, but sometimes it could be untidy, or there might be areas that needed dusting. Patients were supported to clean and tidy their rooms.

Staff had access to cleaning materials and personal protective equipment (PPE). Cleaning was carried out by housekeeping staff and support workers. Staff had completed infection prevention and control training.

The ward looked clean, tidy and was generally well-maintained. Cleaning materials were available and in good condition. Infection prevention and control information was displayed in appropriate areas. For example, there was handwashing information over handwashing sinks, and separate colour-coded mops and buckets for use in general areas, kitchens and toilets.

Staff used separate bags and containers to dispose of waste correctly. This included general and clinical waste, and sharps bins which were stored safely.

Staff followed a routine cleaning schedule, which included daily, weekly and periodic tasks. Staff completed cleaning records, which were routinely reviewed and showed that follow-up actions had been taken.

95% of staff in the hospital were up to date with the mandatory infection prevention and control training.

The hospital had procedures for preventing and managing outbreaks of infection.

Patients told us they could easily contact the doctor if they wanted to discuss their care and treatment. Each patient’s medicines were routinely discussed as part of their monthly multidisciplinary team meeting.

Staff completed training and passed a competency assessment before they administered medicines.

Staff raised no concerns about the management and supply of medicines.

Medicines, including controlled drugs, were stored and disposed of securely and appropriately.

Prescription charts were mostly completed correctly. However, as required medicines (often called “PRN”) were not always reviewed regularly to check that they were still necessary. Any medicines errors were dealt with promptly. They were reported and discussed in the daily morning meeting and any further action taken.

Staff reviewed the effects of medicines on patients’ physical health regularly and in line with the National Institute for Health and Care Excellence (NICE) guidance. This included for patients who were taking medicines such as clozaril, which requires additional monitoring.

An external pharmacist carried out an audit every month. They sent the service a report which highlighted any errors or areas for improvement. The service took action and had to record this on the report before it was marked as completed. The external pharmacist provided information about news and alerts related to medicines. Managers monitored the medicines audits and discussed the alerts, and any actions required, through the monthly clinical governance meeting.