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

Cygnet Lodge Kenton

Overall: Good read more about inspection ratings

74 Kenton Road, Kenton, Middlesex, HA3 8AE (020) 8907 0770

Provided and run by:
Cygnet Health Care Limited

All Inspections

14 and 15 February 2023

During an inspection looking at part of the service

We carried out this unannounced, comprehensive inspection in line with our inspection methodology. At our last inspection visit in April 2022 we rated Cygnet Lodge Kenton as requires improvement overall. Safe was rated inadequate, effective and well-led was rated requires improvement and caring and responsive were rated good. This inspection included a follow up on our last inspection to see if improvements had been made.

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

  • The service had addressed the areas of improvement we outlined in our April 2022 inspection.
  • Staff had improved how they monitored, recorded and escalated patients’ physical health results. Staff ensured they used the correct forms, completed them appropriately and audited their use. Staff escalated their findings when required. Staff and patients told us that physical health monitoring was a priority.
  • The service had put a system in place to regularly monitor side-effects of medicines experienced by patients. All patients received a swallowing risk assessment and side-effect monitoring assessment if they were prescribed anti-psychotic medication. For example, patients prescribed clozapine received a routine bowel movement assessment. Patients who were prescribed lithium received a regular blood test.
  • Staff improved how they recorded and carried out observations of patients in line with the provider’s policy. Staff checked on individual patients four times per hour. The checks were carried out at random times within the hour, with a maximum of 15 minutes between each check.
  • Staff ensured that they had improved their responsibilities under the Mental Health Act (MHA) 1983 and the Mental Capacity Act 2005 in a timely way. Patients detained under the MHA had their rights explained to them as often as required by the provider’s policy. The service had ensured that they had requested a second opinion appointed doctor (SOAD) and had issued a Section 62 of the MHA around the same time. The use of a Section 62 should only be used for urgent treatment, for several months. The service kept in regular communication with the allocated SOAD until the required paperwork had been issued.
  • Since our last inspection in April 2022, the service had ensured that the number of registered nurses deployed on night shifts was in line with the provider’s staffing matrix and decisions in respect of safe staffing levels.
  • The management of medicines had improved. Staff undertook a regular audit that monitored and assessed all aspects of the medication room including medicines and clinical equipment. Clinical equipment was in working order and within date. Medication was stored and managed safely.
  • Staff we spoke with had a better understanding of how to escalate a safeguarding concern to the local authority safeguarding team. Staff had access to a policy that guided them in how to respond to a concern out of hours.
  • The governance systems that were in place had improved and were more robust. The service had implemented an auditing system that monitored aspects of clinical care. This had led to patients receiving safe and effective treatment. For example, staff carried out a monthly physical health monitoring audit, a care record audit, a risk assessment tracker and also an audit that monitored whether patients had been read their rights under the MHA.
  • Whilst patient information continued to be stored both electronically and on paper, and across different systems, the record systems were better organised since our last inspection in April 2022. Staff we spoke with understood how to access all information required to carry out their role effectively. In the last six months, no incidents had occurred as a result of the various electronic and information management systems used within the service.
  • The service had improved how they promoted smoking cessation within the service. The speciality doctor led on smoking cessation and had completed a smoking cessation session with a small number of patients who consented. The patients had received nicotine replacement therapy. Records of the fortnightly ward rounds showed the impact of smoking on individual patients’ physical health.

However:

  • Staff had not always ensured that the level of patient risk and the management of those risks were clearly recorded. In 1 care record, there was no care plan in place that clearly showed how the staff were managing the patients choking risk. Staff we spoke with were able to tell us how they managed the risk, but this was not reflected within the care record. The provider addressed this during the inspection. Another patient’s risk level varied between the different patient record systems used. At the time of the inspection, the provider told us that this was an IT error and would be fixed promptly.
  • Whilst staff understood patients’ individual needs and involved them in their care, care plan records did not always reflect this. Care plans were not always person-centred and did not always link to a patient’s rehabilitation. The care plans did not consistently demonstrate that the patient had been involved in the decision making. This was a record keeping issue. During our inspection, we observed that staff included patients in their care and the multi-disciplinary team had a comprehensive understanding of patients’ individual needs. The service had also identified this in January 2023 through their own audits and had started to make improvements.
  • The service had implemented restrictions on some aspects of the service due to the risks that they presented to some patients. Patients did not have free access to tea, coffee and sugar throughout the day and the garden door was locked due to the risks it posed to patients. The provider told us that they had put these restrictions in place to mitigate the risks and regularly reviewed them. Senior leaders told us that the restrictions in place would be removed once it was safe to do so. During a post-inspection feedback meeting with the provider, the CQC advised the service to continue to regularly assess the restrictions in place to ensure they were appropriate.

31 March 2022, 7 April 2022

During a routine inspection

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

  • At this inspection we rated this service as requires improvement overall and inadequate for safe.
  • Forms used to record patients’ vital signs did not support staff to identify when they needed to escalate findings. Staff did not always record when early warning signs were elevated in the patient electronic record, or record what action had been taken in response. Staff we spoke with did not know the escalation procedure for elevated scores. Patient care records did not always highlight risks from specific medications such as the risk of constipation from Clozapine, which meant this risk was not assessed or monitored consistently. Staff did not regularly monitor side-effects of medicines experienced by patients.
  • Staff did not always record observations of patients in line with the provider’s policy. Intermittent observations were recorded at regular and predictable intervals. There was a risk that the patients would know when observations would take place and they could plan their actions around this.
  • Staff did not always discharge their responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 in a timely way. Patients detained under the Mental Health Act did not always have their rights explained to them as often as required by the provider’s policy. We found three patients where there were delays in seeking a second opinion appointed doctor and the service relied on Section 62 of the Mental Health Act, which should only be used for urgent treatment, for several months.
  • The service did not deploy sufficient registered nurses on night shifts in line with the provider’s staffing matrix and decisions in respect of safe staffing levels.
  • Medicines were not always stored and managed well. For example, we found tablets that had been cut into quarters rather than attempts being made to source tablets of a smaller dose. A strip of tablets had been cut in such a way that the expiry date was no longer visible.
  • Staff did not always know how to escalate a safeguarding concern to the local authority safeguarding team, and the correct escalation process during a night or weekend shift
  • Some clinic room equipment was out of date. Yellow topped blood bottles in the phlebotomy equipment had expired in December 2021. The clinic room was too small for patients to use to self-administer medication, we saw a patient self-medicate in the corridor.
  • The governance systems that were in place were not always effective at identifying concerns within the service. Concerns affecting the safety of patients were not identified or overlooked and patients were not always protected from the risk of avoidable harm.
  • Patient information was stored both electronically and on paper, and across different systems. This meant that some patient care information was duplicated, whilst there were also gaps and care records were not holistic.
  • The service was not proactive in promoting smoking cessation and supported patients to smoke outside the service. One patient was using nicotine replacement therapy at the time of inspection.
  • The furnishings were dated, the patient bedrooms were cluttered, and some had curtains falling of the railings.

However:

  • The ward environments were clean. The level of serious incidents was low.
  • The service had access to medical staff during the day and during night and weekend shifts, or in an emergency.
  • Staff assessed patients’ mental and physical health upon or soon after admission to the service as required. Risk assessments were up to date.
  • The service included the full range of specialists required to meet the needs of patients. Managers ensured that these staff received training, supervision and appraisal. The staff worked well together as a multidisciplinary team.
  • Staff spoke highly of the registered manager and the service culture. Patients said they found staff kind and respectful and they enjoyed being in the service.
  • The service provided a variety of occupational therapy led activities and therapies that patients enjoyed. This included opportunities to exercise and volunteer in the community, and group learning and activities onsite as part of a programme of rehabilitation.

16 February 2016

During a routine inspection

We rated Cygnet Lodge Kenton as good because:

  • The premises were clean and well maintained. The provider had assessed risks to patients due to the layout of the service and taken action to mitigate the risks.
  • Although there were a number of vacancies in the staff team these were covered by experienced bank staff.
  • Staff had completed mandatory training and had the skills to meet patients’ needs.
  • The multidisciplinary team ensured each patient had an effective rehabilitation plan which was well coordinated and reviewed regularly.
  • The multidisciplinary staff team assessed and reviewed risks to each patient and developed plans to manage identified risks.
  • Staff supported patients to express their views and fully participate in planning and reviewing their care and treatment.
  • The registered manager and unit manager provided effective leadership and support to the staff team.
  • Staff told us they enjoyed their work and felt that the whole staff team was committed to improving the service.
  • Cygnet Lodge Kenton has been accredited by the Royal College of Psychiatrists College Centre for Quality Improvement accreditation for inpatient mental health services scheme (AIMS).

18 February 2014

During a routine inspection

We spoke with six people who were detained under the Mental Health Act 1985. No informal patients wished to speak with us during the inspection. People told us that the staff treated them well and respected their privacy and dignity. One person said, 'The care is good here. The staff are caring and welcoming.' Another person told us, 'There is good personal and individual care here.'

People we spoke with told us that they were involved in planning and monitoring their care and treatment programme. Care plans were based on a recovery star, with domains for change including identity and self-esteem, managing mental health, living skills and relationships. Each person set their own goals and assessed their own progress for each domain. One person said, 'My shared care pathway and detailed care plan helps me focus on goals I have to achieve.'

There was a daily programme of therapeutic groups and individual therapy sessions for each person. Groups included self-acceptance, relaxation, well woman, and fitness. There were also groups and individual sessions for behaviour therapy which included analysis and discussion of any incidents that had occurred.

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.

13 August 2013

During an inspection looking at part of the service

We had private conversations with two of the seven people who were currently inpatients at the unit, and we spoke briefly with a group of two people. They told us that they were involved in planning and monitoring their care and treatment programmes. One person said, 'It was helpful to think about and write down my own views and plans.' Another person told us that the process of self-analysis meant that they were more able to control their behaviour and their impulses.'

The minutes of daily planning meetings and weekly community meetings showed that people were able to raise any concerns that they had and to express their views about aspects of their treatment and their daily lives.

One person we spoke with, who was an informal patient, told us that on one occasion they were prevented from leaving the premises when they wished to. We checked the daily notes for the day concerned, and found evidence that confirmed this. This meant that restrictions were placed on the person that contravened their human rights, and the requirements of the Mental Health Act 1985 and the Mental Capacity Act 2005.

30 January 2013

During a routine inspection

Two of the five people we spoke with told us that they were happy with their treatment plans, and they felt that they were improving in their health and their abilities to care for themselves. One person told us that they were involved in choosing their treatment plan. They said that they wanted to come to this service because of the specific treatment they provided. They said, 'It's been very helpful for me. The staff are very helpful and caring.'

However some care plans did not contain clear information about the person's current situation and the care and treatment they needed. One person refused meals and refused to be weighed, but there was no record of any monitoring to ensure that they were not at risk of malnutrition.

People were not supported to express their views and to make decisions about their care and treatment. The five people we spoke with all said that they had not seen an advocate. One person said, 'We are not allowed to have advocacy in meetings with us. We never see an advocate and they can do nothing.'

Three of the five people we spoke with said that they were not allowed to go out in the afternoon if they had not attended their planning meeting in the morning. One person said, 'I cannot leave this place if they do not give me permission. If I miss the day planning meeting I know I will not be given permission to leave, and I ask to leave many times and I am refused to leave.'

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.