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

Cygnet Hospital Godden Green

Overall: Good read more about inspection ratings

Godden Green, Sevenoaks, Kent, TN15 0JR (01732) 763491

Provided and run by:
Cygnet Health Care Limited

All Inspections

29 and 30 September 2021

During a routine inspection

Cygnet Hospital Godden Green is an independent hospital providing specialist inpatient Acute and Psychiatric Intensive Care Unit (PICU) services to adult women of working age.

Our rating of this location improved. We rated it as good because:

The service provided safe care. The ward environments were safe and clean. A housekeeper tended to the wards daily and staff were proactive in repairing or removing anything broken or damaged. Environmental risks were identified and removed or reduced as appropriate.

The wards had enough nurses and doctors. Staff assessed and managed risk well. They managed medicines safely and followed good practice with respect to safeguarding.

The service minimised the use of restrictive practices, with staff making every attempt to avoid using restraint by using de-escalation techniques. The hospital was also training staff in “safewards”. This was an initiative to improve the ward environment, reduce incidents of aggression and improve safety for both patients and staff.

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. The care plans we saw included detailed inputs from other members of the multidisciplinary team. In addition, patients had Positive Behaviour Support (PBS) plans which were in place to support staff to manage challenging behaviours and ensure appropriate follow up with patients.

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.

Risk assessments were updated and reviewed more than once a week and considered any changes/ incidents. Full risk screenings were completed frequently. During this inspection we saw evidence of risk being assessed at admission, as well as frequent risk reviews for both increases and decreases in risk and full justifications of these decisions being recorded.

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 as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare. Staff told us that they were dedicated to fostering effective working relationships and communication within the multidisciplinary teams and worked together to address issues. Staff also told us that they maintained contact with external agencies including care co-ordinators, GPs and social workers.

The service held regular multidisciplinary handover and information sharing meetings, with good attendance and significant information shared which enabled them to monitor and discuss patient’s risks and needs, and other issues impacting the service. We observed positive attendance and information sharing at daily board and flash meetings where staff made sure they shared clear information regarding incidents, risks, safeguarding, medication changes and admissions/ discharges.

Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff knew who their Mental Health Act administrator was and were positive about the support and guidance given by them on both MHA, and MCA. Staff told us that they made sure the service applied the MHA and MCA correctly by completing audits and discussing the findings.

Staff treated patients with compassion and kindness and understood the individual needs of patients. All patients spoke positively of most staff and felt they were respectful, polite and caring. They actively involved patients and relatives/ carers in care decisions. Staff often gave feedback over the phone regarding their relative’s care.

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. The hospital had contracted block beds on each ward to provide availability to the local NHS trust. We saw that patients on Castle ward were reviewed regularly to ensure their placement remained appropriate. On Oakwood ward, the emphasis was on short term treatment with an expectation that the length of stay would be kept to a minimum.

The service was well led, and the governance processes ensured that ward procedures ran smoothly. Staff were complimentary about the leadership and support provided by the senior management team. Staff told us that there were open lines of communication amongst local level teams and senior managers so that risks were shared and managed well.

However:

There was poor practice on both wards of staff frequently entering the clinic rooms without knocking or identifying whether it was suitable to enter. This challenged patient's privacy and dignity and disrupted staff carrying out clinical activities, such as administering medicines.

We were aware that patients on Oakwood Ward did not have access to their own keys for their bedrooms. This challenged their privacy and the safety of their belongings when they left their rooms unattended. We saw that patients had made complaints relating to losses of their possessions to staff.

Patient care plans and PBS plans had improved since the last inspection. However, there was room for further personalisation to include triggers and interventions that were specific to each patient and described individual de-escalation preferences.

10 November 2020

During a routine inspection

On 10 November 2020 the Care Quality Commission undertook an unannounced comprehensive inspection of Cygnet Hospital Godden Green. This was following a focused inspection carried out on 02 October 2020.

We had not previously rated acute wards for working age adults and psychiatric intensive care units at Cygnet Hospital Godden Green under our comprehensive methodology as it had opened since our last comprehensive inspection. At the time of this inspection only one ward was open, Castle ward, a psychiatric intensive care unit for females. Castle ward comprised of 12 en-suite bedrooms. At the time of the inspection there were six patients on the ward.

Our rating of Cygnet Hospital Godden Green stayed the same. We rated it as requires improvement because:

  • Staff did not always use physical restraint as the last resort to manage behaviour. The service had not identified all environmental risks. Personal evacuation plans did not explain to the emergency services how to assist the patient to exit the ward in an emergency. A blanket restriction prevented patients keeping toilet paper in their bedrooms.
  • Staff did not always respect the privacy and dignity of patients. Patients were not always actively involved in planning their care.
  • Patients could not make private telephone calls on the ward. Patients did not have enough storage space, in their bedrooms, for all their belongings.
  • The management team had not fully embedded the governance processes to ensure the ward procedures ran smoothly.

However:

  • There was a new leadership team in place at the hospital who had the experience, knowledge and skills to manage the service.
  • The ward environments were clean. The wards had enough nurses and doctors. Staff managed 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 kept families informed about their relative’s care.

23 September and 2 October 2020

During an inspection looking at part of the service

Cygnet Hospital Godden Green delivers Tier 4 Child and Adolescent Mental Health Service (inpatients CAMHS, Knole and Riverhill wards) and also provides a Psychiatric Intensive Care Unit (PICU, Castle ward) service for women.

On 23 September 2020, we undertook an unannounced focussed inspection of Knole and Riverhill wards. On 2 October 2020, we undertook an unannounced focussed inspection of Castle ward. This was following concerns raised with us by members of the public, complaints from relatives and other professionals. The concerns included the safety and wellbeing of the young people and patients, high levels of incidents resulting in harm, patients’ dignity and sexual safety on the ward, cleanliness of the wards, staff training, complaints handling and leadership.

During our inspection, we had serious concerns about the safety and care of the young people and patients at the service, which we fed back to managers and asked that they took immediate action to address these. The Director of Nursing for Cygnet Health Care Limited commenced immediate action to ensure the safety of young people and patients.

On 5 October 2020, we served a Section 31 Letter of Intent which informed the provider that we were considering possible urgent action should they not provide documentary evidence to reassure us that the risks had been removed or were immediately being removed. Section 31 of the Health and Social Care Act 2008 Act is an urgent procedure whereby CQC could suspend a providers registration for a period of time, or impose, vary or remove conditions on the registration with immediate effect in response to serious concerns.

In response to the Section 31 letter the provider submitted an action plan that set out how some concerns had been addressed and how others were being addressed, including clear time frames for addressing those. No further enforcement action was taken against the provider and CQC continue to monitor the providers progress.

The provider also agreed to suspend admissions to the psychiatric intensive care unit until further notice and to provide us with a range of information that allows us to monitor the services closely. The provider agreed to meet with us on a weekly basis as part of that monitoring process.

In addition, CQC has also worked closely with the NHSE/I and the South East provider collaborative (responsible for commissioning child and adolescent mental health services) who, along with other stakeholders, decided that the Tier 4 child and adolescent unit should temporarily close and so young people would be moved to other appropriate settings, for example, discharged home or onward placement. Following this decision, Cygnet Health Care Limited decided to permanently close the child and adolescent mental health wards. On the 26 October 2020, all the young people had moved from the child and adolescent mental health services at Godden Green Hospital. The previous rating for this service will be rescinded once the service is closed.

CQC continued to work with the provider and stakeholder organisations to ensure safe care of the young people until they were moved to another placement or discharged home.

During the inspections we found:

  • None of the ward environments were safe, clean or well maintained. Staff did not always assess and manage risk well. On Knole and Riverhill wards, environmental and ligature risk assessments did not always capture risks or have appropriate mitigation. Repeated incidents occurred where young people suffered harm and injury. Staff were not always able to keep young people safe from avoidable harm. Restrictive practice was routinely used on Castle ward without any attempt at de-escalation. Incident management was poor on all wards and did not keep patients and young safe.
  • Staff on all wards did not always develop care plans that appropriately reflected patients and young peoples’ assessed needs. Care plans were not always personalised, holistic or recovery orientated.
  • There was not enough staff deployed with the skills, expertise and experience to meet the needs of young people on Knole and Riverhill wards. Most of the staff had no experience of working with young people, and had not received sufficient specific training for their role. Staff did not receive comprehensive induction, and supervisions did not sufficiently support them. On Castle ward, the provider had not ensured the gender mix of staff was appropriate for a female ward.
  • Staff from the different disciplines did not always work together effectively and this resulted in gaps in peoples' care.
  • Physical health management was poor, and records were not an accurate reflection of people’s needs. On Castle ward, we saw conflicting information about physical health diagnoses in patients care plans, and appropriate referrals to specialist services not being made. A number of patients and most young people across all wards did not always receive safe and appropriate physical healthcare. On Knole ward, staff did not always follow the provider’s protocol when young people needed to attend Emergency Departments, resulting in delays to their treatment. On Knole and Riverhill wards, some staff were completing medical assessments, which they were not trained to do.
  • The culture at the hospital was not open, transparent and did not support both staff and patients to raise issues of concern. On Castle ward, a culture of negativity towards patients had developed among some staff. We saw records where patients were referred to as ‘difficult’ and ‘trouble-makers’. We saw some staff acting in an intimidating manner when patient’s behaviour became disturbed with little attempt made to use a calm and considered approach to de-escalate the situation or reassure and comfort patients. Young people said they felt tensions on Knole and Riverhill wards that upset them and made them feel unsafe.
  • Staff did not always treat patients and young people with compassion and kindness. Staff did not always respect patients’ privacy and dignity. On Castle ward, there was a high ratio of male staff working closely with female patients despite them having asked for female staff. Staff did not always knock on bedroom doors before entering, and some patients were afraid to shower as a result. Staff did not always appropriately involve patients, young people, families and carers in care planning. On all wards, there was limited evidence of patient and young peoples’ involvement in their care and treatment. Most patients, young people and their families told us they did not feel included in care decisions.
  • The service did not adequately meet the needs of all patients. Patients did not receive adequate information, cultural needs were often not met, and patients had very limited access to outside space.
  • Complaints were not managed well. The process was ineffective and did not produce good outcomes. There was not enough action taken to learn from complaints, and prevent future occurrences. Patients, families and carers told us they had no faith in the complaints process, as nothing changed as a result and concerns were often played down.
  • On Riverhill and Knole wards, leaders did not have the skills, knowledge and experience to perform their roles, and were not always visible in the service. Leaders did not ensure staff received appropriate support. There was a poor culture on the wards and staff reported exceptionally low morale. Some staff told us they did not feel able to raise concerns without fear of retribution.
  • Governance processes did not operate effectively, and performance and risk were not managed well. Oversight of incidents and complaints was poor, and the processes were not always effective as a result. The leadership team at the hospital had not recognised the concerns identified on the inspection In addition, the senior leadership team at Cygnet Health Care Limited did not have adequate assurance mechanisms in place. They had not picked up that young people and patients were not receiving the care that they should have been and had not acted to make improvements in a timely manner.

However;

  • On Castle ward an environmental ligature risk assessment was completed, with effective mitigation of identified risks. There had been no reported incidents involving fixed point ligatures since the ward opened in November 2019.
  • On Castle ward, staff received appropriate training and effective ongoing supervision to support them in their role.
  • Staff had good working relationships with professionals external to the organisation, such as local authority safeguarding team and community mental health teams.
  • Patients, families and carers told us most staff on Castle ward were kind and respectful, and were doing their best.
  • On Castle ward, staff felt respected, valued and supported. Staff felt confident that they could raise concerns with managers and that they would be listened to, without fear of retribution.

What people who use the service say

On the 23 September 2020, we spoke with six young people. Most young people told us they did not always feel safe on the wards. They spoke about how the ward had been very unsettled over the last few months. They said staff were not always responsive to their needs and sometimes staff did not respond to incidents in a prompt way. Young people told us staff were varied in their approach, and while there were certain staff who they described positively, there were also staff who they felt did not listen to their needs or helped them. They felt that some of the staff said the wrong thing to them and were not always supportive or responsive to their needs when they were having a challenging time.

Patients told us the ward environment was often dirty and not well kept, and bodily fluids from self-injurious behaviour was often left and not cleaned. They said the environment felt very bare and was not decorated for their age and did not feel welcoming.

Young people felt there were not enough activities to do during the week or at weekends. They said they felt staff were often too busy or there were not enough staff to help with activities, so they were cancelled. They told us they often felt bored and unmotivated so would just sleep during the day and be up at night and that is why so many incidents on the ward happened. They said some of the activities that were offered did not interest them.

Young people told us their physical health was not always appropriately managed, specifically if they needed to attend emergency department due to self-injuring behaviour. They said staff responses varied and some of them had experienced lengthy delays in staff making decisions and arrangements for them to attend and be assessed at emergency department . They said this caused them distress.

We spoke with 11 relatives/carers and received mixed reviews about their experience and the care and treatment their relatives received. Three relatives/carers feedback was mostly positive, saying they were invited to meetings and spoke with staff regularly. However, most relatives said that staff did not communicate well with them and they were not always kept informed of every aspect of their relatives care and treatment, including when incidents happened. Some relatives felt their child was not safe on the ward due to incidents and poor communication from staff. They were concerned that staff were not experienced to work on the wards.

On 2 October 2020 we spoke with four patients on the PICU. Feedback about the psychiatric intensive care ward was mixed. Most patients said staff were caring, respectful and were doing their best; however, some felt that staff were only nice because they were being watched and that some staff could be quite bullying towards patients. Feedback about the quality and choice of food was good; however, patients requiring specific diets told us they had limited choice and the hospital didn’t always know what they could and couldn’t eat.

Most patients told us they were uncomfortable having so many male staff members caring for them, despite having asked for female staff. Feedback indicated that patients had not been given adequate information about their treatment and rights. Most patients also told us they had limited access to fresh air and would like to be able to go outside more. This had been repeatedly reported to staff. Some patients told us their belongings had gone missing, including clothes and toiletries.

Carers feedback was also mixed. Some people told us the staff were very caring and kept them appropriately involved. Others said they were not informed at all. Some people felt the process for raising concerns and complaints was effective, others said it was very lengthy, rarely produced a satisfactory outcome and that issues were played down. Most people we spoke with were concerned about physical health management on the ward.

9 April 2019

During a routine inspection

Our rating of this service went down. We rated Cygnet Hospital Godden Green as requires improvement because:

  • Following the last comprehensive inspection when the service was rated good, there was a subsequent focused inspection where the ratings did not change but there were several areas where the provider needed to make improvements. At this inspection we found the provider had made good progress with these improvements but there were some more to complete to ensure safe care.
  • The hospital did not have a permanent registered manager and hospital director although interim arrangements had been put into place. Since the last comprehensive inspection standards of care and treatment had fluctuated and so a permanent manager was needed to deliver consistently high-quality care that could be sustained. In addition, the hospital was still under enhanced surveillance and was only treating six young people. Strong leadership combined with effective governance processes would be needed as this restriction on patient numbers was lifted and more young people were admitted to the hospital. After the inspection we were told that a permanent manager had been appointed but had not yet come into post.
  • Robust systems were not fully embedded to enable staff to safely manage risks to young people. For example staff were not clear which young people could enter the clinic rooms when medication was being administered or where it was safer for this to take place elsewhere. Also, there was a lack of clarity from staff about which items should be removed from young people to avoid repeated self-harm.
  • There were a few areas where medicines management needed to improve. There was medication in the resuscitation bag which was not listed on the audit. The hospital told us after the inspection that this was an error and has been removed. We saw inaccurate record keeping concerning medication management across the hospital’s systems. For example, staff were expected to record information following rapid tranquilisation in multiple locations, leading to discrepancies between the recording information. The provider had not ensured that all the registered nursing staff had completed their medication competency assessment as per the hospital policy.
  • There was no overall list of how many ligature cutters were on the ward. This meant that if a kit was used, there was no way of telling if any equipment had been left on the ward.
  • There was no process in place to ensure that staff tested personal alarms and there was no record of alarms being signed out which could leave broken alarms in circulation.

However:

  • The ward environments were safe and clean. The wards had enough nurses and doctors. Staff 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. 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. 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. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
  • 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.
  • Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

2 and 3 January 2019

During an inspection looking at part of the service

Cygnet Hospital Godden Green has an integrated Tier 4 (inpatient wards) child and adolescent mental health service alongside a Department for Education, Ofsted -registered school, the Knole development centre. Its specialist pathway offers an open acute admissions service (Knole ward), and a pre-discharge ward (Littleoaks ward) to allow for a smooth transition for young people returning home to their families.

We last inspected this service in February 2018. This was a planned, announced comprehensive inspection and we rated the service as good overall and good in all domains.

Prior to this, we had undertaken a focussed inspection in November 2017, due to concerns about the safety of young people at the service including the number and severity of incidents and the lack reporting externally to relevant bodies. At this inspection we told the provider it must improve. From this inspection, we found the provider to be in breach of regulation 12, safe care and treatment, regulation 13, safeguarding service users from abuse and improper treatment and regulation 17, good governance. We also issued the provider with fixed penalty notices under sections 87 and 87 of the Social Care Act and Regulation 28 and Schedule 5 of the Health and Social Care Act20118 (Regulated Activities) Regulations 2014. The fixed penalty notices were issued in relation to multiple failures by the provider to make required notifications to the Care Quality Commission.

On the 2 and 3 January 2019, the Care Quality Commission carried out an urgent, focussed inspection on Knole ward and Littleoaks ward. Concerns had been raised with us, including the leadership of the service, number and severity of incidents affecting the health, safety and welfare of young people on the wards and the safety of the ward environment. We looked at Knole ward, a 15 en-suite bedrooms admission ward, and Littleoaks ward, which comprises seven en-suite bedrooms, both for males and females aged between 12-18 years of age. At the time of the inspection there were 12 young people on Knole ward and 6 young people on Littleoaks ward.

Cygnet Hospital Godden Green is registered for the following regulated activities: assessment or medical treatment, for persons detained under the Mental Health Act 1983; treatment of disease, disorder or injury.

The service had a registered manager at the time of the inspection. However, following the inspection we were informed the registered person no longer worked for the service. The provider informed the Care Quality Commission they had identified a new person to take over as registered manager and the necessary paperwork will be completed.

From November 2017 to October 2018, the service was under enhanced surveillance by relevant stakeholders to ensure that the quality and safety of the service made sufficient improvements.

20 and 21 February 2018

During a routine inspection

We last inspected the child and adolescent service in November 2017, during an unannounced responsive inspection. Concerns had been raised with us, including the number and severity of incidents affecting the health, safety and welfare of young people on the wards, the lack of reporting of incidents to relevant external authorities and the safety of the ward environment.

Following the inspection in November 2017, we found the service provider to be in breach of regulation 12, safe care and treatment, regulation 13, safeguarding service users from abuse and improper treatment, and regulation 17, good governance. We took enforcement action and issued three warning notices under each of the regulations on 23 November 2017. The warning notices served notified the provider that the Care Quality Commission had judged the quality of care being provided as requiring significant improvement. We told the provider they must comply with the requirements of the regulation by 15 January 2018. We had previously taken enforcement action and had already issued a warning notice against the provider for breach of regulation 13, safeguarding service users from abuse and improper treatment, following our last inspection in July, August and September 2017. There was a total of four warning notices issued to the provider.

In response to the concerns raised, the provider made significant management changes in the service and undertook a a review at the hospital which was carried out by managers from the wider organisation, We took the decision to carry out an announced comprehensive inspection, so we could ensure the provider had taken appropriate action to address all the concerns found and make improvement's to the care and treatment provided and the overall running of the service.

We rated Cygnet Hospital Godden Green as good overall because:

  • At this inspection, we found the provider had made significant improvements to the quality and safety of the child and adolescent service and care and treatment given to young people. We have rated each domain as good for both the low secure forensic service and the child and adolescent service.
  • The hospital had appropriate staffing levels to allow safe care and treatment of patients and young people. Observation of patients and young people and risks were well managed. Staff had established good therapeutic relationships with patients and young people and dedicated time to this. There was little use of restraint, rapid tranquilisation or seclusion on Saltwood ward and such incidents had reduced significantly on Littleoaks. Staff were competent and appropriately qualified in their roles and received comprehensive training. Staff understood safeguarding procedures and how to protect patients and young people from abuse. Medicines were managed appropriately at the hospital.
  • Patients and young people were involved in the planning of their individual care on an ongoing basis. There were systems in place to assess, monitor and review the physical healthcare needs of patients and young people. The hospital offered structured psychology and occupational therapy interventions as well as a full therapeutic activity programme.
  • We observed positive interactions between staff and patients and young people. Staff understood the individual needs of patients and young people. Patients and young people were involved in the operation of the hospital and engaged in planning meetings and community meetings to give feedback about the hospital.
  • The hospital proactively planned the discharge of patients and young people. They worked with patients, young people, their families and partner agencies to plan discharges safely.
  • Patients and young people knew how to complain and felt supported by staff. The hospital were proactive in capturing and responding to concerns and complaints raised by patients and young people.
  • Managers within the hospital were visible and offered support to staff. The hospital was responsive to patient feedback and demonstrated clear learning from incidents. Staff were motivated and dedicated to their roles and felt valued by the hospital.
  • A comprehensive schedule of meetings and reporting systems had been introduced to ensure appropriate risk management interventions and good governance of the service.

However;

  • Saltwood ward had a high vacancy rate for nursing staff. The service were actively recruit to vacant positions. Familiar agency staff covered shifts and took on primary nursing roles for the patients’.
  • Some areas of Saltwood ward were unclean. This was a minor concern and related to the kitchen area on the ward where patients’ could make themselves drinks and snacks.
  • Patients on Saltwood told us staff did not always taken appropriate action when other patients had made offensive comments to other patients’.
  • Young people on Littleoaks told us their sleep was interrupted when staff undertook night time observations.
  • Following this inspection, we found significant improvement had been made and all enforcement action associated with this service has now been met.

2 and 3 November 2017

During an inspection looking at part of the service

On the 2 and 3 November 2017, the Care Quality Commission carried out an urgent responsive inspection on Knole ward and Littleoaks. Concerns had been raised with us, including the number and severity of incidents affecting the health, safety and welfare of young people on the wards, the lack of reporting of incidents to relevant external authorities and the safety of the ward environment.

We found the service provider to be in breach of regulation 12, safe care and treatment, regulation 13, safeguarding service users from abuse and improper treatment, and regulation 17, good governance. We took enforcement action and issued three warning notices under each of the regulations on 23 November 2017. The warning notices served notified the provider that the Care Quality Commission had judged the quality of care being provided as requiring significant improvement. We told the provider they must comply with the requirements of the regulation by 15 January 2018. We had previously taken enforcement action and had already issued a warning notice against the provider for breach of regulation 13, safeguarding service users from abuse and improper treatment, following our last inspection in July, August and September 2018.

We also issued the provider with fixed penalty notices under sections 86 and 87 of the Health and the Social Care Act and under Regulation 28 and Schedule 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The fixed penalty notices were issued in relation to multiple failures by the provider to make required notifications to the Care Quality Commission.

A further comprehensive inspection is scheduled to commence on 20 February 2018, where we will look to see what action the provider has taken in respect of each of the breaches of regulation.

We found the following issues the service provider needs to improve:

  • Environmental risk assessments for the wards did not always identify risks that required escalation. We saw examples where incidents had occurred in the environment and assessments were not updated to manage or prevent similar incidents being repeated.
  • The quality of individual risk assessments for young people were poor. Staff did not update or review risk assessments following incidents. The risk of similar incidents being repeated was not mitigated or managed. We saw several examples where similar, preventable incidents reoccurred.
  • Staff were not always competent and skilled to provide care and treatment to young people. Staff had required police assistance on a number of occasions to support and manage incidents on the wards that should not have required the support of the police.
  • Staff were not always supported to prevent, identify and report abuse. Staff were not skilled in making safeguarding referrals to the local authority safeguarding team.
  • Staff did not fully investigate safeguarding concerns and not all safeguarding concerns were reported internally or to the relevant external agencies. We found a number of incidents that had not been appropriately reported.
  • The provider did not always support young people following incidents and provide feedback.
  • Incident forms were poorly completed and missing information. Staff were not following the provider’s process for incident reporting correctly. The provider did not keep an up to date, accurate and complete record of incidents on the wards.
  • The provider did not have effective audit and governance systems in place to monitor the service. There was no effective system in place to ensure there was learning from incidents and action taken to mitigate future risks.

25, 26 July 2017, 4, 8 August 2017 and 4, 5 September 2017

During an inspection looking at part of the service

  • On the 25 and 26 July 2017, we carried out an unannounced responsive inspection on Knole ward due to concerns raised with us including poor discharge planning, lack of communication between staff, relatives and carers and the safety of the ward environment.
  • On the 4 August 2017 we undertook another unannounced, urgent responsive inspection to Knole ward due to further concerns raised with us about risk assessments, care planning, monitoring of physical health, medicines, use of and reporting of restraint and high levels and serious nature of incidents.
  • On the 8 August 2017, a member of the medicines team from the Care Quality Commission carried out an announced, focused inspection on Knole ward to see if medicines were safely managed.
  • Following these inspections, we took enforcement action and issued the provider with an urgent notice of decision under section 31 of the Health and Social Care Act, to impose conditions on their registration specifically on Knole ward, dated 8 August 2017. We told the provider they must not admit any young person to Knole ward without the prior agreement of the Care Quality Commission. This was because we believed a person could or would have been exposed to the risk of harm if we did not do so.

In the notice of decision, we told the service provider they needed to make the following improvements on Knole ward:

  • Ensure there is an effective system in place for the development, review and ongoing monitoring for the assessment of risk for young people.
  • Ensure there is an effective system in place to support the ongoing regular assessment, screening, follow up and intervention in respect of young peoples’ physical health needs.
  • Ensure there is an effective system in place to support and manage the use of restraint.
  • Ensure they follow guidance as set out by the Department of Health, Positive and Proactive Care, NICE guideline NG10: Violence and aggression.
  • Ensure there is an effective system in place to monitor and review young people following the use of rapid tranquillisation.
  • Ensure there is an effective system in place to make certain that prescribed medicines, including the use of PRN (as necessary) are absolutely required.
  • On the 4 and 5 September 2017, we carried out an announced focused inspection, to find out if the service had made improvements to Knole ward. We specifically looked at the concerns identified in the urgent notice of decision.
  • At that inspection, we found the service had made some significant improvements to the safety and quality of care and treatment given to young people. We were satisfied appropriate action had been taken to ensure that young people were no longer exposed to the risk of harm. On the 8 September 2017, we lifted all of the conditions set out in the urgent notice of decision and told the provider they could now admit young people to Knole ward. However, further improvements were required.

We found the following issues the service provider needs to improve:

  • The service did not comply with the Department of Health guidance on same-sex accommodation on Knole ward. Although young people’s bedrooms had en-suite toilet and shower facilities, the ward did not have separated sleeping arrangements in place for males and females and lacked a female only lounge provided.
  • Young people’s medicines were changed without an individual risk review carried out and decisions to change medicines from tablet form to liquid were not based on individual clinical need. We judged this to be restrictive practice, to suit the needs of the service.
  • Medicines were not always available for young people at all times. Where specific medicines were not available, appropriate action was not taken by staff to prevent the risks associated with not taking the medicine prescribed.
  • Learning from complaints and serious incidents was not always identified and there were some missed opportunities to improve the service.
  • Staff did not operate within the service provider’s policy and Mental Health Act Code of Practice to ensure young people were appropriately safeguarded when placed in seclusion or long-term segregation. The use of seclusion and segregation was used to control and contain young people in the absence of other behaviour-based approaches. We took enforcement action and issued a warning notice for regulation 13, safeguarding service users from abuse and improper treatment, on 16 August 2017. The warning notice served, notified the provider the Care Quality Commission had judged the quality of care and treatment being provided to young people as requiring significant improvement. We told the provider they must comply with the requirements of the regulation by 9 October 2017.

However, we also found the following areas of good practice:

  • A proactive approach to anticipating and managing risks to young people was starting to be embedded and recognised by staff. Young people were actively involved in managing their own risks through the use of risk assessment tools and worked collaboratively with staff.
  • Young people, where needed, had a positive behaviour support plan in place. Staff applied effective proactive strategies to de-escalate or prevent young people’s challenging behaviour and applied reactive strategies when needed as per the young person’s positive behavioural support plans. The service had a plan in place to reduce restrictive practices on the ward.
  • All young people had a current, up to date, personalised care plan to support them through their care and treatment pathway. All young people had a comprehensive physical health assessment completed on admission. The service had implemented the use of ‘The Lester Tool’. Physical healthcare needs were mostly incorporated into young people’s care plans and were detailed.However, for one young person a physical health care plan was not in place despite a need for one.
  • Staff completed physical healthcare checks on young people on Knole ward and these were mostly recorded clearly and consistently so that staff could quickly identify any changes or concerns and take the required action. The service used a standardised system called Modified Early Warning System. However, further improvement was needed as staff did not always calculate and record scores on all charts.
  • There were systems in place to monitor performance on Knole ward. This was measured against a range of indicators, which included safeguarding, incidents and types of incident. 

26 - 27 April 2016

During a routine inspection

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We rated Cygnet Hospital Godden Green as good because:

  • The hospital had systems in place to ensure patients were safe. Areas of potential risk to patients were well managed.
  • The hospital had systems to ensure staffing levels were sufficient to provide safe patient care. Staff were appropriately qualified for their roles and attended regular training relevant to their roles. Patients were provided with medical cover 24 hours a day.
  • The hospital carried out comprehensive risk assessments on all patients. They were regularly reviewed and updated in line with incidents. The quality of risk assessments was audited to ensure standards were maintained.
  • Staff had a good approach to reporting incidents and responding to complaints. The hospital had systems in place to ensure incidents and complaints were discussed so lessons could be learnt.
  • The hospital had a good approach to assessing, and responding to, patient’s physical health and psychological needs.
  • Patients were actively involved in planning their care. Staff, from across the multidisciplinary team, worked with patients to ensure that care was delivered based on individual need.
  • The hospital had a good approach to auditing their clinical work. This was supported by the wider organisation who produced a comprehensive clinical audit strategy which included guidance on timescales for completion.
  • Staff received regular supervision and appraisals. Nursing and psychology teams had systems in place to ensure people were supervised by appropriately experienced colleagues. Managers received supervision from senior managers.
  • Patients were treated with dignity and respect and had appropriate access to privacy. Patients had the opportunity to give feedback on the service and this was acted upon. Staff provided good levels of support whilst adhering to professional boundaries.
  • Patient’s families and carers were involved in their care and the hospital offered teleconferencing facilities for families who were not local. In particular, the psychology teams offered flexibility in delivering with their family interventions, including travelling to people’s home addresses.
  • Patients had access to a wide range of activities and facilities to support their care and recovery. Information of importance and interest to patients was clearly displayed within ward areas.
  • Staff morale was high and they were optimistic about the direction the hospital was heading and were kept up to date with developments in the wider organisation. They agreed with the organisations vision and values.
  • The hospital had good governance systems which were adhered to in line with the wider organisation. The registered manager had an organised approach to auditing and quality assurance.
  • Both services provided by the hospital had recently participated in national peer review schemes. They had acted on findings to further improve their practice.

However;

  • The child and adolescent mental health wards were using prone restraint. This is when a patient is restrained on the floor face down. The wards were continually looking at ways to reduce occurrences of prone restraint.
  • Littleoaks required updating to eliminate environmental risks, such as anchor points and fire doors. It also did not have easy access to an outside area.
  • Staff were not provided with a structured local induction. This meant managers could not adequately monitor staff competence in everyday ward activities.
  • We found that some documents, concerning capacity and consent to treatment, for detained patients on Saltwood ward was not available for staff to refer to.
  • Staff on Knole ward were not effectively capturing details of verbal complaints from patients. This meant these issues could not be reviewed and opportunities for lessons learnt could be lost.

19 February 2014

During a routine inspection

The interactions we observed between people using the service and staff were friendly and respectful. The people we spoke with on Saltwood Ward (low secure unit) were mostly positive about the service. We were told the ward was 'good' and 'okay', and that the staff were 'always obliging with assistance if needed.' The people we spoke with on Knole Ward (child and adolescent mental health unit) said they felt they got something out of being in the hospital. They told us that some of the staff were very good. They told us they thought that one-to-one therapy was really good, but would like more time with nursing staff.

There were processes for safeguarding people from the risk of abuse. The people we spoke with told us they felt safe in the service.

People using the service had their own room with ensuite facilities. People could make their own drinks, and there was an interview room for one-to-one sessions and small meetings. The rooms contained anti-ligature furniture. Routine maintenance and safety checks were carried out.

There were adequate numbers of nurses and healthcare assistants on Saltwood Ward. The staffing levels on Knole Ward were maintained, but people told us that there were often agency staff who they did not think were familiar with the ward. People had care and treatment provided by medical and therapy staff.

The service reviewed and took action following incidents and complaints, and looked at ways of improving care within the hospital.

1 October 2012

During a routine inspection

Patients felt involved in their care and part of the treatment process. They felt the staff treated them with dignity and respected their privacy.

Patients were pleased with the quality of care they received. Comments included, ' they are nursing me back to mental health' and ' (staff) have been extremely good to me'. Some staff were seen as, 'marvellous' whereas others were,' ' just doing their job'.

Some patients expressed concerns that there was a lack of activity at the weekends. One patient said weekends were, 'vacant'.

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.