• Mental Health
  • Independent mental health service

Cygnet Manor

Overall: Good read more about inspection ratings

Central Drive, Shirebrook, Mansfield, Nottinghamshire, NG20 8BA (01623) 741730

Provided and run by:
Cygnet Learning Disabilities Midlands Limited

All Inspections

22 - 23 February 2022

During a routine inspection

Cygnet Manor is a high dependency rehabilitation hospital that provides a service for up to 20 men with learning disabilities, people who are expressing emotional distress and mental health needs.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

People were supported by staff to pursue their interests.

Staff supported people to achieve their aspirations and goals.

The service worked with people to plan for when they experienced periods of distress so that their freedoms were restricted only if there was no alternative.

Staff did everything they could to avoid restraining people. The service recorded when staff restrained people, and staff learned from those incidents and how they might be avoided or reduced.

People had a choice about their living environment and were able to personalise their rooms.

Staff enabled people to access specialist health and social care support in the community.

Staff supported people to make decisions following best practice in decision-making. Staff communicated with people in ways that met their needs.

Right Care

Staff promoted equality and diversity in their support for people. They understood people’s cultural needs and provided culturally appropriate care.

People received kind and compassionate care. Staff protected and respected people’s privacy and dignity. They understood and responded to their individual needs.

Staff understood how to protect people from poor care and abuse. 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.

People received care that supported their needs and aspirations, was focused on their quality of life, and followed best practice.

Right Culture

People led inclusive and empowered lives because of the ethos, values, attitudes and behaviours of the management and staff.

People received good quality care, support and treatment because trained staff and specialists could meet their needs and wishes.

People were supported by staff who understood best practice in relation to the wide range of strengths, impairments or sensitivities people with a learning disability and/or autistic people may have. This meant people received compassionate and empowering care that was tailored to their needs.

People and those important to them, including advocates, were involved in planning their care.

Our rating of this service stayed the same. We rated it as good because:

People’s care and support was provided in a safe, clean, well equipped, well-furnished and well-maintained environment which met people's sensory and physical needs.

People were protected from abuse and poor care. The service had sufficient, appropriately skilled staff to meet people’s needs and keep them safe.

People received kind and compassionate care from staff who protected and respected their privacy and dignity and understood each person’s individual needs. People had their communication needs met and information was shared in a way that could be understood.

People’s risks were assessed regularly and managed safely. People were involved in managing their own risks whenever possible.

If restrictive practices were used, there was a reporting system in place and there were comprehensive reviews to try and reduce the use of these practices. We reviewed eight incidents on CCTV and saw staff had managed these appropriately.

People made choices and took part in activities which were part of their planned care and support. Staff supported them to achieve their goals.

People received care, support and treatment that met their needs and aspirations. Care focused on people’s quality of life and followed best practice. Staff used clinical and quality audits to evaluate the quality of care. We saw that these audits were reviewed, and actions were acted upon.

The service provided care, support and treatment from trained staff and specialists able to meet people’s needs. Managers ensured that staff had relevant training, regular supervision and appraisal. All staff had received an appraisal at the time of this inspection.

People and those important to them, including advocates, were actively involved in planning their care. A multidisciplinary team worked well together to provide the planned care.

Staff understood their roles and responsibilities under the Human Rights Act 1998, Equality Act 2010, Mental Health Act 1983 and the Mental Capacity Act 2005.

People were in hospital to receive active, goal oriented treatment. People had clear plans in place to support them to return home or move to a community setting. Staff worked well with services that provide aftercare to ensure people received the right care and support.

Staff supported people through recognised models of care and treatment for people with a learning disability or autistic people. Leadership was good, and governance processes helped the service to keep people safe, protect their human rights and provide good care, support and treatment.

16 October 2020

During an inspection looking at part of the service

Cygnet Manor is a high dependency rehabilitation hospital that provides a service for men with learning disabilities, behaviour that challenges and mental health needs.

This was a focused inspection completed following concerns about staff actions or omissions in care that had contributed to incidents with patients and information to suggest a closed culture at the hospital. A closed culture is a poor culture in health or care services that increase the risk of harm. During this inspection we did not look at all key lines of enquiry in each of the domains. We did not change the hospital’s existing ratings.

  • The provider responded appropriately to concerns about staff practice and conduct with patients. Senior staff escalated, investigated and developed actions in response to incidents and concerns.

  • Leaders knew about risks associated with closed cultures and worked with staff to prevent the development of one. Staff we spoke with knew how to raise concerns and felt confident to do so. During the inspection we did not find evidence to support concerns of a closed culture at the hospital.

  • Leaders were visible in the service and had the skills, knowledge and experience to perform their role. They were aware of and taking actions to improve staff practices that led to concerns about the hospital culture.
  • We saw staff spoke and behaved appropriately with patients. Staff developed and followed plans when communicating and interacting with patients. Senior and multidisciplinary staff were visible and accessible in areas where nurses and support workers delivered care to patients.

  • The hospital environment was safe and clean. We saw good infection prevention and control practices amongst staff. At the time of the inspection, the provider had recorded no cases of Covid-19 at the hospital.

However,

  • Some conversations with staff supported concerns about the hospital’s culture. This included that not all staff recognised signs of burnout in themselves and sometimes did not communicate or behave professionally around patients.

22nd- 23rd November 2018

During a routine inspection

We rated Cygnet Manor overall as good because:

  • Managers were qualified for their roles and had a good understanding of all aspects of the hospital. Staff told us managers supported, respected valued them. Managers encouraged staff to be involved in changes and quality improvement.

  • There was a good two-way communication between senior managers and staff so that information was shared effectively. There was a robust audit cycle and staff took actions where required.

  • Managers managed staffing well and there were enough staff to run the hospital safely and effectively. Managers ensured staff were suitably trained and supervised; 90% of staff were up to date with their supervision and training.

  • Staff managed patients’ risk effectively. Patients had thorough up to date risk assessments. Staff discussed patients’ risk daily and patients had positive behaviour support plans that followed best practice. Staff understood how to safeguard patients and worked with professionals external to the service to do so.

  • Care plans were holistic, person centred and focused on achievable recovery goals, they were individualised and focused on skill building required for discharge. Patients were genuinely involved care planning.

  • Staff offered a range of treatment interventions recommended by the National Institute for Health and Care Excellence. They followed best practice in medicines management and patients engaged in individually tailored activity programmes. Staff ensured that patients had good access to physical health care. Patients had heath action plans and staff promoted healthy life styles.

  • Patients were happy with the way staff treated them. Patients were positive about staff attitudes and patients and staff demonstrated mutual respect. Staff showed in depth understanding of patients’ individual needs and preferences. Staff ensured that patients had access to appropriate spiritual support.

  • Staff communicated with patients in the way that suited patients’ needs best. The speech and language therapist worked to ensure all information was accessible to all patients. Patients were involved in decisions about the service and staff consulted them and asked for feedback at meetings.

  • The service worked to deliver on strategy set out in NHS England’s ‘Transforming Care programme.’ Staff and patients started to plan discharge soon after admission and patients were at the centre of discharge planning

However:

  • Staff completed observations in line with care plans and policy and recorded when they had completed these. However; staff recorded their observations on pre-populated forms. They did not record the actual time they had completed the observation. This was not in line with organisational policy.

  • Not all staff had received an appraisal; 74% of staff were up to date with their appraisal. The hospital manager was aware of this and had booked outstanding appraisals to take place.

  • Staff did not record all aspects of handover meetings. Staff did not record conversations when information about learning from complaints and incidents and daily business was discussed. This meant that there was not a record of these conversations.

6 and 7 November 2017

During a routine inspection

We rated The Manor as good because:

  • The hospital had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and provide the right care and treatment.
  • Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
  • Staff recognised incidents and reported them appropriately.
  • The hospital provided care and treatment based on national guidance and evidence of its effectiveness.
  • The hospital had many easy read information booklets explaining a variety of things including physical and mental health, how to complain and how to use an advocate. Staff also provided easy read care plans to patients.
  • Staff understood Duty of Candour. They were open and honest with patients and carers.
  • Patients, staff and carers said they knew how and who to complain to.
  • All staff had the common vision of providing the best care. The provider had four values of honesty, care, commitment and openness and we saw staff display this in their work.

18 June 2015

During a routine inspection

This inspection took place on the 18 June 2015 and was unannounced.

The Manor is a secure hospital that provides a rehabilitation service for up to 20 men with learning disabilities and/or mental health needs. Some people at the hospital are detained under the Mental Health Act 1983. The hospital is based in the Derbyshire town of Shirebrook close to a range of community services and facilities. The hospital was purpose built and is on two floors with a lift and stairs for access. The hospital has secluded gardens and recreational facilities including a gym and an all-weather pitch for basketball and football.

At the time of this inspection there were 20 people using the service.

The unit has a registered manager. This is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

All the people using service we spoke with said they felt safe at the unit. Staff were trained in safeguarding (protecting people who use care services from abuse) and knew what to do if they were concerned about the welfare of any of the people who used the service. An independent advocate spent one day a week at the unit which gave people the opportunity to speak with someone independent of the unit if they needed to.

There were enough staff on duty to keep people safe and meet their needs. We observed that staff had the time to support people safely and work with them on a one-to-one basis if this was required. If people needed assistance this was provided promptly and at no time were people left unsupported in the unit.

People using the service were encouraged to become responsible for their own medicines with staff support. Medicines was safely managed in the unit and administered by qualified nurses. They understood what the medicines were for and were able to explain this to the people using the service.

People told us the staff know how to support them and understood their needs. Staff had a good rapport with people and worked with them in an empowering and effective way. Staff were trained to carry out their roles and responsibilities effectively.

If people using the service were detained under the Mental Health Act (MHA) 1983 this was done lawfully and their rights were upheld. For example people had the right to see an advocate and this was facilitated at the unit.

Records showed that people had access to a range of health care professionals some of whom were employed by the service and others who were community-based. This meant that people using the service had access to intensive specialist support at all times.

People said the staff were caring, friendly, and helpful. We observed staff were warm in their approaches to people while maintaining their professionalism at all times. They had a genuine interest in the people they supported and were keen to tell us of the progress they’d made towards increasing their independence.

People received personalised care that met their needs. The care plans we looked at were individual to the people using the service and focused on their strengths and preferences. People using the service, relatives, and health and social care professionals were involved in care plan reviews.

The unit supported people to take part in a range of group and one-to-one activities both in the unit and in the wider community. On the day of our inspection people attended a walking group, a music group, an English literature group, played board games, and were planning a social event at a local community centre for the evening.

People told us that if they weren’t happy about something they know how to make a complaint. The provider’s complaints procedure gave clear information on how to do this with support provided where necessary.

People told us the unit was well-led and they got on well with the registered manager. Staff said the registered manager was a team player who was supportive of both the people using the service and the staff. The unit had links with the local community which gave the people using the service the opportunity to take part in local events.

People using the service and relatives had the opportunity to comment on the care provided and make suggestions. They could see the registered manager or the provider’s operations manager in private if they wanted to discuss the service. The registered manager and provider took prompt action if improvements were needed to the unit.

6 November 2013

During a routine inspection

There were 18 people using the service at the time of this inspection. We spoke with five people, six staff and the manager.

We found that people were offered a choice of suitable food and drink. People we spoke with told us they had a 'Good choice', and, 'I find it quite alright.'

There were appropriate arrangements in place to ensure that medicines were given correctly and safely to people using the service. Where possible, people were supported to manage their own medicines.

We found that the provider's recruitment procedures included appropriate checks to ensure staff were suitable for the job. We found that there were enough staff with the right qualifications, skills and experience to ensure that people's needs could be met. Staff we spoke with told us, 'We've got a good staff team and good communication between us.', and, 'We've got a good mix of staff. Teamwork is good.'

There were effective systems to assess and monitor the quality of the service provided. People and staff had opportunities to comment on the service and their views were acted on.

5 September 2012

During a routine inspection

We spoke with two patients currently staying at The Manor and three others more informally during our visit.

Patients were supported in promoting their independence. Patients we spoke with told us about the activities they took part in, including swimming, going to the local disco and going to the gym. One person told us, 'I went shopping yesterday, I went to Mansfield and I got new t-shirts and joggers. I like it here.'

We saw that the patient's needs were assessed and that they were encouraged to take part in their care planning. We were told, 'I had my ward round last week, everyone was really impressed.' Patients told us that they felt safe at The Manor.

Information was provided in a format which met patient's needs and we saw that the patients had regular contact with members of the multi-disciplinary team working at The Manor who provided them with support.

25 January 2012

During a themed inspection looking at Learning Disability Services

We met most of the patients at The Manor and spoke with three of them in more depth to gain their views of the service. Patients were generally positive about The Manor.

One patient said 'this is the best place I have ever lived', and, 'the staff are quite nice'. Another patient told us they wanted to be nearer to their family and said 'a positive thing I have been doing is working hard on my behaviour'.

Patients told us about activities they enjoyed, such as shopping, going to the cinema and ten pin bowling.

Patients told us they felt safe at The Manor. One patient said 'if someone was hurting me, I would tell staff, or if it was staff, I would go to the manager'.