23 June to 24 July 2020
During an inspection looking at part of the service
Cygnet Thors Park is a 14-bed hospital, which provided care and treatment for men aged 18 years and above who have a learning disability, autism and complex needs. The provider has taken the decision to close the hospital: there have been no patients at the hospital since 18 June 2020.
We rated the provider ‘inadequate’ overall at our inspection in September 2019. We rated the safe and well led domains as ‘inadequate. We rated the responsive domain as ‘requires improvement’ and the effective and caring domains as ‘good’.
At our most recent inspection, we did not change amend our previous ratings.
The Care Quality Commission (CQC) placed the hospital in special measures following an inspection in 5 February 2019 and imposed conditions on the provider’s registration at this hospital. These included not admitting any new patients; ensuring there were sufficient competent, skilled staff and ensuring observations of patients were carried out appropriately. As a result of placing the provider in special measures we commenced a programme of enhanced monitoring. During this period of enhanced monitoring both the CQC and the provider identified significant areas of ongoing concern.
On 16 June 2020 the provider took the decision to transfer all patients out of this hospital. On 9 July 2020, the provider submitted a notification to the CQC to cancel the registration of this location and has since deregistered.
We undertook a focused, short notice site inspection on 1 and 7 July 2020 because we had concerns about the safety of patients prior to their transfer to new services and concerns about how the provider had undertaken the transfer of patients.
At this inspection we found:
- The provider did not manage the hospital in order to deliver safe, good quality care to patients. They had not provided effective leadership and did not have robust governance processes in place to ensure that the hospital operated appropriately. They did not have oversight of the way staff assessed and managed risks relating to the patients.
- The provider had not ensured they had taken all the necessary action we told it that it must following our September 2019 inspection. They had not acted to ensure staff undertaking observations, did so in line with the provider’s engagement and observation policy and protocol. They had not acted to ensure there were always sufficiently skilled and competent staff to support patients .
- The provider had not implemented effective monitoring systems to check that staff were observing patients as specified in their care plans. We considered that patients and others were placed at risk of harm and that there was a risk that patients were not getting the care they needed. Hospital managers informed us of multiple incidents (between April to May 2020) where they had found staff were not observing a patient as per their care plan at night. The provider was investigating a number of night staff (support workers and registered nurses) to determine if they had failed in their duties. We viewed samples of closed-circuit television footage where staff had not observed three patients as their care plans specified. We saw that staff had falsified patient notes stating that they had observed one patient when they had not. Hospital managers informed us on 17 July 2020 that they were now investigating 27 staff; mostly night staff but also some day staff.
- We found an example where the provider had not checked that hospital managers ensured staff followed identified learning and recommendations from an incident investigation. The recommendation was to ensure female staff were not allocated to a specific patient due to identified risks but this was not followed. Some staff told us they had raised concerns about patient’s continuous observation levels with hospital managers. They said hospital managers had not acted to address their concerns.
- The provider did not have a system of assurance to check that hospital managers had ensured that staff received adequate training, supervision and appraisal. They had not ensured that staff worked well together as a team. They had not ensured that there were sufficient numbers of suitably qualified, skilled, competent and experienced staff at all times to meet the needs of patients. For example, we checked personnel files for 24 staff (of 27) under investigation and found poor pre employment screening and post employment screening of competency. This related particularly to clinical support worker staff.
- The provider had not ensured there was adequate and consistent leadership at the hospital. There had been six different hospital managers (or senior staff) since our last inspection in September 2019. The Care Quality Commission had taken enforcement action in 2019 to ensure the hospital had a registered manager in post. Over the period covered by the last three inspections, the risks identified at the hospital had increased. We found evidence that a culture of poor care had developed particularly during night shifts , where staff did not follow the instructions contained in patient care plans, or the provider’s observation policy.
At this inspection we found the following relating to patients transfers out of the hospital:
- Provider staff told us they were closing the service and transferring patients as they could not provide safe care.The provider had not treated patients with respect compassion and kindness, when they transferred patients out of the hospital within 24 to 48 hours. Whilst CQC does not disagree with the provider’s decision to close this service for this reason, we were concerned about the extreme short notice period within which these transfers were completed, the difficulties commissioners would have in considering alternative and appropriate placements, the complex needs of the patients and the length of time patients had been within this service.
- There were no apparent individualised plans detailing how staff should best support patients for their transfer to minimise the impact of the sudden move. The provider had not actively involved patients and families and carers in the decision or plans/preparation for the transfer. They had not given sufficient notice to patients, carers and commissioners about the transfer of patients out of the hospital. Some patients had received care and treatment at the hospital from between 15 months to 17 years and no consideration had been given to the impact and considerable distress the move would cause for them. Patients’ care plans showed they all had differing levels of capacity to understand information and differing communication needs and many would not be able to comprehend what was happening or why it was happening at such short notice. One patient had only been given two hour's notice.
- The provider had not ensured that staff developed care plans informed by a comprehensive assessment to support patients transfer. This was not in line with national guidance about best practice. The provider had not planned and managed patient’s transfers well and liaised with services that would provide ongoing care and support this includes commissioners and community teams.
- Additionally, the provider had not effectively communicated with their staff, commissioners and the CQC about the transfers. They had not ensured that staff assessed patients’ individual needs and developed support plans to give them the support they needed when moving.
However:
- Hospital managers had ensured staff had reviewed all patients’ observation records to ensure that the level of observations prescribed were individualised, detailed specifically when levels of observations should reduce or increase and were based on individual risk assessments, including mitigation of risks identified.
- Hospital managers had ensured there was documentation to inform staff of the current observation level of all patients. This included details of any changes to their observation levels. All documentation was accessible to relevant staff.