The Care Quality Commission
  • Mental Health
  • Independent mental health service

Cygnet Hospital Bierley

Overall: Requires improvement read more about inspection ratings

Bierley Lane, Bierley, Bradford, West Yorkshire, BD4 6AD (01274) 686767

Provided and run by:
Cygnet Health Care Limited

All Inspections

12 & 13 September 2023

During a routine inspection

Our overall rating of this location improved. We rated it as requires improvement. This inspection covered the acute wards for adults of working age and psychiatric intensive care units core service only as the forensic inpatient or secure wards core service had been inspected in November 2022 prior to the 2 acute wards being opened.

Cygnet Hospital Bierley had been placed into special measures based on our inspection findings in January and February 2022. The report from that inspection was published in May 2022. Based on the findings of our inspection of the forensic inpatient or secure wards core service in November 2022, alongside this inspection of the acute wards for adults of working age in September 2023, Cygnet Hospital Bierley will be removed from special measures.

7, 8, 9 and 10 November 2022

During a routine inspection

Our rating of this service stayed the same. This inspection covered the forensic core service only as the other 2 wards were closed at the time we inspected. As the acute and personality disorder core services were not re-rated the overall rating for the hospital remains inadequate, despite the improvements noted in the forensic core service as outlined below.

31 January 2022 to 2nd February 2022 and 8th February 2022

During an inspection looking at part of the service

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

  • The service did not reduce or remove all risks identified on the wards and staff could not always observe patients in all parts of the wards.
  • The service did not have enough nursing staff, who knew the patients and received basic information to keep people safe from avoidable harm.
  • Staff did not always identify and respond to any changes in risks to, or posed, by patients. Staff did not participate in a restrictive intervention’s reduction programme, which met best practice standards.
  • The service did not always have access to the full range of specialists required to meet the needs of patients on the wards. On Bronte ward they did not always support staff with appraisals and supervision.
  • Staff did not always treat patients with compassion and kindness. They did not always respect patients’ privacy and dignity. They did not always understand the individual needs of patients and did not always support patients to understand and manage their care, treatment, or condition.
  • Leaders did not always have the skills, knowledge, and experience to perform their roles. They did not always have a good understanding of the services they managed and were not always visible in the service and approachable for patients and staff.
  • Some staff did not feel respected, supported, and valued. They could not raise concerns without fear of retribution.
  • On Bowling ward, staff did not consistently follow systems and processes to safely prescribe, administer, record and store medicines.
  • On Denholme ward, some staff did not always have easy access to clinical information.
  • The service did not manage patient safety incidents well. Staff did not recognise incidents and report them appropriately. Managers did not always investigate incidents and share with the appropriate organisations.

Letter from the Chief Inspector of Hospitals

I am placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Chief Inspector of Hospitals

A final version of this report, which we will publish in due course, will include full information about our regulatory response to the concerns we have described.

11 May 2021 and 12 May 2021

During a routine inspection

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

  • Although we found the service largely performed well, it did not meet legal requirements relating to the below points, meaning we could not give it a rating higher than requires improvement.
  • The service did not always use systems and processes to safely prescribe, administer, record and store medicines. Staff did not always regularly review the effects of medications on each patient’s mental and physical health.
  • Staff did not always have easy access to clinical information, and it was not easy for them to maintain high quality clinical records – whether paper-based or electronic. On the low secure forensic wards, admission assessment documents were not always available for review and care records were not always updated as needed. Care plans did not always reflect patients’ assessed needs, or were always personalised, holistic and recovery oriented.
  • Staff did not always document the assessed and managed risks to patients and themselves.
  • On the low secure forensic wards, the clinic rooms were not always checked and maintained regularly.
  • Patients who required easy read documentation did not always have this need met. Staff did not always involve patients in care planning and risk assessments.
  • The ward teams did not always have access to the full range of specialists required to meet the needs of patients on the wards.

However,

  • All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Each patient had their own bedroom with an en-suite bathroom and could keep their personal belongings safe. There were quiet areas for privacy. The food was of good quality and patients could make hot drinks and snacks at any time.
  • The service had enough nursing and medical staff who had received basic training to keep people safe from avoidable harm. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Managers made sure they had staff with the range of skills needed to provide high quality care. They supported staff with appraisals, supervision and opportunities to update and further develop their skills. Managers provided an induction programme for new staff.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

6 and 11 August 2020

During an inspection looking at part of the service

We did not plan to re-rate the hospital at this inspection as it was a focused inspection of key lines of enquiry related to the safe, caring and well led key questions only. However due to the inspection findings we have re-rated the core service as requires improvement.

We rated Cygnet Bierley as requires improvement because:

  • Staff did not consistently review the effects of each patient’s medication on their physical health according to National Institute for Health and Care Excellence guidance or the provider’s policy following the use of rapid tranquilisation.
  • Staff utilised mechanical restraint to transport a patient to seclusion which was against hospital policy and restrictive interventions training.
  • It was not clear from documentation that staff made the decision to end seclusion at the earliest opportunity on all wards.
  • Staff, especially those on the psychiatric intensive care unit ward, cited negative morale and lack of team cohesion as a result of the whistle-blowing complaints being made to the Care Quality Commission.
  • Some patients and carers told us that staff did not always engage with them in a positive manner.
  • Governance systems in place were not entirely effective in identify areas of concern found during inspection.

However, we found the following areas of good practice:

  • The ward environments were safe and clean. Staff minimised the use of restrictive practices and followed good practice with respect to safeguarding.
  • Patients told us they felt safe, listened to, and respected by staff.

26-27 November 2019

During a routine inspection

Cygnet Hospital Bierley is an independent mental health hospital that provides care for patients on low-secure forensic, personality disorder, and psychiatric intensive care unit wards.

We rated Cygnet Hospital Bierley as good because :

  • The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices 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. For example, each ward had access to a psychology team who provided specific interventions such as offering dialectical behaviour therapy on the personality disorder ward and coping skills work on the low-secure forensic and psychiatric intensive care unit wards.  
  • 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 there were sufficient numbers of staff who had 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 ensured that patients had good access to physical healthcare throughout their admission, including access to specialists when needed. Since our last inspection the hospital had employed a registered general nurse to oversee the physical health needs of patients across all four wards.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions through involvement in care planning and review meetings.
  • Staff planned and managed admissions and discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The service was well-led, and the governance processes ensured that ward procedures ran smoothly. The service had made improvements in their governance systems since our last inspection. Previous breaches of regulation and areas where we had identified the provider should take action to improve the service had been addressed.
  • Staff at the hospital were engaged in opportunities for quality improvement and research and had recently won an award at the ‘Association of Psychological Therapies Awards’ for the hospital’s Relaxation Workshop. The provider recognised staff success through an ‘employee of the month’ award and ‘random acts of kindness’ award.
  • Patients and carers were involved in decision-making about changes to the service and a ‘you said, we did’ board in reception which reflected suggestions made by patients and changes made as a result, such as staff purchasing a number of cameras to allow patients to take and print their own photos.

However:

  • The service did not consistently provide safe care with regards to the management of medicines including in relation to prescribing, administering, recording and storing medicines. On the psychiatric intensive care unit and low-secure forensic wards staff did not always keep accurate records of the treatment patients received and did not consistently administer medication in the manner prescribed. For example, a patient continued to be administered medication after their prescription had finished and medication cards were not always signed so it was unclear if medication was given. Consent to treatment documents were not always signed by patients or the responsible clinician and were not all reviewed in a timely manner. On the psychiatric intensive care unit and specialist personality disorder ward we found staff were storing patient specific medication that was either no longer prescribed or was for patients no longer on the wards and on the specialist personality disorder ward staff were storing general skin creams in the clinic room that were not prescribed to individual patients but used for any patient on the ward and as such could be an infection control risk. On the psychiatric intensive care unit staff did not follow systems and processes to accurately record, store and dispose of illicit substances brought onto the ward.
  • Staff did not consistently follow guidance from the National Institute of Health and Care Excellence and Mental Health Act Code of Practice in relation to physical health monitoring following rapid tranquilisation on the female low-secure forensic ward and personality disorder service ward, and with regards to completion of independent multi-disciplinary reviews during episodes of seclusion on the psychiatric intensive care unit.
  • The ground-floor seclusion room, which could be used by patients from any ward, did not fully comply with guidance in the Mental Health Act code of practice as there was no facility to dim any of the lights.
  • A blanket restriction was identified with regards to the type of e-cigarettes patients could use across the hospital. This had not been individually risk assessed and was not noted on any of the ward blanket restriction logs at the time of inspection.

17-19 April 2018

During a routine inspection

We rated Cygnet Hospital Bierley as ‘requires improvement’ because:

  • The hospital did not always provide safe care and treatment. We had concerns about the safety of the environment. Not all ligature risks had been appropriately risk assessed and those risks mitigated. The ground floor seclusion room had a viewing panel that could be obscured from the inside to prevent the use of staff viewing points, which could compromise patient and staff safety. Staff sometimes transported patients in restraint holds whilst using stairs, and there was no risk assessment for staff to follow for this procedure. On the psychiatric intensive care unit, the use of planned prone restraint was not always in line with national guidance. On the specialist personality ward patients did not have risk assessments, which staff regularly updated following every incident. There were some blanket restrictions in place on the specialist personality disorder ward and low secure forensic wards which were not included in the blanket restriction audits undertaken.
  • The hospital was not always providing effective care. The monitoring of patient’s physical health did not always take place according to best practice guidance or the provider’s own policy. This included patients who the service had newly admitted to the psychiatric intensive care unit, patients who had received rapid tranquilisation and patients with long term physical health needs. Staff did not always monitor patients’ potential side effects when they prescribed medication to patients. Staff did not always ensure patients gave consent and that staff recorded this in line with the Mental Health Act. When patients lacked capacity to make specific decisions, staff did not act in accordance with the Mental Capacity Act. Staff told us that they did not always receive monthly formal supervision.
  • The service was not always responsive to the privacy and dignity of patients on the psychiatric intensive care unit, because staff brought patients through communal areas of the hospital when they were admitted to the unit. The ward was on the first floor of the hospital and did not have a separate entrance.
  • There were elements of the governance processes across the whole service, which were not entirely effective. Audits taking place such as in physical health monitoring, ligature risk assessments and blanket restrictions audits did not ensure that all areas of risk and concern were monitored to ensure the senior managers were aware of all areas of concern. The service did not have written protocols or risk assessments in place for staff to follow when transferring patients to seclusion using stairs, or for admitting patients through communal areas, and using stairs to the psychiatric intensive care unit.

However:

  • The hospital provided care, which was compassionate, and empowered patients to be active partners in their care. Patients described staff as kind and caring and we witnessed this behaviour during our inspection. Patients had access to advocates, and were able to make complaints and give feedback about the service they received. The service was routed in patient involvement and the feedback of patients was important to the leaders of the service.
  • The hospital had a high quality therapy service, which encompassed a focus on patient recovery. The therapy service had received national recognition, and staff were proud and passionate about its achievements.
  • Patients had access to therapies and activities, which were high quality, and met their emotional, spiritual and cultural needs. The services were discharge focussed and the length of patient admissions was appropriate to their needs. The service had made adjustments to meet the needs of patients with mobility needs, and was able to ensure person centred care for patients with specific cultural and religious needs.
  • The senior leadership team were knowledgeable, qualified and experienced. They were passionate about improving the quality of care and treatment at the service. Staff felt valued and supported by managers and the service continued to request feedback from staff.
  • The service was committed to quality improvement and innovation and had been involved in a number of projects and awards all of which involved the support of patients.

11 May 2017

During an inspection looking at part of the service

We rated Cygnet Hospital Bierley as good overall, we were unable to re-rate the service overall as we did not carry out an inspection including all of our key lines of enquiry. However, during this inspection, we found breaches of regulation in all domains other than caring and responsive. Due to this, we have suspended the ratings of good in the effective and well–led domains.

  • Following our inspection in August 2016, we rated the service as good for caring. Since that inspection we have received no information that would cause us to re-inspect this key question or change the rating.
  • We also rated responsive as good at the last inspection but we received information prior to this inspection in May 2017 raising concerns related to levels of activity and discharge planning. However, at this inspection we found that patients accessed a range of activities throughout the week, including weekends, and the services continued to discharge patients following discharge planning.
  • The service had addressed the specific issues that had caused us to rate safe as requires improvement following the August 2016 inspection. All wards were clean and furniture had been replaced on Bowling ward (female specialist personality disorder service). Patients told us that staff always kept the hospital clean. The service was now meeting regulation 15 of the Health and Social Care Act (Regulated Activities) Regulations 2014: premises and equipment. The provider had created a system of mapping ligature points to reduce the risk to patients and increase staff awareness. The system was working well and staff were aware of the risk and mitigated it via observations.
  • There was a range of rooms where patients could take part in activities such as art therapy, using the gym, computers, outside activities and therapy sessions. Wards and communal areas contained information for patients. Patients told us that they knew how to complain and that staff took their concerns seriously when they raised an issue. This had improved following the actions we reported the provider should improve at our visit in August 2016.
  • Patients told us that ward rounds were more consistent and this was an improvement following our recommendation at our visit in August 2016.
  • The provider had conducted a corporate risk assessment following guidance from the resuscitation council UK which mitigated the requirement for keeping the reversing agent with emergency drugs and so had addressed the action recommended at the last inspection in August 2016.
  • The service had begun work on building a specific spiritual room for patients (as recommended at our inspection in August 2016). Patients and staff were involved in the planning and design of the room.

However:

  • Despite the work by the provider to risk assess, eliminate and mitigate ligature points, this location remained in breach of regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014: safe care and treatment. Staff carried out seclusion and rapid tranquilisation with patients and they did not always ensure they had done this safely. We reviewed specific episodes of both interventions and found that physical health observations were not always completed and recorded as per the provider’s own policy. This increased the risk of harm to patients and on one occasion had resulted in a serious incident. The providers own governance system had not identified this issue.
  • Although we did not receive information prior to this inspection in order to change the rating of ‘good’ in the well-led domain, during this inspection we found that systems and processes were not operating effectively or sufficiently embedded to ensure the service was safe.
  • Staff had not always updated patient risk assessments after a significant incident of harm.
  • The service had a high turnover of staff at 31% at the end of December 2016, but at the time of inspection this was 13%. This had led to a vacancy rate of 46% of nursing staff and 17% of healthcare support workers. This had caused significant use of bank and agency staff.
  • Staff did not adhere to internal policies and procedures and did not follow the Mental Health Act Code of Practice when using restrictive practices with patients.

1, 2 and 3 August 2016

During an inspection looking at part of the service

We carried out this unannounced focused follow-up inspection to confirm whether Cygnet Hospital Bierley had made improvements to its service since our last comprehensive inspection of the hospital on 16, 17 and 18 June 2015.

When we last inspected Cygnet Hospital Bierley in June 2015, we rated the service as requires improvement. We rated safe as inadequate, and effective, caring, responsive and well led as requires improvement. There were six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to the provision of safe care and treatment, treating patients with dignity and respect, delivering person centred care, safeguarding patients from abuse, the management of premises and equipment, and the overall governance of the service.

The provider had sent us an action plan telling us how it would ensure that it had made the improvements required in relation to these breaches of regulation. At this inspection, we confirmed that some improvements had been made.

We rated Cygnet Hospital Bierley as good because:

  • There were sufficient numbers of trained staff on the wards who had the skills they required to carry out their roles. All staff who worked on Bowling ward had received training in dialectical behaviour therapy, the model of treatment used on the ward. Staff accessed clinical supervision and had annual appraisals where they had the opportunity to discuss their performance at work. Staff were positive about the service. They told us that they felt supported and saw senior managers frequently on the ward areas and at meetings.
  • Staff carried out thorough patient assessments that were holistic and covered all aspects of patient need, including physical health. Patients had a full physical assessment on the day of admission with the nurse and the doctor. Each patient had a range of comprehensive risk assessments and care plans in place, including discharge plans, which were updated and reviewed on a regular basis. Care records we reviewed showed there was a person centred approach to recovery.
  • On Bowling ward, where there had previously been a lack of patient supervision in communal areas, we observed staff to be with patients in all communal areas. Patients reported that this was now normal daily practice. The service operated a buddy system across all four wards where possible to support patients during admission on to the wards. This included information on how to complain. Patients had their own bedrooms with en-suite facilities that they were able to personalise. Activities were available for all patients seven days a week. Patients on Bowling ward told us that they were treated with dignity and had sufficient privacy. The service’s involvement coordinator surveyed patients twice a year to monitor progress on areas of concern and to highlight areas of success.
  • The service had implemented a ‘Restrictive practice reduction strategy’ across all wards in the hospital. The strategy outlines the actions taken to reduce the use of all restrictive interventions including prone restraint. Improvements had been made to remove blanket restrictions on Bowling ward which we identified at the previous inspection in June 2015. This included searching patients and restricting access to bedrooms. The hospital search policy for searching patients, visitors, property and the environment had been revised and now met the current guidance within the Mental Health code of practice. The hospital undertook regular audits of compliance with the Mental Health Act.
  • Systems were in place across the hospital regarding the storage, disposal and recording of medicines. Nurses completed daily checks of the clinic room to help ensure medicines, including controlled drugs were stored safely and re-ordered when needed.
  • There were procedures for reporting incidents and staff said they were clear about what to report. Staff told us they received feedback from managers following incidents which included reassurance and support. The hospital had a local risk register. Systems had been improved to ensure that data reviewed at board level accurately reflected data collected at ward level. In November 2015, the hospital successfully completed the self and peer review parts of the quality network for forensic mental health services annual review cycle. It was reported by the lead psychologist, that there is a commitment to ongoing training evaluation and audit for Bowling Ward and the psychology service across the whole hospital.

However;

  • There remained some concerns on Bowling Ward. The communal bathroom on Bowling ward had areas where the seal had cracked around both the bath and shower. This was an infection risk as it could not be cleaned properly. Area of potential ligature risk were identified by the inspection team during the visit. Furniture on Bowling ward needed replacing. Patient care plans did not always address the potential risks to people of early exit from the dialectical behaviour therapy programme. In addition, the timing of the ward rounds were inconsistent causing distress to patients who told us they would like this to change.
  • The hospital had a spiritual room available. However, on the day of the inspection it was being used to store furniture including sofas and chairs.
  • Although pharmacist advice was available, clear individual strategies for the use of ‘when required’ medication were not documented for patients who were at risk of violence and aggression, in line with the National Institute for Health and Care Excellence guidance. There were supplies of emergency medicines and equipment on each ward but wards that used Lorazepam injections for rapid tranquilisation did not keep a stock of the reversing agent. The hospital should discuss and assess this as part of their policy for rapid tranquilisation. Rapid tranquillisation is when medicines are given to a person who is very agitated or displaying aggressive behaviour to help quickly calm them. This is to reduce any risk to themselves or others, and allow them to receive the medical care that they need.

16 - 18 June 2015

During an inspection looking at part of the service

We rated Cygnet Hospital Bierley as requires improvement because:

  • The seclusion rooms did not meet the required standards of the National Institute for Health and Care Excellence (NICE) published guidance 2015, ‘Violence, and aggression: short-term management in mental health, health and community settings’.

  • There was a lack of awareness among senior managers of issues relating to Bowling ward.These issues included repeated use of prone restraint, a high number of incidents which had resulted in restraint and the impact on patients who told us they felt staff did not have the necessary skills to support them when they experienced distress.

  • Staff on Bowling ward told us they felt unable to meet the clinical needs of patients on the ward. This was in relation to practising and using DBT skills they had learnt in therapy.

  • The policy for searching patients, visitors, property and the environment did not follow current Mental Health Code of Practice guidance. Neither did it differentiate between informal and detained patients.

  • There were no action plans in place to evidence how the hospital was working towards achieving a reduction in use of prone restraint.

  • The wards had ‘blind spots’ and ligature points. The hospital was unable to confirm dates for completion of works to remove these. Measures in place to mitigate some of these risks on Bowling ward were undignified for patients. For example, staff supervised patients when they had showers.

  • We looked at the management of medicines across the hospital and found issues relating to the storage, recording and administration of medicines across all four ward areas.

  • Patient feedback on the approach of staff was not consistently good. During a patient-led meeting on Bowling ward, 14 patients reported that staff did not always treat them with empathy and, while, some staff took the time to listen to them, others did not. All fourteen patients reported not receiving sufficient information before their admission to Bowling ward.

  • Access to bedrooms on Bowling ward was restricted for some patients. Incident records showed this had led to incidents where staff were injured and patients restrained and secluded.

  • Patients had time-limited access to a shared outside space. Incident records we reviewed showed this had led to incidents of violence and aggression. Ward managers reported this as being one of the main challenges they experienced.

  • Patients had access to facilities to make hot drinks however, patients on Bowling ward told us they had to ask staff for cups.

  • A review of incident records showed there had been instances where doctors had not reviewed patients following incidents of self-harming behaviour.

  • Care plans did not provide staff with clear guidance regarding checking of wounds sustained during self-harming behaviour.

  • Staff did not receive sufficient information on risk and other matters for patients who had arrived at the Psychiatric Intensive Care Unit (PICU) as urgent cases.

  • Ward managers reported a lack of storage within the hospital for patients to store their belongings.

  • Clinical audit and governance systems and processes in place were not robust, as they had failed to identify areas of concern, which we highlighted during the inspection to the senior management team.

  • Data gathered at ward level was inconsistent with data reviewed at board level. This meant the governance system was not robust and did not support effective lesson learning or the development of new operational policies and local protocols.

4 April 2014

During an inspection looking at part of the service

When we last inspected this hospital in September 2013 we identified concerns. We issued compliance actions and commenced enforcement action which required the provider to ensure they became compliant with the Essential Standards of Quality and Safety. After our inspection the provider wrote to us to tell us how they would improve and reach compliance with the required standards.

At this inspection three inspectors were assisted by three specialist advisers from National Health England.

Two patients on Bowling ward told us the hospital had improved, and that there was now a structured programme of meaningful activities for them to take part in. They told us were involved in the development of their care and treatment plans and felt they were being helped by the staff towards recovery. They told us they felt 'safe' on the ward.

At this inspection we found systems were in place to protect patients from the risk of abuse. Improvements had been made to patient records and patients were now protected from the risks of unsafe or inappropriate care and treatment because accurate care records were maintained.

We continued to find evidence that patients were not always protected against the risks associated with medicines.

We found that although improvements had been made since our last inspection visit, the provider did not had an effective system in place to regularly assess and monitor the quality of service. This was specific to management of risk, policy updates and learning from audit and clinical incidents.

24, 25 September 2013

During an inspection looking at part of the service

Three compliance inspectors carried out the inspection over two days. They were accompanied on the inspection by two specialist advisers who looked specifically at the use of restraint and what actions staff had taken to safeguard patients from abuse and how the provider monitored and assessed the quality of the service they provided.

They found the hospital and the new clinical manager were implementing many changes to improve the quality of the service provided to patients. Patients we spoke with said they felt in general, staff were, 'Doing the best they could to help them'. One patient told us, 'This is the best ward I have been on.' We found patients' needs were assessed and care and treatment was planned and delivered in line with their individual needs.

We found improvements needed to be made to the internal safeguarding reporting systems to ensure all allegations of abuse were identified and where appropriate alerted to the relevant agencies. The provider did not have effective systems in place to identify, assess and manage risks to the health, safety and welfare of patients and others.

Also patients were not always protected against the risks associated with medicines because the provider did not always have appropriate arrangements in place to manage medicines.

When we visited in November 2012 we found we had concerns because patients were at risk as their care records were not accurate and not fit for purpose. The provider wrote to us in February and July and met with us in June 2013 and told us they would take action to ensure they were compliant. At this inspection we found although there were improvement in the care records on Denholme and Bronte wards. However on Bowling ward we found patients not were protected from the risks of unsafe or inappropriate care and treatment because inaccurate and inappropriate records had been maintained.

20, 23 November 2012

During a routine inspection

During our inspection we visited Denholme ward and Bowling ward, and Halifax ward. A expert by experience also visited Moorside ward to ask patients about their experience.

We talked to 12 Patients. They told us they had been informed about their care and treatment. They told us staff sat down and discussed their care with them; one said 'my named nurse explained my care plan two days ago'.

We asked patients if their needs were met, on Moorside ward five patients told us they were 'sort of' or 'mostly', on Bowling ward four patients said 'yes', one patient on Fairfax ward told us they were 'definitely met'. We asked if staff offered them support, on Moorside ward they told us they 'did' when they were sufficiently staffed. On Bowling and Fairfax ward they said 'yes'. Patients also told us most staff was responsive to their needs and approachable. One patient described them as 'excellent'.

Following our inspection in July a new hospital manager has been appointed and they were able to tell us they had already identified many of the areas at the hospital which needed improvements. However during this inspection we were only able to review the progress actually made. We therefore found further improvements were needed to be carried out to ensure the records were maintained to a sufficient standard to ensure patients received the care and treatment they needed.

20 July 2012

During an inspection in response to concerns

We carried out an inspection on the 20 July because we had received information of concern that on the 21 June 2012 on the psychiatric intensive care unit (Denholme ward), staff called for police assistance, and this had resulted in a taser being used by the police to subdue a patient. We therefore visited only Denholme ward and looked specifically at how the staff were managing patients when they became a risk to themselves or others.

During our inspection on the 20 July 2012 we reviewed outcome four (regulation 9) to assure that the patients experienced care, treatment and support that met their needs and protected their rights.

We talked to one person using the service and we used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not always able to tell us their experiences. The person using the service and our findings indicated to us that the systems in place did not fully protect people's rights.

12 April 2012

During an inspection looking at part of the service

Following our inspection on the 7th February 2012 we issued a warning notice because there were concerns that patients' were not provided with sufficient information to ensure their rights and best interests were being properly protected. Also because some patients' care records were incomplete, inaccurate and illegible, and patients were at risk of not receiving the care and treatment they require.

At our inspection on the 4th April 2012 we talked with nine patients and reviewed four patients care and treatment records. We found the records were maintained and patients were protected from the risks of unsafe or inappropriate care and treatment. Also patients were being informed of their legal rights and informed about their care and treatment.

We talked to nine patients who told us they were now provided with the information they needed and that they did have access to an independent mental health advocate (IMHA). They met regularly with their named nurse, and they were able to contribute to the weekly ward rounds, where their care and treatment was discussed. However all did say they did not feel fully involved in the development of their care and treatment plans.

7 February 2012

During an inspection looking at part of the service

We carried out a visit to Cygnet Hospital Bierley on 07 February 2012 to follow up compliance actions made when we last visited the service in September 2011.

In view of the major concerns identified in two outcome areas the Care Quality Commission served Warning Notices on the Registered Provider and the Registered Manager on 2 March 2012.

During the follow up inspection, because we needed specific information from the management to demonstrate their compliance with the essential standards, we did not need to speak directly with patients from the wards.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.