Cygnet Churchill

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We rated responsive as good. We assessed 1 quality statement from the responsive key question and found areas of concern. The scores for these areas of concern have been combined with the scores for the other quality statements which are based on the key question ratings from the last inspection. Though the assessment of this quality statement indicated areas of concern since the last inspection, our overall rating of responsive for this service remains good. We found 1 breach of Regulation 16 in relation to findings that the service did not always ensure patients were provided with information about how to make a complaint. Furthermore, complaints were not always responded to within the timeframe outlined in the provider’s policy, and actions from complaints were not always monitored for implementation or clearly discussed.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Person-centred Care during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Care provision, Integration and continuity during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Providing Information during this assessment. The score for this quality statement is based on the previous rating for Responsive.

Patients we spoke with gave mixed feedback about the complaints process, suggesting some were unclear. For example, 3 patients said they would go to the office if they wanted to make a complaint, 1 patient said they would just ask repeatedly, and 1 said they had been given a complaints form but did not know how to complete it. Another patient said they had made 2 complaints but had received no feedback in relation to these. This meant that not all patients understood their rights regarding complaints, which was not in line with the provider’s policy.

Staff and leaders described the ward as patient-led and said patient views were taken seriously. They said patients were invited to attend clinical governance meetings, bi-monthly all staff meetings, community meetings, and to give feedback via the people’s council.

We observed a ward round which the patient attended, and those present contributed to the meeting. The patient told staff they wanted to be discharged and did not feel listened to, but staff explained they needed to ensure their home environment was suitable for their needs prior to discharge. The occupational therapist had conducted a home visit with the patient, and external partners were also aware of the patient’s accommodation issues. We observed 2 interactions that did not demonstrate patients were always listened to. Please refer to this information under the key question of caring.

Incidents and complaints were investigated, but we found some delays in responses to complainants by leaders. We reviewed a sample of 3 complaints and found that 2 of them were not responded to within the provider’s timeframe of 20 working days. The complaints were received in December 2023 and responded to in March 2024. Furthermore, actions for improvement resulting from these complaints had not been added to the OLAP so it was unclear how leaders had oversight of their completion. The last complaint related action added to the OLAP was in November 2023. Clinical governance meeting minutes did not demonstrate that leaders monitored themes and trends in relation to complaints. We also did not see evidence that complaints were discussed during ward team meetings. This meant it was unclear how staff learned from complaints and used them as an opportunity to make improvements. However, as mentioned previously, we saw evidence that patient feedback obtained during weekly community meetings was taken seriously. Patients were provided with information about how their feedback had been acted on.

We did not look at Equity in access during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Equity in experiences and outcomes during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Planning for the future during this assessment. The score for this quality statement is based on the previous rating for Responsive.