All inspections: Cygnet Hospital Harrow

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.

Our rating of Cygnet Hospital Harrow stayed the same. We did not re-rate at this inspection.

This was a focused inspection of the three wards for men with autism (Springs Centre, Springs Unit and Springs Wing) due to a number of concerns we received regarding the care of patients.

We found:

Overall, staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Patients undertook a range of individual activities and staff provided them with support.
Staff involved patients in care planning and risk assessment.

However:

Staff did not always support, involve and communicate effectively with patients’ families and carers.
A number of patients had generic risk assessments and care plans for COVID-19 which were not specific to the patient. This meant that individual patients’ understanding and needs related to COVID-19 had not been considered.

As this was an unannounced, focused inspection of Byron Ward we did not rate this service following this inspection. During the inspection we focused on patient observation levels, physical restraint and how nursing staff cared for patients.

We undertook this inspection due to information of concern we had received about Byron Ward. This information described the frequent physical restraint of patients, without staff attempting to minimise this, all patients being subject to continuous observation by staff on admission, and staff behaviour being described as rude and unprofessional.

We found:

Nursing staff did not always follow current infection control procedures and guidance concerning COVID-19.

Two patients said that staff did not always knock on their bedroom doors before entering their bedrooms.

Nursing staff had not received training in the safewards model of conflict management, which had been introduced the previous year. This meant individual staff members may have different levels of knowledge and understanding about safewards. This could impact on the ability of staff to anticipate and manage patients’ distress or conflict.

However:

Staff dealt with patient conflict, aggression and distress by verbal de-escalation. There had been no recent incidents of the physical restraint of patients and restraint was used as a last resort.

Staffing arrangements ensured consistency of care. Staffing vacancies were covered by long-term agency staff.

Staff assessed potential risks to patients when they were first admitted. The ward had appropriate procedures for the management of risk when patients were first admitted to the ward. The level of staff observation of patients was based on individual patients’ risk assessment.

Staff treated patients with compassion and kindness. Patients were complimentary regarding nursing staff and how they were cared for.

Our overall rating for the hospital improved. We had previously rated the service as requires improvement. During this inspection we rated the service as good because:

The provider had taken action to address breaches of regulation and best practice recommendations made at a previous inspection in July 2017. Safeguards were now in place to protect patients on Byron Ward from defacto seclusion and excessive restriction when they were nursed on one-to-one observations. Patients with a primary need for substance misuse detoxification were no longer admitted to Byron Ward. Staff on this ward had now received training in substance misuse issues and were able to safely support patients with a dual diagnosis.

We also saw that staff on the Springs Unit discussed, shared and implemented learning from serious incidents. Stock control of medical items on Springs Wing had improved and expired items were removed in a timely fashion. All wards were now undertaking a comprehensive range of audits that fed into governance processes. There had been improvements in how the Mental Health Act was managed, for example, where patients were entitled to statutory aftercare this was outlined in their care plan. In addition, robust systems were in place to monitor patients leave.

We also saw that patients on the Springs Unit were now supported to maintain appropriate levels of cleanliness and that on the Springs Wing, physical health interventions were now carried out in accordance with patients care plans.

Governance systems to monitor the safety, quality and effectiveness of the service had improved. On Bryon Ward, a system to listen to and act upon staff concerns had been implemented. Overall, the hospital collected, analysed, managed and used information well to support all its activities.

The service had enough staff with the right qualifications, skills and experience to keep people safe and to provide the right care and treatment.
Patients had their holistic needs assessed on admission and care plans to address these were in place. Robust arrangements to meet patients’ physical health needs were also in place. Patients received the right medication at the right dose at the right time.
Staff assessed individual patient risk and put plans in place to keep them safe. Restrictive interventions were only used as a last resort, when staff attempts at de-escalation had failed.

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. The service managed patient safety incidents well. The service treated concerns and complaints seriously. The hospital was committed to improving services by learning from when things go well and when they go wrong.
The service provided care and treatment based on national guidance. The service monitored the effectiveness of care and treatment and used the findings to improve them.
Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Staff received annual appraisals. Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff involved patients and those close to them in decisions about their care and treatment.
People could access the service when they needed it. Waiting times from assessment and arrangements to admit, treat and discharge patients were in line with good practice. Staff were working with partners to reduce delayed discharges for patients ready to move on. Clients were not moved between wards unless there was a clinical need for this.
Ward environments were comfortable and well looked after. The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
The service took account of patients’ protected characteristics and addressed these in the care and treatment provided. Patients were able to access the hospitals recovery college and a range of meaningful activities were provided both on and off the wards.
The hospital had managers at all levels with the right skills and abilities to run a service providing good quality sustainable care. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on these values.
The hospital had effective systems for identifying risks, planning to eliminate or reduce them. The service planned for emergencies and staff understood their roles if one should happen.
The hospital engaged well with patients, staff, carers and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

However;

On all wards, robust systems were not in place to ensure that equipment used to monitor patients’ physical health was calibrated and maintained.
On Byron Ward, controlled drugs were not safely and appropriately stored. Many medicines on this ward were overstocked. We raised this at the time of inspection and the provider subsequently told us that a larger medicines cabinet was ordered and fitted by the end of November 2018.
At the Springs Unit, appropriate measures were not in place to identify, mitigate and manage potential ligature anchor points. However, the provider told us there was a works programme planned to further reduce ligature points for completion by the end of June 2019. The ligature map was updated by the provider at the time of inspection to reflect the ligature points that had been identified during this inspection.
Whilst the providers overall compliance rate for staff take up of mandatory training was above its target of 80%, there were some key mandatory training courses where take up was considerably lower, including some that could impact upon patient safety. The provider did not have up to date training records available at the time of our inspection due after a recent change to the database they were using.
Since the last inspection the provider had made improvements to Byron Ward to make it safer as it accommodated both male and female patients. However, further improvements were needed to comply with national guidance on mixed sex accommodation. Whilst building works were planned, no date for these had been fixed.
The four wards were not connected by a single alarm system. To summon the hospital wide emergency response team, staff used a radio. The provider had planned works to address this issue, but no date for the works had been set. In addition, on Springs Unit and Springs Centre, patients did not have access to call alarm systems they could use to summon staff in an emergency.
An inappropriate blanket restriction was in place on Springs Wing rehabilitation unit, where patient toilets in communal areas were locked, preventing patients from using them.
Whilst the provider had made progress since the last inspection in ensuring that staff on Springs Unit, Springs Centre and Springs Ward received regular supervision and that supervision records were securely stored, this remained an issue on Bryon Ward. Staff on Byron ward were not receiving regular supervision that provided them with support and monitored their performance.
Whilst overall, the range of facilities on each ward meant that patients could have their treatment needs met, further improvements were needed at the Springs Centre to ensure the ward was an appropriate environment. For example, a sensory room was planned for the ward, but no date for the work to commence had been fixed. Subsequently the provider told us building works were due to commence between January and June 2019.
Some further strengthening of governance systems was required to ensure that on each ward and across the hospital, governance systems effectively identified all areas where quality, safety and effectiveness could be improved. For example, the calibration of physical health monitoring equipment across all wards and storage of medicines on Byron Ward.

We rated Cygnet Hospital Harrow as requires improvement because:

The provider did not take sufficient precautions to ensure patients’ safety. For patients on Byron ward receiving alcohol detoxification, the service did not measure the level of dependency or symptoms of withdrawal.
The provider did not always provide care that was sufficiently person centred and appropriate. On Byron ward, staff carried out one to one observations of informal patients without ensuring the patient’s consent and understanding.
On the Springs unit, staff did not always support patients appropriately to keep their bedrooms safe, clean and tidy.
On Byron ward, there were no designated areas for male and female bedrooms. During enhanced observations, staff propped bedroom doors open. This meant that patients’ privacy was compromised.
On the Springs unit, staff did not meet together to discuss incidents. The staff team did not have the opportunity to learn from incidents and make improvements to the service.
On Byron ward and the Springs unit, there were no records of concerns raised by staff and patients. This meant that staff and patients felt their views were being ignored and opportunities to improve the service could be missed.

However:

At our last inspection in October 2015, we said the provider must ensure that staff on the Spring wing and Spring unit complete specialist training in autism. At this inspection, we found this had been addressed.

Following the last inspection in October 2015, we made a number of recommendations for the service. At this inspection, we found that most of these improvements had been made.
Overall, patients were positive about the service. Patients described staff as being kind, polite, caring and respectful. Patients felt safe on the wards. Patients also spoke positively about therapeutic activities.

We rated Cygnet Hospital Harrow as good because:

Byron ward and Springs wing were clean and well furnished.
The provider was refurbishing the wards to address ligature risks.
Patients could access regular one-to-one time with their named nurse and staff rarely cancelled activities and leave.
Patients said they felt safe on the wards.
The provider used regular bank workers to cover vacancies and was actively recruiting to fill posts.
Staff completed patients’ risk assessments on admission and reviewed them regularly.
Most staff were up to date with mandatory training and there were systems in place to monitor this.
Staff completed patients’ assessments on admission and most care records were complete, up to date and personalised to the individual patient’s needs.
Patients had access to a range of psychological therapies recommended by the National Institute for Health and Care Excellence (NICE) guidelines.
The wards had good multidisciplinary input and respected all staff’s clinical backgrounds within teams.
External stakeholders spoke positively about the relationship they had with the hospital, which provided regular updates on patients.
Staff understood how to use the Mental Health Act (MHA) and completed MHA paperwork accurately.
We observed kind and caring interactions between staff and patients on all three wards. Patients’ family and carers were involved with their care where appropriate.
The provider had regular integrated governance meetings and fed this information back to staff teams.
Staff were positive about their teams, managers and felt respected.

However,

There were some environmental concerns on Springs unit, including the nature of the environment, layout of the ward, lack of visual signs and the way it served the needs of patients with autism.
Staff on Springs wing and Springs unit had not completed specialist training in autism. This meant that staff were not adequately trained to understand and manage patients’ needs.
Staff did not always address patients’ physical health needs in a timely manner.
Information stored in patients’ paper files was not always easily accessible.
Staff on Byron ward had not had regular supervision in the last three months.
Patients admitted to the wards informally did not have clear information about their rights to leave the ward.
Staff’s knowledge on the use and application of the MCA varied across the wards.

We spoke with four people who were detained under the Mental Health Act 1983 and with four informal patients. People told us that the staff treated them well and respected their privacy and dignity. One person said, 'This place is fantastic. (Named doctor) is the best consultant. All the staff are so friendly, when you have problems there is always someone to approach.'

There was a daily programme of therapeutic groups and individual therapy sessions for each person. All the people we spoke with said that the groups were 'really good'. One person told us, 'Therapy helps me to understand the cause of my illness and coping strategies that I can use.' Another person said, 'Group therapy is invaluable. It helps you deal with your emotions.'

Accurate records were maintained of the care provided for each person, and of how each person set and monitored their own goals. Staff records and other records relevant to the management of the services were accurate and fit for purpose.

We checked the records of physical restraints and noted that all incidents of restraint were fully recorded and that the restraints were used appropriately.

All the care plans that we saw contained clear information on each person's needs, and on their rights under the Mental Health Act 1983. The people who we spoke with told us that they had a copy of their care plan, and that they were treated well. One person said, 'I am ready to go home now. I was down when I came in, but I'm much better now.'

We spoke with the family of one of the informal patients who had been admitted voluntarily for treatment. They told us that they had been informed of their relative's admission, and they were having a meeting to discuss the planned treatment.

An independent advocate visited the hospital each week to discuss any concerns with patients. We saw evidence that the advocate supported people to make complaints when they had concerns about their treatment or choices in the hospital.

We spoke with both informal patients who were admitted voluntarily for treatment and with patients who were detained under the Mental Health Act1983. We checked the records of their consent to treatment. We saw evidence that care and treatment plans were discussed with informal patients, and that mental capacity assessments were carried out when appropriate. However the records for detained patients showed that the provider did not follow the code of practice of the Mental Health Act 1983 for obtaining a second opinion when medicines were prescribed for urgent treatment.

Patients told us that they felt safe in the hospital. They felt that their views were taken into account and respected and their dignity upheld. They told us that staff were approachable and listened to them.

Where patients had experienced restraint they felt that it was carried out in an appropriate way and for the right reasons.

Patients told us that they understood why their medicines had been prescribed.

Everyone we spoke with said that they were happy with the care they had received.

People told us that they are happy in the service. They said that they feel involved in their care and are aware of and attend reviews. They told us that they find the staff friendly, helpful and approachable and that they have regular contact with their consultant, key workers and other staff and know who to speak to about their care and choices and how to complain. They said that they make decisions about the activities in which they take part. They told us that they are aware of the medication they are taking and why they are taking it. They told us "I'm happy here"; and "my medication makes me feel better".

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.

These older reports are from our old approaches to inspection, including those from before CQC was created.

Cygnet Hospital Harrow

All Inspections

23 and 24 May and 6, 7 & 11 June 2023

During a routine inspection

03 November 2020

During an inspection looking at part of the service

2 August 2020

During an inspection looking at part of the service

30 October and 1 November 2018

During a routine inspection

13-15, 29 June 2017

During an inspection looking at part of the service

13 – 14 October 2015

During a routine inspection

21 February 2014

During a routine inspection

12 December 2012

During a routine inspection

12 October 2011

During a routine inspection

13 December 2010

During an inspection in response to concerns

Mental Health Act Commissioner reports

Reports under our old system of regulation