Cygnet Hospital Hexham

We rated Cygnet Chesterholme as inadequate because:

• Our findings from our key questions did not demonstrate that governance processes operated effectively at ward level and that risks were managed well. The provider had not ensured that there was sufficient oversight of governance processes. During our inspection, there were some issues that we identified with governance which were not picked up by the provider.
• The provider’s governance systems were not always sufficiently assessing, managing and mitigating risks for the patient. Risk assessments were not consistently updated and reviewed following incidents or changes to a patient’s presentation or increased use of medication.
• Information identified within risk and care plans, such as how patients should be restrained if this was required (e.g. patient at risk of positional asphyxia due to obesity) was not evident within positive behaviour support (PBS) plans. PBS plans were generic and did not refer to information captured elsewhere that was specific to the patient and their likes/dislikes. 
• The provider’s systems for ensuring staff recorded their handover of patients’ epilepsy monitors was not robust as we found gaps in records.
• The Resuscitation Council UK quality standards for cardiopulmonary resuscitation practice and training state that the provider should have the equipment and medication to manage medical emergencies arising from rapid tranquilisation. The hospital did not hold a supply of medicines for emergency use and had not completed a risk assessment to demonstrate the rationale for this decision at the time of inspection. 
• The provider did not have the correct paperwork within the individual agency staff personnel folders to show that thorough checks had been made. These documents were subsequently located and filed appropriately.
• Although the hospital had been taken over by Cygnet in 2018, there was confusion amongst staff about which policies procedures and paperwork they should be using. Two of the provider’s policies that staff were following were still those of the previous organisation that managed the hospital (Danshell) and were overdue for review. Staff did not know whether they should be following Cygnet’s vision and values or those from the previous provider Danshell.
• Staff recruitment and retention at the hospital was not always effective.
• Staff did not have the necessary skills and knowledge to work with patients who had a learning disability or autism.

However:

• Patients were receiving structured and consistent activities to undertake, including at the weekends.
• Staff interactions we observed were mostly positive.
• Notifications to the care quality commission were now being submitted correctly.
• We received positive feedback from carers we spoke to.
• An informal patient now had a key fob to allow them to leave the building without delay.

We rated Chesterholme as requires improvement because;

• There were insufficient staff on duty to ensure patients were able to have dedicated one to one time with their named nurse. Staffing figures did not allow staff to respond to incidents and maintain the required observation levels for patients at all times. Staff were regularly injured as a result of incidents.
• Patients were not provided with the level of meaningful activity as described in the provider’s policy each week. Staff who were observing patients did not make efforts to engage patients in activities.
• There was a failure to deal with specific risk issues like falls. Staff did not review and update risk assessments and risk management plans regularly. Agency staff were not familiar with the patients and this resulted in incorrect treatment.
• Incident forms were not completed correctly and there were often several incidents recorded on the same form. Statutory notifications were not always completed as required by the Health and Social Care Act. Senior staff were not always aware of what incidents required reporting.
• The internal teams did not work effectively and required the activity co-ordinator to pass information between the teams.
• Staff did not receive regular clinical supervisions in line with the provider’s policy. Staff did not feel respected, valued and supported. Staff were fearful of reporting concerns and incidents due to concerns about their jobs. Staff were not always provided with debriefs or support after incidents.

However;

• Permanent staff displayed a caring approach to patients and encouraged them to participate in activities outside the service.
• Staff participated in an annual audit schedule to ensure the safety and quality of the service provision.
• Access to the service was well managed and there were always beds available when patients returned from leave.
• The service was clean and tidy with good furnishings.