Archived: Cygnet Newbus Grange

We rated Cygnet Newbus Grange as inadequate because:

• We have taken enforcement action against the registered provider in relation to our concerns about this location. This limits our overall rating of this location to inadequate.
• The staff at the hospital imposed a number of restrictions on patients. For example, no patient was allowed use a mobile phone, camera or tablet unless supervised by staff, to use ceramic crockery, to hold keys for their bedrooms or to access some parts of the building. Six patients were routinely denied access to their own possessions. This meant that their bedrooms were bare of the person’s personal effects. These blanket restrictions were applied without having made individual assessments of the risks posed to individual patients. We therefore concluded that the service had inadequate systems and processes around restrictive practices. They did not have formal governance processes to identify, approve and review individual and blanket restrictions, and little documentation to record that these decisions were proportionate and the least restrictive option. At the factual accuracy stage, the provider submitted documents completed in July 2019 to show they had undertaken work to address these issues and had appointed a reducing restrictive practice lead.
• There had been a very substantial increase in the use of restraint since 2016. This was despite the provider having written a strategy to support a restrictive interventions reduction programme. We saw no evidence of this strategy having been turned into tangible action.
• Although the hospital had been taken over by Cygnet in August 2018, staff were still using the previous provider’s policies and documentation at the time of our inspection. The medication policy had passed its review date and the on-call policy did not reflect national guidance on doctors’ attendance to psychiatric emergencies.
• One patient was at risk of harm because staff had not ensured they had followed the medication policy for administering medication off-licence. They had not completed a risk assessment or produced a care plan for crushing a medicine and giving it in that form. Until we raised it with the provider, there was no mental capacity assessment or best interest decision in place for the administration of this medication.
• Patient safety, privacy and dignity was not a sufficient priority. Two patients’ bedrooms did not have any blinds or curtains to protect their privacy and dignity and to allow them to block out natural light. There were safety risks from exposed blind cords in some bedrooms which had not been considered on the hospital’s risk register and there were no actions to reduce or remove these risks following risk assessments.
• Staff did not always demonstrate good practice when working with patients. Managers had identified both individual staff performance issues and general cultural issues with the staff team. These included staff sleeping while on duty and one incident of staff using inappropriate techniques when restraining a patient. Two carers told us that they had raised concerns around staff interactions. One member of staff described the hospital had a ‘zero tolerance approach to wrong doing’ culture and we were concerned this could make staff reluctant to bring forward concerns. We carried out 13 periods of observation of the interactions between staff and patients. These amounted to about five hours of observations. The analysis found that one-half of the interactions observed were poor or neutral. Staff did not respond to patients promptly, nor did they often initiate interactions or activities.
• The managers and staff did not do all they could to keep the hospital in a good condition. The interior of the building was worn and tired in places and some rooms smelt of damp or urine. Also, staff did not always follow good infection control practices in relation to food storage.
• We raised a safeguarding alert because two carers raised concerns about unexplained injuries to one patient and one carer raised concern about the same patient not receiving appropriate medical attention following an injury. The provider told us after this they had completed some monitoring at Newbus Grange instead of taking the patient the hospital for treatment.
• The hospital had a high staff turnover rate of 39%. In the 12 months prior to our inspection, 24% of shifts were filled by bank or agency staff. There was not enough substantive nursing staff to cover the shifts available.
• None of the staff had received training in immediate life support.

However:

• There was no reported use of seclusion, long-term segregation, rapid tranquilisation or prone restraint.
• Staff ensured that patients had easy access to physical healthcare.

We carried this unannounced inspection in response to concerns that had been shared with us about the leadership and culture at Newbus Grange. We looked at the specific concerns which had been reported to us and have reported on these in the safe and well led domains. The ratings for these domains remains the same, which means the rating for the service is unchanged since the May 2019 inspection.

The rating of Newbus Grange remained the same. We rated Newbus Grange as inadequate because:

• Not all areas of the hospital were clean. We found sticky floors and door handles; dead flies, cobwebs, thick dust and plaster debris on some windowsills; and there was an unpleasant odour of urine in some patient bedroom areas. A door to a food storage area marked “keep closed” was left open and unattended. Some patient bedrooms had no window covering and one bedroom window blind cord posed a risk of accidental or intentional hanging. The provider removed this risk after we pointed it out to them.
• Staff did not effectively identify and respond to poor care practice. Staff had training on how to recognise and report abuse and they knew how to apply it but were less able to identify and report poor care practice. The body language and posture of some staff who were present during restraint was not always inclusive or calming. It was remote and authoritarian at times, showing staff with their hands on their hips or pointing their fingers. Such body language can have a negative impact on the person being restrained and could in fact prolong the incident.
• The delivery of high quality care was not assured by the leadership, governance or culture of the hospital. There was no understanding of the importance of culture. Leaders failed to identify and challenge all elements of poor staff practice. This had led to the development of an unrecognised, unhealthy culture. We heard allegations suggesting that some permanent staff showed intolerances of a racial, gender or cultural nature. Staff were frequently observed talking with each other and not engaging with the patient they were working with. This poor practice went unreported and unchallenged.
• Staff failed to implement de-escalation techniques before moving to apply supine restraint in each of the seven incidents we reviewed.
• Nurses were not able to spend as much time on the ward as they would prefer or as much time as would be beneficial to running of the ward because they had to spend a lot of time in the office.
• Recruitment procedures were not robust. There was no evidence the provider had considered the suitability, or made adjustments, for staff with criminal convictions or cautions to work with vulnerable adults.
• Supervision processes were not robust and the staff supervision matrix was not up to date. Between January and June 2019, 10 staff had no supervision. Nursing staff did not engage in clinical supervision and there was no reflective work done with support workers. Managers did not effectively analyse why staff left the service. Staff turnover was high, 39% at the last inspection in May 2019.
• There were high levels of violence in the hospital and allegations of discrimination. Leaders were not taking adequate action to address this. Support workers and nurses were regularly assaulted by patients. Injuries included being bitten, scratched, kicked and fingers bent backwards. These were often not reported. One member of staff who had left the organisation, told us they were seen as weak because they were frightened by patients who assaulted and hurt them. Several staff told us they were not given enough information or support when they started working at Newbus Grange. They had not been prepared for the level of violence and aggression they would encounter from patients.
• Incident reports did not always accurately reflect the incident. We found discrepancies in the description of some incidents and the number of times physical intervention had been used. Staff did not always follow a patient’s positive behaviour support plan or care plan during incidents.
• A room used for family visits contained files with patient activity information inside them.

However:

• Staff observed good hand hygiene principles. The ward was mostly safe, well equipped, well furnished, and fit for purpose.
• The service had enough nursing and medical staff, who knew the patients and received basic training to keep patients safe from avoidable harm.
• Staff were confident there was no abuse taking place the hospital. They told us they would know if other staff were delivering care in a way which was unacceptable and if they discovered issues of concern they would report it straight away.

We rated Newbus Grange as outstanding because:

• Feedback for the service and the staff working there was positive. Carers and family members, told us that staff went the extra mile to support the patients in the hospital. Staff were highly motivated to care for patients in a kind and dignified way. Staff recognised the value of patients’ relationships and supported patients to maintain relationships with those who were close to them. Staff in the service recognised the totality of patients’ needs and showed determination and creativity in overcoming obstacles to delivering care.
• Staff supported patients in having access to advocacy and their support network. Staff in the service were aware of patients’ communication needs and ensured that people who needed to know understood these. Staff had received training in Makaton and voice output communication aids to support patients and also used pictures and simple sentences to communicate with patients.
• There was compassionate, inclusive and effective leadership at all levels. Leaders understood the issues, priorities and challenges of their service and beyond. There was a systematic and integrated approach to monitoring, reviewing and providing evidence of progress against the provider’s strategy and plans. Plans were consistently implemented and had a positive impact on quality and sustainability of the service.
• Leaders had an inspiring and shared purpose and strived to deliver and motivate staff to succeed. Staff were proud to work for the organisation and spoke highly of the culture. Staff at all levels were actively encouraged to speak up and raise concerns, and policies and procedures positively supported this. There was strong collaboration, team working and support and a strong focus on improving the quality of care and sustainability of the service and of improving patient’s experiences.
• There was a demonstrated commitment to best practice performance and risk management systems and processes. The organisation reviewed how they functioned and ensured that staff at all levels had the skills and knowledge to use those systems and processes effectively. Problems were identified and addressed quickly and openly.
• There were consistently high levels of constructive engagement with staff and people who used services. Rigorous and constructive challenge from people who used services, the public and stakeholders was welcomed and seen as a vital way of holding services to account. There was a demonstrated commitment to acting on feedback.
• Staffing levels were appropriate to the needs of the patients. There were effective handovers at every shift change and staff were aware of any changes to patients’ needs. Risks to patients were monitored and risk management plans were updated when patients’ needs changed or following incidents. Staff followed best practice in relation to prescribing and medicines management, including storage, transportation and disposal.
• Patients’ care and treatment was delivered in line with national guidance. Staff carried out a comprehensive assessment of patients’ needs when they were admitted to the hospital. Staff understood patients’ rights and protected them. Patients who were detained under the Mental Health Act were advised of their rights regularly and staff did this in a way they could understand. Patients were supported to make decisions about their care and where patients lacked capacity there was evidence of decisions being made in their best interests.
• Staff routinely collected and monitored information about patients’ treatment and outcomes and used it to improve care. Staff participated in accreditation schemes to ensure patients received the best care and treatment possible. All staff participated in the provider’s mandatory training schedule. Staff, including agency staff, were supported in their roles with regular supervisions and appraisal. Care and treatment was supported through close and effective team working, including with outside agencies. Staff were consistent and proactive in supporting patients to lead healthier lives.
• Patients’ needs and preferences were taken into account to ensure that care was provided in an appropriate way.

However:

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• There was a group of patients in the unit who had been there for many years. However, we concluded that the principal reason that these people were still in hospital was because of difficulty in finding alternative placements and that this was not under the direct control of the provider. The current average length of stay is four years, which is below the current NHS length of stay. The provider worked actively with commissioners to facilitate discharge.