Cygnet Acer Clinic

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

• The service did not consistently provide safe care. Staff did not always maintain complete records of clinical cleaning and equipment maintenance checks. This included cleaning of portable physical healthcare equipment and checks of emergency equipment.
• There were discrepancies between the systems used to monitor staff attendance within the service. This made it difficult to confirm the exact number of staff on duty to maintain safe staffing levels.
• Staff did not always follow the provider’s observation policy and procedures to ensure patients risks were safely managed. This included missed observations and inaccurate records of observations.

• Staff did not always keep complete records of medicines management. This included records of drugs liable for misuse and medicine self-administration records.
• Staff treated patients with compassion and kindness, but did not always respect their privacy and dignity, Patients raised concerns about staff attitudes towards them and engagement with them. We saw staff did not always maintain the confidentiality of patient information.
• The governance of the record keeping in the hospital was not effective. Although the service had made improvements in the safety of the service since our previous inspection, the systems used to accurately identify, understand, monitor and reduce or eliminate risks required improvement.

However:

• Safety risks were being addressed. The service had addressed safety issues identified in the last inspection and the wards had been subject to a thorough Manchester ligature risk assessment and remedial works to reduce identified risks.
• Staffing levels for qualified nurses had increased since the last inspection.
• Staff provided a range of treatment and care for patients based on national guidance and best practice. This included access to psychological therapies, support for self-care and the development of everyday living skills and meaningful occupation. Staff supported patients with their physical health and encouraged them to live healthier lives. Staff used recognised rating scales to assess and record severity and outcomes.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff planned and managed discharge well and liaised effectively with services that would provide aftercare. As a result, discharge was rarely delayed. The service worked to a recognised model of mental health rehabilitation.

We undertook a focused inspection of Cygnet Acer Clinic, looking at only the safe and well-led key questions. This inspection was undertaken following a serious incident and other information of concern we received.

We rated safe and well-led at this service as inadequate. This means the service is now rated as inadequate overall. The rating for these key questions is limited to inadequate due to the enforcement action we have taken. During this inspection we served notice on the provider under section 31 of the Health and Social Care Act 2008 to urgently impose conditions on the registration of this service. This was due to the serious concerns we found that affected the safety of patients and placed patients at risk of avoidable harm. The urgent conditions included stopping the service admitting any new patients.

We found:

• The service was not safe. The number of incidents of self harm by patients had increased significantly in the three months before the inspection. Almost half of the incidents during that time had involved patients using a ligature. The ligature risk assessments for the wards was too generalised and unstructured and did not include all ligature anchor points on the wards. Service leaders and staff had not effectively minimised the risk of serious harm to patients.

• Over 75% of nursing staff were unqualified. This was not an acceptable skill mix of staff to provide care and treatment to up to 28 patients with complex needs and behaviours. On 60% of shifts there was only one registered nurse on each ward. Senior nursing staff did not recognise that having only one registered nurse on shift, particularly in Upper House, did not provide the skills mix required to support the complex needs of patients.

• On at least four occasions during the inspection patients congregated on the ward, in front of the reception area, banging on windows to attract the attention of staff who were not on the ward. Staff were not available to support patients when they needed them.

• When patients’ risks increased this was not always communicated clearly and documents contained different information. The clinical team did not always respond appropriately when patient risks were escalating. Patient risks was not always managed well, particularly on Upper House which had seen a dramatic increase in incidents of self harm.

• When staff observed patients intermittently, this was undertaken at fixed times. This meant patients could predict when staff would check on them. This increased the risk of self harm by patients in between those fixed times.

• The wards were large and spread over two floors. With bedrooms on both floors, the layout of Upper House hindered staff observations of patients. Senior staff had not reviewed the environment to identify ways to increase the observation of patients whilst also maintaining their privacy and dignity.

• Staff worked shifts of 12 or more hours per day or night, in some cases, working up to seven days without a day off. Working these hours for four or more days and nights, without a day off, was not best practice, particularly with a patient group with such complex needs and risk behaviours.

• At least two staff who had worked in the service for two or more years had not undertaken face-to-face training on working with people with personality disorders. There was a risk that staff did not have a good understanding of how to work effectively with patients with personality disorders. There was a risk that long-standing staff who had not undertaken this face-to-face training would not be able to fully support newly appointed support workers.

• Leaders in the service did not consistently demonstrate that they had all of the skills and knowledge to manage the service safely. Following a patient death and feedback from a visit by the local clinical commissioning group, the June 2019 ligature risk assessment had a short addendum highlighting one further type of ligature risk. Other ligature risks were not identified or risk assessed. Investigations and reviews of incidents by senior staff had not always maximised the opportunity for learning from these incidents. Important areas of learning were missed.

• There had been no analysis of themes or trends of self harm incidents in the service. These were the most frequent type of incident in the service and such an anaylsis should have been in place.

• A staff whistleblower had contacted the Care Quality Commission in May 2019. Two further whistleblowers contacted us during the inspection. They reported low staffing levels, a lack of support from managers, and a lack of action by managers when they raised concerns.

However:

• There were clear processes for dealing with complaints, monitoring safeguarding referrals and making statutory notifications to the Care Quality Commission.

• Although staff restrained patients 91 times in the three months before the inspection, none of these restraints were in the prone position. This followed best practice guidance due to the risks to patients when restrained in the prone position.

• Patients were able to progress to self medicate on Upper House and Lower House. This involved a clear system of multidisciplinary reviews to ensure any risks to patients were minimised.

• Following the imposition of conditions on the provider they conducted an analysis of self harm incidents including themes and trends. When we returned to the service on 28 August for the last day of this inspection we saw that the provider was acting on this information to minimise incidents when they were most frequent. The provider also took other immediate action concerning staffing levels, staff training, the environment and the risk management of patients.