Cygnet Hospital Harrow

Updated 18 October 2023

Cygnet Hospital Harrow was registered with the CQC on 15 November 2010. The hospital is made up of 4 wards across 4 core services which include acute wards for adults of working age and psychiatric intensive care units, a low secure forensic ward for people with autism, a ward for people with learning disabilities or autism and a long stay rehabilitation ward for people with autism.

• Byron ward is an acute service for men of working age. The ward can accommodate up to 20 patients. The beds are commissioned by 2 London based NHS trusts.

• Spring Unit is a specialist low-secure forensic ward for up to 12 male patients with autistic spectrum disorders and who also present with mental health needs.

• Springs Wing is a specialist rehabilitation ward for up to 10 male patients with autistic spectrum disorders.

• Springs Centre is a specialist ward for up to 14 male patients with a diagnosis of autism and who also present with mental health needs. This ward opened in January 2018.

We have inspected Cygnet Hospital Harrow 3 times since October and November 2018. Our most recent comprehensive inspection of Cygnet Hospital Harrow took place in October and November 2018. Following this inspection, the hospital achieved an overall rating of good. The hospital was rated as requires improvement for safe and good for effective, caring, responsive and well-led. We issued requirement notices for four separate breaches of regulation in relation to regulation 12 (safe care and treatment), regulation 15 (premises and equipment), and regulation 18 (staffing), and made recommendations to the provider to improve in a few areas.

Since then, we have carried out a focused inspection of the acute ward in August 2020 and of the ward for people with autism in November 2020, following a number of concerns raised about the care people had received. We did not re rate the service at these inspections. We did not identify any breaches of regulation for the specialist autism wards. We found one breach of regulation related to the use of personal protective equipment during COVID-19.

We undertook an unannounced comprehensive inspection in May and June 2023 to find out whether the quality of services at Cygnet Hospital Harrow had changed since our previous comprehensive inspection in October and November 2018.

Cygnet Hospital Harrow is registered to provide the treatment of disease, disorder or injury and assessment or medical treatment of persons detained under the Mental Health Act 1983. There was a registered manager in place at the time of our inspection.

What people who use the service say

We spoke with 1 person on Springs Wing, the rehabilitation ward for people with autism who was positive about their overall experience on the ward. The person told us that they felt listened to and that staff supported them. We offered to speak with more people on the ward but they either declined or was off of the ward at the time of our inspection.

On Byron ward, the acute wards for adults of working age, we spoke with 7 patients who spoke positively about staff attitudes overall. Patients liked the food. However, not all patients said they were involved in their care and treatment.

We spoke with 7 people from Springs Centre, the ward for people with a learning disability or autism. They had mixed views about the ward they were living in. Three people raised their concerns about how staff treated them. Three people said that staff mimicked them and laughed at them. Some people told us that there were not enough activities especially at the weekends.

On Springs Unit, the low secure forensic ward, we spoke with 5 people. Three out of 5 people told us that they felt ignored during periods of seclusion and that staff were unable to meet their needs. A small number of people had said that they felt safe on the wards.

On Springs Wing we spoke with 3 carers. All carers said that their relative felt safe on the ward and felt comfortable to raise concerns. Two carers told us that they were concerned that their relative had gained a lot of weight since being in hospital and that they did not feel involved in their relative’s care. One carer told us that they felt that the ward was dirty.

On Byron ward we spoke with 5 carers. Overall, carers were positive about staff on the ward. They said staff involved them with care if the patient had consented to this. However, some carers had not been informed about visiting times which had resulted in long waits or being turned away.

Most patients and carers from Byron ward did not know how to complain.

On Springs Unit, we spoke with 2 carers. Both carers we spoke with told us that they felt communication from the ward could be improved. One of the 2 carers we spoke with told us that the service had never contacted them to inform them of when their relative had been involved in an incident. One carer told us that staff were not supporting their relative to manage their oral hygiene and since being in the hospital it had worsened. Most carers understood how to raise concerns and felt comfortable to do so.

During our inspection we spoke with 4 carers from Springs Centre. Three out of the 4 carers we spoke with told us that they felt that staff communicated with them. One carer told us that they felt that there was an unreasonable limitation on their visits to the ward and they were unable to visit as often as they would like.

Updated 18 October 2023

Our inspection of Cygnet Hospital Harrow took place between the 23 May and 11 June 2023. We completed full inspections of the four core services provided at the hospital. These services were the acute wards for adults of working age and psychiatric intensive care units (Byron ward) and the wards for people with autism (Springs Centre); forensic inpatient wards for autistic people (Springs unit); rehabilitation ward for autistic people (Springs Wing).

When we report on services for people with learning disabilities and autism, we refer to people who use services as ‘people’. When we report on acute wards for adults of working age and psychiatric intensive care units, we refer to people who use services as ‘patients’.

Our overall rating of this hospital went down. We had previously rated the service as good. At this inspection we rated it as inadequate because:

• The overall rating of inadequate was the combined ratings for the four services. Forensic inpatient wards for autistic people were rated inadequate across all five domains. Wards for autistic people were rated inadequate for safe, effective, caring and well led and requires improvement for responsive. Rehabilitation wards for autistic people were rated inadequate for effective, requires improvement for safe, caring and responsive. Acute wards for working age adults were rated inadequate for safe and well-led and requires improvement for effective, caring, responsive.
• The Springs Centre, Springs Unit and Springs Wing were described by the provider as delivering a specialist service for men with a diagnosis of autism spectrum disorder. However, our inspection found that this was not the case, and the service was not meeting the needs of autistic people using this service.
• Nursing and care staff who worked on Springs Unit, Springs Wing and Springs Centre which provided care and treatment for autistic people were not adequately trained to communicate effectively with people using the service. This impacted on how staff interacted and communicated with people. People told us that they did not feel they were treated with compassion and kindness.
• The environment of Springs Centre and Springs Unit was not suitable for autistic people. We found the environment to be institutional and noisy. There were no improvement plans in place on both wards with clear timescales to bring the environment to an adequate standard.
• Restrictions in place on Springs Wing, Springs Unit and Springs Centre were not always recognised or reviewed on a regular basis. Our inspection identified a person being taken to appointments wearing handcuffs (a mechanical restraint) and the restraint had not been reviewed by the clinical team. Other blanket restrictions such as access to hot drinks had not been kept under review.
• Springs Unit and Springs Centre were not kept adequately clean. One person on Springs Unit was in seclusion for 17 hours before smeared faeces was cleaned up.
• Some people on Springs Unit, Springs Centre and Springs Wing who may be in hospital for lengthy periods said the food was not always of good quality, could be too cold (when it was a hot meal), portions were too small and so they were eating snacks. Some carers told us that their relatives were gaining weight.
• People were living on the wards for autistic people for lengthy periods of time but were not having routine health checks such as appointments with the optician or dentist or an annual health check with the GP. Autistic people have a shorter life expectancy as their physical health needs are often not met and so it is important these health care appointments take place.
• People were not being offered sufficient therapeutic activities that met their needs. We found that activities significantly reduced at the weekends on Springs Unit, Springs Wing and Spring Centre. This impacted on the need for autistic people to have structured activities in place. On Byron Ward some patients told us that they were dissatisfied with the activities available. Where patients had attended activities, this was not always reflected on their care records.
• The provider had not addressed all the previous breaches from the previous inspection report. We found ongoing issues across all wards inspected. For example, clinical and emergency equipment continued to not be routinely calibrated and checked it was in working order. This meant that in the event of an emergency the equipment might not work.
• On Byron ward, staff continued from the previous inspection to not always receive regular supervision. Group supervision was not always of a high quality. However, supervision on the wards for autistic people had improved.
• The provider did not take sufficient precautions to ensure patients’ safety across all wards inspected. We found staff did not complete records to confirm physical health monitoring after rapid tranquilisation medicines were administered. This treatment can result in serious side effects including death, so it is imperative monitoring is carried out.
• On Byron ward, despite the ward having blind spots, there was no clear plan in place to mitigate the risk and staff did not observe patients in all parts of the ward in order to keep patients safe.
• Staff who worked on all wards across the hospital did not always treat patients with compassion or respect their dignity. On Byron ward we found that some patients had complained but their concerns had not been acknowledged or addressed by staff. Patients did not always receive visits from their families and carers because staff were unclear about the ward’s rules on visitors.
• Across all wards inspected, there was a culture of patients eating meals in their bedrooms rather than in a more social environment.
• The care record systems on Springs Unit, Springs Centre and Springs Wing were poorly organised, and staff struggled at times to find important information.
• On Byron ward not all patients were given person-centred care. Patients did not always receive a one-to-one session with their named nurse, not all patients were given advice about their medicines or side effects, and nursing staff did not provide patients with a copy of their care plans.
• Carers were not adequately informed of the operation of the service. Some carers told us that they did not feel included in their relative’s care, and they did not know how to complain. The provider recognised that carer engagement required improvement and had plans in place to provide face to face meetings with carers.
• Incidents that took place across the hospital were not always reported so there was not sufficient management oversight and lessons could not be learnt to improve the safety of the services.
• The hospital’s governance systems and processes were not robust. The processes in place had not identified many of the issues found in our inspection.

However:

• The ward teams across the hospital included or had access to the full range of professional staff required. Some person-centred work was taking place on Springs Unit, Springs Wing and Springs centre by the allied health professionals and psychologists to promote positive care and recovery.
• People on Springs Unit, Springs Wing and Springs centre had access to a range of therapeutic activities during the week including some community-based activities that met their needs.
• Staff had a good understanding of safeguarding processes.
• Staff worked well with external stakeholders and professionals to support people’s discharge plans. The ward manager of Springs Unit was involved in the North London forensic provider collaborative which was an opportunity for providers in the collaborative to provide updates about their services and learn from best practice guidance. On Byron ward patients were discharged promptly.
• Staff completed a comprehensive assessment when patients arrived on the ward and records were usually holistic. Staff understood the individual risks for people using the service and ensured there were thorough handovers between shifts.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Managers met regularly to discuss staffing to ensure there were always enough staff on shift. Staff felt managers were supportive and approachable.

Updated 18 October 2023

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

• Springs Centre is described as being a specialised service for men with a diagnosis of autism spectrum disorder. However, our inspection found that the service was not meeting the needs of autistic people using this service.
• Nursing and care staff were not adequately trained to communicate effectively with people using the service. This meant that while people felt safe, they did not feel treated with compassion and kindness. Some people said they did not have a positive rapport with the staff and that staff sometimes laughed and mimicked them.
• The environment was not suitable for autistic people. The environment was institutional, noisy with alarms ringing, the lighting was too harsh. Ward leaders had some plans to make improvements but not all actions identified had clear timescales in place.
• Restrictions were not always recognised or reviewed on a regular basis. The provider was unable to evidence that restrictions on the ward was routinely reviewed in between the hospital’s restriction audit that took place every 6 months. People on the ward did not understand why there were restrictions in place.
• People said the food was not always of good quality, portions were too small and so they were eating snacks, some relatives said people were gaining weight. People were regularly eating in their bedrooms rather than using the dining area.
• People were not being offered sufficient therapeutic activities at the weekend which meant they did not have a structure which met their individual needs.
• People were not recorded as having the correct monitoring after receiving rapid tranquilisation. Staff had not ensured that they signed for medicines that had been administered.
• The ward was not kept adequately clean. The ward environment was visibly dirty.
• Care records were poorly organised, and staff struggled at times to find basic information.
• Governance processes were not sufficiently robust and had not identified some of the issues found in the inspection.
• Carers were not adequately informed and engaged in the operation of the service.

However:

• Some person-centred work was taking placed by the allied health professionals and psychologists to promote positive care.
• Therapeutic activities took place during the week including some community-based activities.
• Staff had a good understanding of safeguarding processes.
• Staff supervision had improved since the previous inspection.
• Staff understood the risks for people using the service and carried out thorough handovers between shifts.
• The ward had implemented emergency simulations that provided staff with an opportunity to practice how to respond in a variety of emergency situations.
• Staff worked well with external stakeholders and professionals to support people’s discharge plans.
• The provider had improved the level of mandatory training compliance since our most recent inspection.

Updated 18 October 2023

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

• Springs Unit is described as being a specialised service for men with a diagnosis of autism spectrum disorder. However, our inspection found that the service was not meeting the needs of autistic people using this service.
• Nursing and care staff were not adequately trained to communicate effectively with people using the service. This meant that while people felt safe, they did not feel treated with compassion and kindness. Some people said they did not have a positive rapport with the staff. The approach of the nursing and care staff was at times custodial and threatening rather than supportive. Staff did not communicate consistently with the people which caused them to be distressed.
• The environment was not suitable for autistic people. The environment was institutional, noisy with alarms ringing, the lighting was too harsh. There were no plans in place with clear timescales for improvements to take place.
• Restrictions were not always recognised or reviewed on a regular basis. One person was wearing handcuffs (a mechanical restraint) when travelling to appointments at the acute hospital and this restraint had not been reviewed by the clinical team.
• People were living on the units for lengthy periods of time but were not having health checks such as appointments with the optician or dentist or an annual health check with their GP.
• People were not being offered sufficient therapeutic activities at the weekend which meant they did not have a structure which met their individual needs.
• Some basic safety measures were not in place. Checks of equipment used for resuscitation were not taking place regularly which was outstanding from the previous inspection. People were not recorded as having the correct monitoring after receiving rapid tranquilisation. Controlled drugs were not always being administered correctly.
• The ward was not kept adequately clean. One person was in seclusion for 17 hours before smeared faeces was cleaned up.
• Incidents were not always reported so there was not sufficient management oversight.
• Care records including seclusion records were poorly organised and badly filed.
• The provider recognised that the food was not always of good quality. Some relatives said people were gaining weight.
• Governance processes were not sufficiently robust and had not identified many of the issues found in the inspection.
• Carers were not adequately informed and engaged in the operation of the service.

However:

• Some person-centred work was taking placed by the allied health professionals and psychologists to promote positive care.
• Therapeutic activities took place during the week including some community-based activities.
• Staff had a good understanding of safeguarding processes.
• Staff supervision had improved since the previous inspection.
• Staff understood the risks for people using the service and carried out thorough handovers between shifts.
• Staff worked well with external stakeholders and professionals to support people’s discharge plans.
• The provider had improved the level of mandatory training compliance since our most recent inspection.

Updated 18 October 2023

Our rating of this service went down. We rated it as requires improvement because:

• Springs Wing is described as being a specialised service for men with a diagnosis of autism spectrum disorder. Whilst our inspection found that the service was generally meeting people’s day to day care needs, staff did not receive specialist communication training to be able to effectively communicate with autistic people who used the service. Staff only had access to basic awareness training which meant they would not be appropriately trained in how to communicate with people using the service and how to use a range of communication aids.
• Restrictions were not always recognised or reviewed on a regular basis. The provider was unable to evidence that restrictions on the ward was routinely reviewed in between the hospital’s restriction audit that took place every 6 months.
• The ward had not ensured that they had become fully compliant with the requirement notice that the CQC issued following our most recent inspection in 2018 that related to the calibration of physical health equipment. During our latest inspection in May 2023, we identified physical health equipment that had not been appropriately calibrated, increasing the risks to people’s health and wellbeing.
• The hospital induction checklist record did not include a prompt to ensure the staff member was shown the ward ligature points and how they were managed. At the time of inspection, a few members of staff we spoke with were not aware of the environmental risks and management plan in place.
• People were living on the rehabilitation ward for autistic people for lengthy periods of time but were not having routine health checks such as appointments with the optician or dentist or an annual health check with the GP. Autistic people have a shorter life expectancy as their physical health needs are often not met and so it is important these health care appointments take place. Some carers said people were gaining weight and they did not feel as though the service was supporting them to reduce it.
• Governance processes were not sufficiently robust and had not identified some of the issues found in the inspection.
• People did not always receive a copy of their care plan.
• The care record system in place was not easy to follow. Information and people’s care and treatment was stored across two separate electronic care record systems as well as in paper folders.
• Carers were not adequately informed and engaged in the operation of the service.

However:

• Person-centred work was taking placed by the allied health professionals and psychologists to promote positive care.
• People were encouraged to attend therapeutic activities and leave the ward to visit the community. Some people took part in community-based activities such as swimming and voluntary work.
• Staff had a good understanding of safeguarding processes.
• Staff supervision had improved since the previous inspection.
• Staff understood the risks for people using the service and carried out thorough handovers between shifts.
• Staff worked well with external stakeholders and professionals to support people’s discharge plans.
• The provider had improved the level of mandatory training compliance since our most recent inspection.

Updated 18 October 2023

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

• The provider had not addressed all the previous breaches from the previous inspection report. We found ongoing issues with clinical equipment to monitor physical health not being calibrated. This included life saving equipment such as the ward’s defibrillator. However, since the inspection the provider confirmed all equipment had been calibrated. We also found ongoing issues with supervision; not all staff received supervision, and group supervision was not always of a high quality.

• The safe domain was rated as inadequate as there were several areas for improvement which impacted on patient safety. We found staff did not complete records to confirm physical health monitoring after rapid tranquilisation medicines were administered. This treatment can result in serious side effects including death, so it is imperative monitoring is carried out.

• Staff did not always record incidents on the electronic incident reporting system. Some incidents of restraint that had been recorded on the system did not contain sufficient levels of detail. This meant that incidents were not always appropriately reviewed and investigated.

• Despite the ward being large and having blind spots, there was no blind spot audit and staff did not observe patients in all parts of the ward in order to keep patients safe.

• Not all care was person-centred. We found not all patients had one-to-one sessions with their named nurse, not all patients were given advice about their medicines or side effects, and not all felt involved with their care. Staff did not provide patients with copied of their care plans.

• Where patients had attended activities, this was not always reflected on their care records which meant it was unclear how often patients engaged with meaningful activities. Some patients we spoke with said they were dissatisfied with the activities.

• Not all ward staff had access to ward team meetings, and some said communication could be improved. However, the ward manager started to arrange these following our inspection.

• Staff did not always treat patients with compassion or respect their dignity. We found that some patients did not have access to personal hygiene products, some patients had complained but their concerns had not been acknowledged or addressed by staff, and most patients ate meals in their bedrooms rather than in a more social environment. Staff were unclear about the ward’s rules on visitors which meant not all patients received visits from families and carers.

• Not all concerns and complaints raised by patients to staff were responded to or addressed in a timely manner. Most patients and carers we spoke with did not know how to complain.

• Our inspection findings across the key questions demonstrate that while the hospital had governance systems and processes in place, these did not always operate effectively. We identified that areas of practice were not being closely assessed and monitored which affected the quality of care delivered.

However:

• The ward environment was clean. The ward had enough nurses and doctors. Patients were offered regular physical health checks. They minimised the use of restrictive practices, managed medicines safely, and followed good practice with respect to safeguarding.

• Staff completed a comprehensive assessment when patients arrived on the ward and records were usually holistic. The service provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.

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

• Most patients we spoke with said staff treated them well and with kindness. Staff actively involved patients and families and carers in care decisions.

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

• 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.

• Managers met regularly to discuss staffing to ensure there were always enough staff on shift. Staff felt managers were supportive and approachable.