Cygnet Lodge Woking

Updated 3 April 2023

Cygnet Lodge Woking is a 31-bed service providing acute and high dependency rehabilitation services for adult men with complex mental health needs. The service is purpose-built and located in a residential area close to its sister site, Cygnet Hospital Woking. The service has 31 beds split across three wards. George Willard is an acute ward with 11 beds. The high dependency rehabilitation unit is split over two wards and consists of Marlowe ward with 12 beds and Milligan House has eight beds which consist of six pre-discharge beds and two self-contained flatlets. Milligan House allows Cygnet Lodge Woking to provide a three-tier care pathway for service users as they reach a level of increased stability.

The service outline their high dependency rehabilitation service as a recovery focused service that delivers high quality care balancing risk management with therapeutic optimism and encourages men to break cycles of relapse and build upon skills needed to move towards the least restrictive care option or return to the community. The National Institute for Health and Care Excellence (NICE) defines high dependency rehabilitation units as “Inpatient rehabilitation units for people with complex psychosis whose symptoms have not yet been stabilised and whose associated risks and challenging behaviours remain problematic. These units aim to maximise benefits of medicine, address physical health comorbidities, reduce challenging behaviours, re‑engage families and facilitate access to the community.” The primary diagnoses of the patients referred to the high dependency rehabilitation unit was a mental health condition with may include complex co-morbities, substance misuse, treatment resistance and behaviours that challenge. The provider described how most of their patients came to them following multiple placement breakdowns, failed treatment programmes or as a step down from secure settings.

Cygnet Lodge Woking is registered to provide the following regulated activities:

• Assessment or treatment for persons detained under the Mental Health Act 1983
• Diagnostic and Screening Procedures
• Treatment of disease, disorder and injury

The hospital manager has been registered with the Care Quality Commission (CQC) as the registered manager for the location since March 2022. The registered manager, along with the registered provider, is legally responsible and accountable for compliance with the requirements of the Health and Social Care Act 2008 and associated regulations.

We carried out this focused inspection of the high dependency rehabilitation unit because at our last inspection in 2022 we rated them Inadequate in Safe and told the provider that they must take action to improve the following:

• The service must ensure that the activities on Marlowe and Milligan wards are suitable for a long stay rehabilitation service and meet the needs of the patient group.

• The service must ensure that patients are aware of and encouraged to attend community-oriented care, education and vocational opportunities.

• The service must ensure that the patients are involved in developing their care plans. Care plans must describe how staff support patients in the early stages of crisis in line with their wishes.

• The service must ensure that patients with an autism/Asperger’s diagnosis have care plans that support their care and treatment.

• The service must ensure that patient identifiable information is not accessible or available for patients to read/see.

• The service must ensure that physical observations are conducted in a way that protects the patient’s privacy and dignity.

• The service must ensure that the senior management team have appropriate oversight of the provision of activities being delivered on both Milligan and Marlowe wards.

• The provider must ensure that medicines supplies are stored within the recommended temperature limits on Marlowe and Milligan wards.

• The provider must ensure that medicines to be administered off the wards are given with the correct instructions and in appropriate packaging.

• The provider must ensure that the medical equipment for measuring blood glucose levels is calibrated at the frequency required for this equipment.

Following the 2022 inspection the hospital responded to the concerns and provided the CQC with an action plan to address them. We monitored the progress of the action plan and held frequent engagement meetings with them. We undertook this focused inspection of this service to check they had followed their action plan and to confirm they now met the required standards. Based on the findings at this inspection, we saw that the provider had made improvements to address all of the required standards and we did not identify any outstanding breaches.

This report covers our findings in relation to the key questions: Safe and Well led which have been inspected and re-rated. We also inspected how the provider had specifically addressed the previous concerns under Effective, although not all parts of this key question were inspected and as such, not able to be re-rated. For the key questions of Caring and Reponsive which were not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained as requires improvement, however the rating for the key question of Safe has improved.

What people who use the service say

At the time of the inspection there were 15 patients on the high dependency rehabilitation unit, out of a total capacity of 20. We spoke with two patients who both gave us positive feedback on their experience of the service. Most patients were out on leave during our visit.

Both patients we spoke with told us that they felt safe, with one who explained that this had been the safest place that they had been and the other told us that this had been the best ward that they had been on. They told us that they were engaged in regular activities including quiz nights, community skills, and shopping/ cooking and breakfast groups, as well as therapy sessions, including both occupational therapy and psychology. One told us that they would like more sport based activities to engage with. They told us that they could have one to ones with staff when they wanted them, and that staff were nice and kind towards them and treated them with respect. One told us that staff worked hard and listened to them when they raised concerns. Both patients were aware of how to make a complaint. They told us that they were involved in their care planning and had seen a copy and signed their care plans. Both patients told us that the service was clean and that the ward was cleaned daily. They also told us that they loved the food.

Updated 3 April 2023

Our rating of this service stayed the same. We rated it as requires improvement because:

• The ligature risk assessment for Marlowe ward did not accurately reflect the identified ligature risks of the bedroom environment. For example, although the bedrooms were suitably rated as high risk, there were identified ligature risks that were shown as low risk. The mitigation provided in the assessment for one of these risks was also not accurate with what was in place at the time. We fed this back during the inspection and have seen evidence that the provider addressed this for the bedrooms, as well as reassessing and developing new ligature forms for other areas of the ward, though these should be reviewed regularly to ensure they remain accurate.
• At the time of the inspection, the service did not have a maintenance log in place to record repairs that were needed, or that had been requested. This meant that they could not monitor and ensure that maintenance actions already reported were rectified in a timely way. We found maintenance issues on Marlowe ward including a broken fridge that was still being used, and a broken door handle, both of which had been reported but not addressed. Since inspection, the service has sent evidence of a new log which will monitor the progress of maintenance issues.
• Some staff raised concerns around the safety of staffing numbers on Milligan ward when it was expected that one support worker would be on the ward with four patients. Although, there had not been any reported incidents as a result of this lone working and staff confirmed that there was support from staff on Marlowe ward if an incident was to occur or if cover was needed for breaks. Management assured staff that they would review and increase the staffing numbers, yet this had not been done. Leaders told us that staffing was based on the ward acuity and the resources needed to escort community patients.
• Not all managers were visible within the service. Some staff told us that the ward manager was not always visible on the wards although the senior nurses and deputy manager were supportive and available when needed. The consultant psychiatrist was also not visible on the wards to both staff and patients other than during ward rounds, and some staff felt that a greater presence on the wards would have a positive impact for both patients and staff.
• Although the service had positive behaviour support (PBS) plans in place which identified triggers and described how to work with individuals diagnosed with autism, this information was not clear throughout the care plans. Given the use of agency staff on the wards who may not be familiar with these individuals, this could impact the care and appropriate risk management of these patients. Following initial feedback, the senior leaders and wider directors reviewed this and developed a more suitable template to ensure that this information is captured fully within the care plans.
• We saw discharge planning discussed as part of the ward round, although we only saw discharge plans outlined in one of the seven care records we reviewed and there was clearly still a need for this to be embedded fully. Leaders acknowledged that these needed to be captured in care plans.

However:

• The ward environments were clean and well furnished. Staff assessed risk well. They analysed and minimised the use of restrictive practices through clinical governance, they managed medicines safely and followed good practice with respect to safeguarding.
• Staff provided a range of activities and treatments suitable to the needs of the patients and in line with national guidance about best practice. Patients told us that they engaged in regular activities including quiz nights, community skills, shopping/ cooking and breakfast groups, as well as therapy sessions, including both occupational therapy and psychology. Staff engaged in clinical audits to evaluate the quality of care they provided.
• We saw good practice around physical health monitoring including clozapine and stool monitoring.
• The ward teams 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.
• We saw that each patient had their care team details on the front of their bedroom door, so they knew which staff were caring for them. Ward rounds were inclusive and patient feedback was respected.
• Staff understood and discharged their roles and responsibilities with the use of the Mental Health Act 1983 and the Mental Capacity Act 2005 safely.
• Patients reported that staff treated them with kindness and respect. Patients we spoke with felt safe and told us that they had access to nursing and care staff when they needed. They actively involved patients, families and carers in care decisions.
• The service worked to a recognised model of mental health rehabilitation. It was well led, and the governance processes ensured that ward procedures ran smoothly.

Updated 3 April 2023

Our rating of this service stayed the same. We rated it as requires improvement because:

• The ligature risk assessment for Marlowe ward did not accurately reflect the identified ligature risks of the bedroom environment. For example, although the bedrooms were suitably rated as high risk, there were identified ligature risks that were shown as low risk. The mitigation provided in the assessment for one of these risks was also not accurate with what was in place at the time. We fed this back during the inspection and have seen evidence that the provider addressed this for the bedrooms, as well as reassessing and developing new ligature forms for other areas of the ward, though these should be reviewed regularly to ensure they remain accurate.
• At the time of the inspection, the service did not have a maintenance log in place to record repairs that were needed, or that had been requested. This meant that they could not monitor and ensure that maintenance actions already reported were rectified in a timely way. We found maintenance issues on Marlowe ward including a broken fridge that was still being used, and a broken door handle, both of which had been reported but not addressed. Since inspection, the service has sent evidence of a new log which will monitor the progress of maintenance issues.
• Some staff raised concerns around the safety of staffing numbers on Milligan ward when it was expected that one support worker would be on the ward with four patients. Although, there had not been any reported incidents as a result of this lone working and staff confirmed that there was support from staff on Marlowe ward if an incident was to occur or if cover was needed for breaks. Management assured staff that they would review and increase the staffing numbers, yet this had not been done. Leaders told us that staffing was based on the ward acuity and the resources needed to escort community patients.
• Not all managers were visible within the service. Some staff told us that the ward manager was not always visible on the wards although the senior nurses and deputy manager were supportive and available when needed. The consultant psychiatrist was also not visible on the wards to both staff and patients other than during ward rounds, and some staff felt that a greater presence on the wards would have a positive impact for both patients and staff.
• Although the service had positive behaviour support (PBS) plans in place which identified triggers and described how to work with individuals diagnosed with autism, this information was not clear throughout the care plans. Given the use of agency staff on the wards who may not be familiar with these individuals, this could impact the care and appropriate risk management of these patients. Following initial feedback, the senior leaders and wider directors reviewed this and developed a more suitable template to ensure that this information is captured fully within the care plans.
• We saw discharge planning discussed as part of the ward round, although we only saw discharge plans outlined in one of the seven care records we reviewed and there was clearly still a need for this to be embedded fully. Leaders acknowledged that these needed to be captured in care plans.

However:

• The ward environments were clean and well furnished. Staff assessed risk well. They analysed and minimised the use of restrictive practices through clinical governance, they managed medicines safely and followed good practice with respect to safeguarding.
• Staff provided a range of activities and treatments suitable to the needs of the patients and in line with national guidance about best practice. Patients told us that they engaged in regular activities including quiz nights, community skills, shopping/ cooking and breakfast groups, as well as therapy sessions, including both occupational therapy and psychology. Staff engaged in clinical audits to evaluate the quality of care they provided.
• We saw good practice around physical health monitoring including clozapine and stool monitoring.
• The ward teams 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.
• We saw that each patient had their care team details on the front of their bedroom door, so they knew which staff were caring for them. Ward rounds were inclusive and patient feedback was respected.
• Staff understood and discharged their roles and responsibilities with the use of the Mental Health Act 1983 and the Mental Capacity Act 2005 safely.
• Patients reported that staff treated them with kindness and respect. Patients we spoke with felt safe and told us that they had access to nursing and care staff when they needed. They actively involved patients, families and carers in care decisions.
• The service worked to a recognised model of mental health rehabilitation. It was well led, and the governance processes ensured that ward procedures ran smoothly.

Updated 3 April 2023