Cygnet Hospital Maidstone

Updated 8 September 2023

Cygnet Hospital Maidstone is a purpose built, 65-bed mental health facility for adults. The hospital has four wards:

Roseacre ward is a 16-bed specialised personality disorder ward for women. The aim of the service is to support service users manage their mental health, develop coping strategies, reinforce daily living skills, and prepare for a return to independent living. Roseacre Ward provides a care pathway for service users who are preparing to step down to community living and uses a recovery focused model. The ward supports individuals with primary diagnoses of personality disorder, schizophrenia, schizoaffective disorder, bipolar affective disorder, and depression.

Bearsted ward is a 15-bed male psychiatric intensive care unit (PICU) service at Cygnet Hospital Maidstone and accepts emergency and crisis admissions. Referrals are accepted from all areas, including acute and prison services. The ward provides support for individuals experiencing difficulties that present a risk to the well-being of themselves or others that cannot be treated in an open environment.

Kingswood ward is a 16-bed service providing acute and high dependency rehabilitation services for adult men with complex mental health needs. The service outlined their high dependency rehabilitation service as a recovery focused service delivering high quality care, balancing risk management with therapeutic optimism and encourages men to build upon skills needed to move towards the least restrictive care option or return to the community. The National Institute for Health and Care Excellence (NICE) defines high dependency rehabilitation units as “Inpatient rehabilitation units for people with complex psychosis whose symptoms have not yet been stabilised and whose associated risks and challenging behaviours remain problematic. These units aim to maximise benefits of medication, address physical health comorbidities, reduce challenging behaviours, re‑engage families and facilitate access to the community.” The primary diagnoses of the patients referred to the high dependency rehabilitation unit was a mental health condition which may include complex co-morbidities, substance misuse, treatment resistance and behaviours that challenge.

Saltwood Ward is a 16 bed low secure service for men with enduring mental illness, including those with a personality disorder. The service is provided in a joint working arrangement with Kent and Medway Partnership NHS Foundation Trust and promotes shared understanding and practice. The NHS Trust undertakes case management and until May 2023 they employed social workers who worked at the hospital. Cygnet Health Care provides psychiatry, nursing, therapy, social workers and ancillary staff, and they operate the service. This allows for opportunities of shared learning and shared excellence.

The multidisciplinary team is integrated and work as one, sharing expertise. The Trust also has extensive community links which can be particularly helpful for service users moving towards discharge, thus helping to keep lengths of stay to a minimum.

Cygnet Hospital Maidstone was registered with the Care Quality Commission (CQC) on 5 October 2018 to provide:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983,
• Treatment of disease, disorder or injury.

The hospital has been inspected twice since registering with the CQC. We first carried out a comprehensive inspection of this hospital on 19 and 20 March 2019. Following that inspection, we rated the provider good overall and requires improvement for safe. On that inspection we issued the provider with requirement notice for the breach of Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment because risk assessments were not always completed and did not identify and mitigate all risks. Appropriate action was not always taken in response to incidents to remedy the situation and prevent future reoccurrence. We told the provider that it must make the following improvements:

• The provider must ensure that when incidents take place, appropriate action is always taken to remedy the situation and prevent future reoccurrence.

The most recent inspection was conducted on 2 and 3 December 2019 where we carried a focussed inspection of the Safe, effective and well led domain. We did not rerate the service following this inspection. However, we issued the provider with a requirement notice under Regulation 12 HSCA (RA) Regulations 2014 Safe Care and Treatment. We told the provider it must make the following improvements:

• The provider must ensure they improve information recorded in patients’ risk assessments, risk management and care plans. Risk assessments and risk management plans should be updated following a change in risk and reflective of all risks identified.

At the time of the inspection, the hospital had a registered manager in post.

What people who use the service say.

Forensic inpatient or secure wards

We spoke with six patients whilst on site and the feedback we received was mixed. Patients reported that while the day staff cared for them well with kindness and compassion, they did not always receive the same level of support and care from the night staff. Two patients reported that staff did not always respect their dignity and privacy and they often entered their bedrooms without permission. Some patients felt staff did not always listen to them or respected their wishes. Some patients told us they had refused their care plans because they did not always reflect their assessed needs. However, patients told us they generally felt safe on the ward and the food was of good quality. Patients told us they knew how to make a complaint or raise a concern when they needed to.

Acute wards for adults of working age and psychiatric intensive care unit

During this inspection, we spoke with a total of 11 patients. Feedback we received from the patients was mixed. Patients told us night staff did not always treat them with compassion and kindness. Staff especially at night did not always respect their privacy and dignity. Patients told us that staff did not always understand their individual needs and did not always support them to understand and manage their care, treatment or condition.

Four patients told us night staff used unprofessional language such as ‘patients kicking off’ and ‘jabbing’ patients.

Patients gave mixed feedback about the quality of food. Six out of 11 patients we spoke with were satisfied with the food. However, five patients were not happy with either the portion sizes, the quality, and lack of vegan food.

Feedback we received about the day staff was more positive. Patients described the day staff as approachable, polite, kind, and respectful.

Feedback we received from carers was overall positive. Three out of four carers told us they felt their relatives were safe and were very happy with the care their relatives received. However, one carer told us their complaint was poorly dealt with and not in a timely manner. They did not receive feedback following the complaint. The staff did not give them enough information, and the initial communication they had received from the ward staff was poor.

Long stay or rehabilitation mental health wards for working age adults.

At the time of the inspection there were 15 patients on the high dependency rehabilitation unit, out of a total capacity of 16. All patients were detained under the Mental Health Act. We spoke with three patients whilst on site and we spoke with three patients via telephone. All patients told us that they felt safe and were happy with the care they received. They told us that the ward was clean and comfortable, and that staff treated them with kindness and respect. They told us that they felt involved in their care, although, one patient told us that they were ready to leave but were still waiting for an assessment on a flat and two patients were not aware of their discharge plans. Some patients told us that smoking breaks were activities for them and that the available activities were not always focused on what they liked to do, although they told us that there were lots of therapies available and four patients told us how they had found these helpful. One patient told us they did not go to therapies as they were not awake to go to them.

We spoke with five relatives of people using the service. All relatives told us that the service helped them to keep in touch with their loved one. Most relatives told us that they were kept informed with their loved one’s care. They all told us how their loved ones felt safe. Most relatives told us that they knew how to raise a concern and were also able to provide feedback for the service verbally and through a survey. However, four of the five relatives raised concerns about the activity provision both on and off the wards. One told us that their loved one did not have a lot going on all day. Another told us that their loved one was not inspired to get up and do anything. Another relative told us how their loved one had started smoking again since being there as something to do. Two of the five relatives told us that they were not aware of discharge plans for their loved one, and one told us that they had not seen any plans for their care and treatment progress. Other relatives told us that they had not been involved in discharge planning but felt that as the follow-on plans had not been put in place, they preferred that their loved one was not being discharged.

Updated 8 September 2023

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

• The provider did not manage ligature risks well. There were multiple ligature points across the ward which were not sufficiently mitigated. The provider's ligature risk assessment process was not robust enough to remove ligature risks. Staff had not received training on how to complete a thorough and detailed environmental and ligature risk assessment. Due to the nature of the concern, the provider was issued a warning notice immediately after the inspection to address this concern. A warning notice is what we serve to a provider where we identify a concern with the quality of care they are responsible for that requires a current need for significant improvement.
• Staff did not ensure that patients’ medicines were managed safely. Staff did not ensure that medicines were safely administered and recorded. Staff did not ensure that the physical health of patients who were administered rapid tranquilisation were sufficiently monitored to mitigate against or reduce the risk of harm. For example, patients were administered overdose of rapid tranquilisation medicines above the recommended limits. Staff did not ensure that controlled drugs were appropriately signed for. On Kingswood ward, staff did not always ensure the emergency bag check list was up to date with the relevant contents in the bag. The index on drugs liable for misuse was not completed. There were no cleaning records or audits in place for clinic room equipment. The emergency bag was not sealed with a standardised fitting which meant that it required cutting with scissors to gain access.
• Not all patients had a care plan that met their holistic needs, and care plans were not always written to reflect patients’ views. For example, on Saltwood ward, one patient who had been prescribed medicines for substance misuse disorder did not have a specific substance misuse management plan in place. Some patients told us they had refused their care plans because they did not reflect their views or assessed needs. One patient was discharged from their section following a tribunal, but staff did not have aftercare plans in place. On Kingswood ward, care plans we reviewed did not identify whether a patient had signed or been given a copy of their care plan. In addition, recording of patient involvement was not seen in all care plans.
• The provider did not always ensure the provision of meaningful activities suitable for the rehabilitative needs of patients. On Kingswood ward, there was no focus on recovery- orientated activities within care planning, ward rounds or team meetings. When meaningful activity engagement was recorded as below 25 hours per week on the ward, leaders did not put in place actions to address this. Patients on Saltwood ward told us that planned activities were sometimes cancelled. Some patients reported that their section 17 leave was often cancelled.
• Staff did not always treat patients with kindness and compassion. Four out of six patients we spoke with on Saltwood ward told us that night staff did not always care for them well or treated them kindly. Patients said that staff did not always listen to them or respected their wishes. Two patients on Saltwood ward reported that staff did not respect their dignity or privacy and often walked in on them in the shower. On Kingswood ward, four patients said the night staff were disrespectful, were not caring and did not respect their privacy and dignity.
• Governance processes around quality assurance and audits were not robust enough to mitigate or reduce risks. We saw that there were concerns in prescription charts and care records which had previously been identified in the pharmacy audit but had not been acted upon. When lessons were learnt following an incident, the provider did not ensure that the actions were embedded to reduce such risks. For example, there were two battery swallowing incidents within a 48 period in February 2023. Although the provider took some action, we saw that another battery swallowing incident occurred again in May 2023. The provider did not ensure that actions following Mental Health Act 1983 (MHA) monitoring visits were completed and improvements were fully embedded.

However:

• The ward environments were clean. The wards had enough nurses and doctors. They followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. Staff engaged in clinical audits 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.
• Spoke highly of the culture and the senior leadership team. They felt the senior leaders were very supportive and valued them. Staff reported that managers cared for their wellbeing and gave them opportunities and support to grow in their careers.

Updated 8 September 2023

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

• The provider did not manage ligature risks well. There were multiple ligature points across the ward which were not sufficiently mitigated. The providers ligature risk assessment process was not robust enough to remove ligature risks. Staff had not received training on how to complete a thorough and detailed environmental and ligature risk assessment.
• The seclusion suite had blind spots that were not sufficiently mitigated by either a parabolic mirror or CCTV camera and staff could not maintain a continuous line of sight for patients in seclusion.
• Staff did not keep up to date with their mandatory training. For example, only 34% of staff had completed the awareness of self-harm training and suicide course and only 64% of staff had completed the ligature rescue training on Saltwood ward which were below the provider’s target of 90%. Only 29% of staff had received up to date training on safeguarding individuals at risk (intermediate) virtual classroom training and only 36% of eligible staff had completed the safeguarding programme training.
• Staff did not ensure that patients’ medicines were managed safely. Staff did not ensure that medicines were safely administered and recorded. Staff did not ensure that physical health of patients who were administered rapid tranquilisation were sufficiently monitored to mitigate against or reduce the risk of harm. For example, patients were administered overdose of rapid tranquilisation medicines above the recommended limits. They did not ensure that the physical health of patients who were administered rapid tranquilisation was adequately monitored to reduce harm. Staff did not ensure that controlled drugs were appropriately signed for.
• Not all patients had a care plan that met their holistic needs, and care plans were not always written to reflect patients’ views. For example, one patient who had been prescribed medicines for substance misuse disorder did not have a specific substance misuse management plan in place. Some patients told us they had refused their care plans because they did not reflect their views or assessed needs. One patient was discharged from their section following a tribunal, but staff did not have aftercare plans in place. Although the service responded appropriate to arrange transport for them so they could get their depot medicine next day.
• Some patients told us there were not always enough meaningful activities on the ward which upskilled them for independent living. Patients told us that planned activities were sometimes cancelled. Some patients reported that their section 17 leave were often cancelled.
• Staff did not always treat patients with kindness and compassion. Four out of six patients we spoke with on Saltwood ward told us that night staff did not always care for them well or treated them kindly. Patients said that staff did not always listen to them or respected their wishes. Two patients on Saltwood ward reported that staff did not respect their dignity or privacy and often walked in on them in the shower.
• The service had blanket restrictions in place without clear rationale. For example, patients reported that staff kept the quiet room locked without a clear explanation or rationale. Although staff reported that this was because of a high risk patient on the ward. There was a hot and cold water urn, patients who needed to make hot drinks were dependent on staff, as the water was tepid.
• Governance processes around quality assurance and audits were not robust enough to mitigate or reduce risks. We saw that there were concerns in prescription charts and care records which had previously been identified in the pharmacy audit but had not been acted upon. When lessons were learnt following an incident, the provider did not ensure that the actions were embedded to reduce such risks. For example, there were two battery swallowing incidents within a 48 period in February 2023. Although the provider took some action, we saw that another battery swallowing incident occurred again in May 2023. The provider did not ensure that actions from previous Mental Health Act (MHA) 1983 monitoring visits were completed and improvements were fully embedded.

However,

• The ward environments were clean and generally well maintained. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
• Staff provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
• 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.
• On most occasions, staff planned and managed discharges well and liaised with services to ensure that discharges were successful. Managers monitored delayed discharges to ensure that patients did not stay in hospital longer than they needed to.
• Leaders had a clear vision of what they wanted to achieve. Staff were very positive about their leaders and the culture. Staff said leaders were very kind and supportive.

Updated 8 September 2023

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

• The service did not have adequate ligature risk assessment audits in place to accurately identify environmental risks and provide suitable mitigations. 35% of staff were awaiting allocation of ligature rescue training. Leaders acknowledged that training and confidence building was needed for managers and staff. Due to the nature of the concern, the provider was issued a warning notice immediately after the inspection to address this concern. A warning notice is what we serve to a provider where we identify a concern with the quality of the care they are responsible for that requires a current need for significant improvement.
• The service did not always have adequate record keeping in place around medicines and clinical equipment. The emergency bag check list was not up to date with the relevant contents in the bag. The index on drugs liable for misuse was not completed. There were no cleaning records or audits in place for clinic room equipment. The emergency bag was not sealed with a standardised fitting which meant that it required cutting with scissors to gain access.
• The service did not always ensure the provision of meaningful activities suitable for the rehabilitative needs of the patient group. In addition, there was not always a focus on recovery orientated activities within some care planning, ward rounds or team meetings. When meaningful activity engagement was recorded as below 25 hours per week on the ward, leaders did not put in place actions to address this.
• Data provided on restrictive practices, including restraints and rapid tranquilisation, was not accurate with the data held within incident records. This raised concerns as to the accuracy of recorded restrictive interventions and adequate oversight of these. Although, the provider has since informed us that there had been an error in the data shared at the time of the inspection. They advised that all incidents of rapid tranquilisation and restraints were recorded at their daily flash meeting.
• The service did not hold regular team meetings to ensure information was shared consistently with staff. Leaders acknowledged that the team meeting minutes provided did not always demonstrate sharing of information from governance meetings.
• Some patients did not have a clear plan for discharge and some relatives were not involved and kept informed of recovery progress and discharge planning.
• All care plans we reviewed did not identify whether a patient had signed or been given a copy of their care plan. In addition, recording of patient involvement was not seen in all care plans.
• The service was told about displayed food menus being out of date on a Mental Health Act Review visit in August 2022. The provider reported to have taken action, though we found that all four-week menus were on display, and it was not clear which was the current week.
• The service did not always provide updates to feedback or actions raised by patients, such as those within community meeting minutes.

However,

• The ward environments were clean. The wards had enough nurses and doctors. They followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. 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, respected their privacy and dignity, and understood the individual needs of patients.

Updated 8 September 2023

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

• The ward environments were not safely managed. Staff did not assess and manage ligature risks well. There were fixed ligature anchor and high-risk ligature points across the wards without sufficient mitigations in place to manage the risks. The environmental ligature risk audit programme was not robust enough to mitigate or remove risks.
• There were blind spots in the bathroom in the seclusion room on Bearsted ward which were not sufficiently mitigated by either a CCTV or parabolic mirrors. At the previous inspection in 2019, we raised concerns about the safety of the seclusion suite on Bearsted ward with senior managers. We also told them that there were no clear lines of sight in the seclusion suite bathroom. During this inspection we found that these concerns had not been addressed.
• Staff did not ensure that medicines were managed safely. Records we reviewed showed that the provider did not always administer people’s medicines safely or in line with the prescriber’s instructions.
• Staff did not ensure that fridge temperatures were monitored appropriately. When temperatures sometimes went above the recommended range there was no record of actions taken or to explain why the temperature was out of range.
• Staff did not follow the providers policy or national guidance on conducting and recording physical health monitoring after the use of an intramuscular rapid tranquilisation medicine. We did not see evidence that baseline physical health checks were always completed for people prescribed with HDAT (high dose antipsychotic therapies).
• Staff did not always treat patients with compassion and kindness. They did not always respect patients’ privacy and dignity. They did not always understand the individual needs of patients and did not always support patients to understand and manage their care, treatment, or condition. For example, patients reported that some members of staff especially at night were not always discrete, respectful and responsive to their needs.
• The governance processes around the management of patient and ward risks were not robust enough to ensure that ward processes ran smoothly.

However:

• The wards were clean and well maintained. Staff followed infection control policy including handwashing and completed enhanced infection control checklists daily.
• The wards had enough nurses and doctors to provide care and treatment for patients. 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 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 followed good practice with respect to safeguarding. They understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• The service managed beds well so that a bed was always available locally to a person who would benefit from admission and staff ensured that patients were discharged promptly.
• 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 audits to evaluate the quality of care they provided.
• Staff actively involved patients and families and carers in care decisions.