Cygnet Hospital Ealing

Cygnet Hospital Ealing provides specialist eating disorder and personality disorder services for women over 18 years.

During this inspection we saw that the service had made the improvements we required it to make following our previous inspection when we placed it in special measure because we had serious concerns about the quality and safety of services. As a result, we have taken it out of special measures. However, a condition to restrict the number of patients that can be admitted to Sunrise Ward (eating disorders) remains in place. This allows the ward to admit a maximum of 10 patients.

Our rating of the service overall improved from inadequate to requires improvement. Our rating for the safe and well led domains improved from inadequate to requires improvement. Our rating for caring improved from inadequate to good. Our ratings for effective and responsive improved from requires improvement to good.

We rated Cygnet hospital Ealing as requires improvement because:

• Whilst governance systems had improved since our last inspection, further work was needed to ensure these were robust and effective in driving safety and improvement of the service, and to ensure they were fully embedded. For example, further work was needed to ensure that themes from informal complaints were captured and reviewed and that complaints were dealt with in a timely manner. Further work was also needed to ensure that all staff were able to access regular team meetings that appropriately addressed the work of the ward.

• Some managers were continuing to receive support to improve and sustain the quality of individual and group supervision sessions.

• On New Dawn Ward, staff were not involved in initiatives to improve the quality of services. Staff on this ward were also not aware of learning from incidents from other hospitals with the organisation or how they may impact on the service they were providing.

• The patient call alarm system had been deactivated and patients could not call for help if they needed to.

• Further work was needed to ensure that the ligature risk assessment for the ground floor area clearly identified what management and mitigation was needed by staff to keep patients safe.

• Systems for recording patient safety incidents needed to be improved to ensure staff could report incidents easily. More robust systems were needed to ensure learning from incidents was shared with all staff.
• Staff were not always familiar with their responsibilities to closely monitor the physical health of patients who had received medication by rapid tranquilisation and Some incidents of restraint on New Dawn Ward were not recorded in line with the providers policy and procedure.

However:

• The ward environments were clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They were working to minimise the use of restrictive practices, managed most medicines safely and followed good practice with respect to safeguarding.

• Staff developed holistic, recovery-oriented 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. Staff engaged in clinical audit to evaluate the quality of care they provided.

• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

• 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.

• The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.

Due to the concerns we found during this inspection, we used our powers under section 31 of the Health and Social Care Act to take immediate enforcement action and placed a number of conditions on the provider’s registration. This meant that the provider could not admit patients to Sunrise Ward until improvements had been made. The imposition of conditions also serves as a ratings limiter for the key questions of safe and well-led for the hospital overall.

We rated Cygnet Hospital Ealing as inadequate because:

• The provider was not delivering safe care. Patients were at high risk of avoidable harm on Sunrise Ward. Four patients had self-harmed during a two-month period when they were being observed on a 1:1 basis by staff. There were shortfalls in the management and recording of some medicines.

• Some nursing staff on both wards did not have experience and were not offered adequate training to enable them to care for patients with an eating disorder or personality disorder. The multidisciplinary team on Sunrise Ward had completed appropriate assessments and care plans, but the nursing team was too disorganised to implement them reliably.

• On Sunrise Ward some nursing staff spoke to patients in an off-hand manner and did not display kindness or compassion, although patients on New Dawn Ward said staff were kind.

• Sunrise Ward did not offer a therapeutic environment for patients with eating disorders Nationally recommended psychological therapies were not available and some nursing staff had no insight into how to work with patients around meal times and snacks. There was a lack of weekend activities on both wards.

• Some parts of the building were poorly maintained. For example, the patient alarms and the lift.

• The service was not well led. There had been a high turnover of senior staff within the hospital and, whilst posts had been covered for most of the interim period, this was impacting adversely on the nurse leadership. Staff on both wards reported instances of bullying. Patients on both wards complained about a lack of timely feedback when they raised any issues. The provider had appropriate systems in place to monitor quality and safety, but no one was systematically checking that they were being used or looking at what needed further follow up.

• The provider had not made all the necessary improvements from the previous inspection in November 2018. The provider’s self-assessment said that the work had been completed. We concluded that, although some improvements had been made to paperwork, this had not led to a consistent improvement in practice. This failure was linked to the ongoing leadership changes which meant that the oversight was not in place.

However:

• New Dawn Ward had a permanent ward manager in place and was better managed than Sunrise Ward.

• Most clinicians within the multidisciplinary team were working hard to build good working relationships internally and externally. They were using clinical tools and guidance appropriate for their professions on both wards and they were participating in clinical audits.

• Patients’ mental and physical healthcare needs were assessed on admission and regularly monitored. Referrals were made to specialists when required.

• All permanent staff received annual appraisals and most staff received regular supervision, although it did not always cover all relevant issues.

• Discharges were well planned in conjunction with patients’ local health and care teams.

• There was sufficient space for all the on-ward activities to be carried out; a range of rooms were available.

• Patients had access to independent advocacy and staff carried out their duties in line with the Mental Health Act and the Mental Capacity Act.

We did not re-rate this hospital as a result of this focused inspection. This was because we only looked at specific issues on one ward that staff and patients had contacted us about. We issued two warning notices immediately after the inspection telling the service it must make immediate improvements around the documentation and management of risk and the governance of the service. We will return to inspect the service shortly to ensure that actions taken by the provider are embedded and that patients at the service are safe.

We found:

• Sunrise ward did not have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Many of the patients were being supported using one-to-one observations. High numbers of temporary staff were used to carry out this role. This meant permanent staff, including registered nurses in charge of shifts, spent a disproportionate amount of time managing staff who were unfamiliar with the ward. This had the potential to impact on the quality and safety of patient care.
• Despite the high use of temporary staff there were still shifts with insufficient staff on duty to carry out one-to-one observations of all patients with an assessed need for this.
• Staff did not keep up-to-date and accurate records of patient care and treatment. Key information about risk was missing from patient records. This meant that information needed by staff to keep patients safe was not always available. This was a concern as many of the staff on the ward did not know the patients well and therefore relied on the accuracy of these records.
• The one-to-one observations were not recognised as a restrictive practice, so their use was not kept under careful review.
• Patient and carer feedback indicated that patients were not consistently listened to and provided with compassionate care by all staff.
• The ward did not have effective governance systems in place to monitor actions to improve the service. The hospital risk register and the CQC action plan did not accurately reflect work that still needed to take place.
• Staff had little opportunity to discuss learning from incidents, complaints and audits.
• Staff morale on the ward was low. Staff told us about divisions within the ward team and this affected the ability of staff to work together productively for the benefit of patients.

However:

• Staff and patients were positive about the impact of the new ward consultant who had recently started at the service
• The service management along with the new ward consultant, were committed to the improving the care model provided within the service. We received positive feedback about the moves already taken to improve the service.
• Patients told us that there were some staff who responded to them with kindness and care.
• The service provided an independent advocacy service which patients were positive about.