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

Cygnet Bury Dunes

Overall: Requires improvement read more about inspection ratings

Buller Street, Off Bolton Road, Bury, Lancashire, BL8 2BS (0161) 762 7200

Provided and run by:
Cygnet NW Limited

All Inspections

27,28 and 29 September 2022

During a routine inspection

We rated the service overall as requires improvement. We rated the forensic and secure wards as requires improvement. We rated the acute and PICU wards as good. This meant that overall, the rating for the location was requires improvement.

We rated the forensic and secure wards as requires improvement because:

  • Staff had not minimised the use of restrictive practices. The rationale for some restrictions was unclear and not all restrictions were individually applied. Where a service has unnecessary restrictions that are not individually assessed and applied, there is an increased risk of a closed culture forming. Unnecessary restrictions placed on individuals offers no therapeutic value to patients.
  • Staff did not provide the full range of care and treatment suitable for the patients in the service. Although they delivered clinical care in line with best practice and national guidance, the therapeutic activities offered did not meet the needs of all the patients. Activities were not tailored to the individual and offered seven days a week.
  • The forensic and secure wards supported both hearing and deaf patients. Not all staff had completed British Sign Language training and compliance figures were lower than expected. Recent staff turnover had affected the availability of trained British Sign Language signing staff which had impacted on patient care and staff stress. There were multiple shifts that had no deaf or signing staff on shift.

In both core services:

  • Staff did not fully understand how to safely dispose of spoiled medicines.
  • There was limited oversight of the agency induction paperwork which meant staff may not receive an induction.
  • Not all staff files reviewed contained full employment history.

However;

  • 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, 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.
  • 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.
  • The service was well led, and the governance processes ensured that ward procedures ran smoothly. Managers ensured that staff received mandatory 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.

23 and 27 July 2020

During an inspection looking at part of the service

We did not plan to rate the hospital at this inspection as it was a focused inspection of the safe and well led key questions for two wards. However due to the inspection findings we have rated the core service as good, with the well led key question as requires improvement.

At this inspection we rated the Forensic inpatient/secure wards as good because:

  • The service provided safe care. Patients on Columbus ward felt safe and well supported. Staff assessed risk well.
  • We reviewed all patients in seclusion across Madison and Columbus wards. The patients understood the reason they were secluded. Person centred seclusion management plans were in place for patients we reviewed in seclusion.
  • Staff received a thorough induction to the service and safeguarding training levels were high for both Madison and Columbus wards.
  • Managers completed an action plan to address areas of concern in relation to professional boundaries of staff and patients. During the inspection we saw changes that had been implemented including changes in the staff team on Madison ward.
  • The previous ratings of good for the effective, caring and responsive key questions from the 2019 inspection still applies.

However;

  • Patients on Madison ward had not felt safe. Staff did not have the training to care for patients with a personality disorder.
  • Staff did not follow the recruitment and selection policies.
  • There was limited governance or audit of the safeguarding procedures to ensure agreed actions were completed.
  • There was limited oversight of the Mental Health Act requirements, resulting in detention of a patient expiring and hospital managers hearings not taking place when they should.

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

2 to 4 April 2019

During a routine inspection

We rated Cygnet Hospital Bury as good because:

  • The hospital had met the requirement notices issued at the inspection in February 2017, staff received training relevant to their role and staff who could sign were available to support deaf patients.
  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. 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. 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 understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

However:

  • Oversight of physical health and risk and the communication of this to staff at handover and within ward records was not fully in place.
  • Provision of environments, information and care to meet the needs of patients with additional needs was not always in place.
  • Agency staff did not always have access to necessary information regarding patients and did not always follow their care plans.

14 to 16 February 2017

During a routine inspection

We rated Cygnet Hospital Bury as good because:

  • During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe, responsive and well led as requires improvement following the May 2016 inspection.
  • The hospital was meeting Regulations 10, 11, 12, 17 and 20 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
  • The required policies of the Mental Health Act code of practice were in place and complied with the code.
  • The hospital had created and implemented an action plan following our last inspection to address the concerns we had raised.
  • The registered manager held monthly team briefs with all managers to share learning and changes within the hospital.
  • The hospital shared learning from incidents via team meetings and monthly lessons learnt bulletins.
  • Managers ensured staff received regular supervision, team meetings and annual appraisal.
  • Care plans were accessible for patients.
  • Staff were aware of the Mental Capacity Act, Mental Health Act and duty of candour and their responsibilities in relation to these.
  • New staff received a comprehensive two-week induction.
  • We observed caring and supportive interactions between staff and patients, staff knew the patients well.
  • The hospital had made real progress to ensure the care plan documentation was accessible for deaf patients, including recording patients’ aims and goals from their reviews to DVD for patients to watch.
  • There was a variety of activities available for patients including those that were rehabilitative in focus.
  • The hospital was managing complaints well and patients knew how to complain.
  • The governance structure was fully embedded with clear lines of accountability and reporting.

However:

  • The hospital had not fully achieved the actions in relation to Regulations 9 and 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
  • Staff working on Bridge Hampton ward, a ward caring for patients, most of whom had a learning disability, had not received training in learning disability.
  • Staff working on Columbus and Madison ward, specialist wards for patients with a personality disorder had low levels of attendance at personality disorder training with Columbus 32% and Madison 37%
  • British Sign Language training levels for staff working on the four wards caring for deaf patients was low and meant there would be times where staff could not effectively communicate with patients. This included when deaf patients were secluded on Upper West ward.
  • There were inconsistencies in the opportunity for patients to have access to mobile phones that had not been individually assessed.
  • Bedrooms on the female wards were locked off for seven hours a day; this meant all patients had to be in the communal area together.

17 – 19 May 2016

During a routine inspection

We rated Cygnet Bury as requires improvement because:

  • Staff did not always meet the requirements of the Mental Health Act and its Code of Practice. There were occasions where staff submitted requests for second opinion appointed doctors late. The seclusion policy did not comply with the Mental Health Act Code of Practice. Staff sometimes did not keep correct records of seclusion or end seclusion as soon as patients were settled. The provider had not ensured that staff had undertaken training on the revised version of the Mental Health Act Code of Practice, published 2015.
  • Staff did not follow best practice with respect to Mental Capacity.  The Mental Capacity Act policy did not comply with the Mental Health Act Code of Practice.   The provider had not ensured that all staff had undertaken mandatory training in the Mental Capacity Act and specific capacity frameworks for children and patients including Gillick Competence.  Staff had a limited understanding of the Deprivation of Liberty Safeguards; one patient was detained without following the requirements under the Court of Protection to apply for a Deprivation of Liberty. The provider did not have a policy in relation to the Deprivation of Liberty Safeguards.
  • Patients care and treatment did not reflect current evidence based guidance. There was not always enough skilled staff to communicate effectively with patients who were deaf. Not all staff working within the wards for deaf patients had received the appropriate level of training in British Sign Language. Staff working with patients with a personality disorder or a learning disability had not received training in this area. Outcome measures were not being used to monitor the progress of patients within the adult services. This meant that it was difficult to capture the progress patients had made. The provider was not considering the impact of patients stopping or reducing smoking on their medication. The provider did not ensure that a patient assessed as needing aids and adaptations for a physical health condition in June 2015 had received the assessed equipment. Within the secure and rehabilitation services, the activities were not focused on rehabilitation. For patients with a learning disability, the care plans were not accessible and meaningful to patients.
  • Patients did not have their privacy and dignity protected whilst using the toilet and shower facilities within the seclusion rooms where the facilities were all in one room and there were no mitigation plans in place regarding protecting patient’s privacy and dignity.
  • Within the secure services, there were examples of overly restrictive practices including the stages approach in the female services and searching within the rehabilitation service.
  • Policies did not reflect current legislation and guidance. The safeguarding policy did not include requirements under the Care Act 2014.
  • The hospital was not following their policies and procedures. This included the absent without leave policy, recruitment and selection policy and reviews of patients after they had been administered rapid tranquilisation policy. Not all staff were receiving supervision and appraisals as per hospital policy.
  • Staff knowledge of duty of candour and how it applied to them was variable within the service.
  • The governance structure did not ensure that where incidents had occurred, lessons learnt had been shared across adult and child and adolescent services within the hospital and actions following serious incidents had been completed. Learning from incidents was not routinely shared at a team level.

However:

  • Risk assessments and risk management plans were detailed and in place in all the care records, we reviewed.
  • The child and adolescent services had made significant progress in reducing their restrictive practices since our last inspection in January 2016.
  • Staff had a good knowledge of safeguarding, could identify what constituted a safeguarding concern and how to respond.
  • There was a well-established physical health care team who provided regular and effective monitoring of patients’ physical well-being throughout their inpatient admission.
  • Weekly community meetings took place on the wards for patients to provide feedback. The majority of patients were involved in the creation of their care plans and received a copy of their care plan if they wished.
  • We observed positive, caring interactions between staff and patients. Patients reported staff were caring and supportive.
  • Staff felt supported by their managers and advised the senior managers were visible.
  • Following the appointment of a complaints officer, the complaints policy was being followed and complaints were being resolved in a timely manner.

12 and 13 January 2016

During an inspection looking at part of the service

We visited Cygnet Bury Hospital unannounced to conduct a focused inspection within the child and adolescent services. This was due to an increase in incidents being reported to CQC and information from whistleblowers. We looked at the safe domain as concerns related to staff and medicines.

We also reviewed one requirement notice, which related to the child and adolescent service from the last inspection in February 2015. When we last visited the CAMHS we found that staff were not always carrying out physical health checks on young people following the use of rapid tranquillisation (rapid tranquillisation is when medicines are given to a person who is very agitated or displaying aggressive behaviour to help quickly calm them).

The inspection team were assured that this requirement notice had been met. We reviewed rapid tranquillisation (RT) records and saw evidence that staff had completed the practice audit tool after each use of RT. The ward managers received weekly summaries of the use of restraint, RT, and seclusion. We reviewed medicine management committee minutes where the senior team at the hospital reviewed the use of RT. Night quality managers reviewed the RT forms to ensure physical observations had taken place and provided a summary for ward managers daily.

27 May 2014

During a routine inspection

This was a follow-up inspection from November 2013 to check whether the outstanding compliance action had been completed at the hospital. Specialist advice/support was provided for the above inspection by a specialist advisor and Mental Health Act Commissioner. A separate Mental Health Act Commission report will also be produced.

We also looked at the service provision on the adolescent unit also known as a children and adolescent mental health services (CAMHS) and governance because concerns had been identified at our previous visit. We visited Lower West, Upper West and Madison wards on the adult side of the hospital. We visited the CAMHS unit and saw positive improvement in the care of young people.

There was evidence to show that learning from incidents and investigations took place and appropriate changes were implemented.

We saw the new registered manager had introduced a lot of changes, which was commented on positively by staff. Prior to the inspection we had several whistle blowing enquiries about the introduction of zonal observations and staffing levels. The provider at our request did a thorough investigation into the concerns and this included visiting all wards and departments and speaking to patients and staff at all grades during the day, night and at the weekend. No further concerns were raised during the inspection.

27 February 2014

During an inspection looking at part of the service

At our inspection undertaken in November 2013 we issued the provider with three warning notices and two compliance actions in relation to our findings on the adolescent service. An immediate and interim action plan was put into place by the hospital director and the registered manager at that time, which was monitored by us. This inspection was undertaken to check compliance.

The director of nursing who was also registered with us to manager the service and identified in this report had recently resigned. A new director of nursing was in post and was in the process of registering with us.

We were informed by the new manager for the adolescent service that a triage system was now in place to help ensure that the adolescent service could safely and effectively meet the young patient's individual needs. A review of parental access to the adolescent wards had been carried out.

Young patients were protected against the risk of unlawful or excessive control or restraint because the provider had suitable arrangements in place to monitor what was happening.

Young patients were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We were told by the new service manager for the adolescent service and the staffing co-ordinator that there had been a review of the staffing arrangements to ensure that there were enough qualified, skilled and experienced staff to meet young patient's needs at all times of the day and night.

Young patients were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained and could be located promptly when needed.

7, 8, 11, 13, 21 November 2013

During an inspection looking at part of the service

This inspection comprised of a follow up visit to check that improvements had been made following our scheduled visit in May 2013 and the action plan sent to us had been completed in line with the hospitals timescale. We also looked in more detail at the service provision on the adolescent unit also known as a CAMHS and governance because concerns had been raised with us.

We visited Upper West and Madison wards on the adult side of the hospital. We found that they had met the action plan in relation to our visit in May 2013 in relation to seclusion practices, the administration of medication, records and other planned improvements. We visited the CAMHS unit and found that the action plan had not been met.

Young people were not always protected against the risk of unlawful or excessive control because the provider had not made suitable arrangements.

Young people were not always protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to safely manage them.

There were not always enough qualified, skilled and experienced staff available to consistently meet young people's needs, particularly at night.

There was little evidence to show that learning from incidents and investigations took place and appropriate changes were implemented.

Young people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained.

6, 7 October 2013

During an inspection in response to concerns

We carried out this responsive inspection visit because we received information of concern from the local children's safeguarding team. It was agreed with the local authority that we could share some of the information with Alpha Hospital Bury.

On Sunday 6 October 2013 we visited Forestwood, an inpatient children and adolescent mental health service (CAMHS). We looked at what was happening on the wards and spoke with three nurses. On Monday 7 October 2013 we made a return visit to the hospital. We spoke with the hospital director, the registered manager, the medical director for children's services, the director of children's nursing, the Mental Health Act manager and an administrator.

Patients individual care and treatment was not always planned and delivered in a way that protected them from unlawful discrimination.

Patients health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others.

There were enough qualified, skilled and experienced staff to meet patients needs.

It should be noted that Wizard House (CAMHS) was closed at the time of our visit and the adult side of the hospital was not looked at. In the Mental Health Code of Practice children are defined as being under 16 and young people as 16 or 17 years old.

7, 8, 9 May 2013

During a routine inspection

People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

People were provided with a choice of suitable and nutritious food and drink.

People were not always protected by the safeguards offered by the Mental Health Act Code of Practice in relation to seclusion practices in the "extra care" area.

People were not protected against the risks associated with medicines because the hospital programme of medicines audit was not consistently adhered to.

People who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

People were cared for by staff that were supported to deliver care and treatment safely and to an appropriate standard.

The provider had systems in place to assess and monitor the quality of service that people receive.

People's personal records were not accurate and could not always be located promptly when needed.

14 December 2012

During an inspection in response to concerns

On 19 November 2012 we received an anonymous concern from a staff member telling us that the staffing levels at Alpha Hospital Bury were very low and were affecting patient care.

We saw that the information gathered by the contract compliance team based at the hospital showed that wards were above the agreed set core hours by between 29 ' 45 shifts a week between 14 November 2012 and 11 December 2012.

One nurse said that at the time of our visit the ward was 'over run' with staff and another told us that the shift had started with three staff down due to sickness and had ended with one staff member over due to a person coming back onto the ward following a seclusion review.

Although we spoke briefly with some people living on each ward we did not ask them about staffing levels. We observed that wards were generally calm and relaxed and interactions between people and staff were seen to be warm and friendly. We saw that there was a significant number of staff on some wards we visited.

14, 15, 17 October 2012

During a routine inspection

We saw copies of information that were available to people [patients are referred to as people throughout our report] who were coming to live at Alpha. We saw a copy of 'Helpful Information for Patients.' Information clearly stated what people's rights were and what the 'rules' of the ward were to ensure that people were kept safe. It also informed people about how to make a complaint and gave the names and addresses of other organisations they could contact should they had any concerns.

People were involved in the Shared Pathway Programme which is a new person centred approach to care and treatment that is being introduced to all secure hospitals throughout the country. The aim is to improve people's experience of treatment in a secure hospital, make recovery outcome focussed to reduce the length of stay and ensure that people take as much responsibility for their own care pathway as possible.

Throughout our visits to the wards we saw that people appeared well cared for and their appearance was age appropriate. Interactions between people and young people using the service and staff were seen to be frequent and friendly and the atmosphere was calm and relaxed. Several staff members made reference to the view that this was the person's home throughout their stay.

During our visit we saw that some young people were either going out on leave with their family or that their family, including brothers and sisters, were coming to see them using the visitor's room.

30 April 2012

During an inspection in response to concerns

We spoke with four people about how they received support from staff on the wards. They told us that if they were upset then staff would take them to a quiet place and talk or communicate with them to try and calm the situation down. One person said that sometimes they might ask for additional medication to help them calm down. They said they could not see the point of seclusion and it made them feel claustrophobic like 'being in a mouse trap.'

One person told us that they were not happy about the new activities structure being put in place and would prefer to be able to go to their bedroom and sleep when they wanted. However they also said that they enjoyed taking part in the activities provided. Another person said that they were not happy about having a structured day and getting involved in activities. They told us that they could see the benefit of the changes because they were not as withdrawn and they were talking more to people. They said they enjoyed the activities being provided for example the beauty room, using computers and making cards. A young person told us that they enjoyed going to education classes everyday and this would help them when they went back to school once they returned home.

We spoke with four people on two wards about their medicines and the care they received. People we spoke with confirmed that their medicines and any changes to them were discussed with them. We heard that they usually had enough privacy and support when taking their medication. However, one person felt that other patients were sometimes 'quite near' when they were taking their medicines at the clinic. One person self-administered their own medication. We saw that suitable arrangements were in place to support this.

People told us that they could see the GP to discuss any physical health needs. Nurses confirmed that a GP visited each week and the hospital also employed a nurse practitioner to help ensure any minor ailments could be promptly treated.

We asked people whether all their medicines were always available. Two people told us that although it was usually okay, they had experienced one of their medicines being out-of-stock, but this was not for long. Senior staff explained that they had recently started to capture information when medicines were out-of-stock so it could be measured and addressed as appropriate.

People who used sign language said that they found it difficult to lip read staff were English was a second language. People we spoke with said that they had not noticed staff speaking in their native language.

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.