Cygnet Churchill

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We rated safe as requires improvement. We assessed all 8 quality statements and found 2 breaches of regulation under safe. One breach of Regulation 15 in relation to poor cleanliness and maintenance of the ward, and 1 breach of Regulation 12 in relation to staff not always updating risk assessments or managing physical health risks appropriately. Concerns around the cleanliness and comfort of the ward environment had been raised by staff and patients over several months prior to the assessment, and patients raised concerns over the ward temperature at the last inspection. Leaders and governance processes had not been effective at improving the ward environment while awaiting refurbishment works later in 2024. Care records were not always updated with risk mitigations following incidents, and staff did not always record patients’ vital signs as frequently as their care plans stipulated. Mandatory training was comprehensive and met the needs of patients and staff, but we found lower compliance rates for some courses. However, most staff demonstrated good knowledge and understanding of safeguarding. Most patients told us they felt safe on the ward. The ward had processes in place to communicate risks to staff effectively, such as in handover documents and daily operations meetings. Patients and external partners were invited to attend ward rounds and their views were incorporated into care plans. Staff knowledge about ligature risks on the ward had improved, and there was a detailed ligature risk assessment. Staff knowledge of the intermittent observation process had also improved since the last inspection. Patients had the opportunity to provide regular feedback about their experience on the ward and we saw evidence that staff responded to improvement suggestions. Most staff reported that the staffing situation had improved on the ward in recent months and had noticed improvements to how the ward was run since the new ward manager started their role.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients were encouraged and supported to raise concerns. Weekly community meetings were planned and organised with the patients in a way that promoted their independence and involvement. Standing agenda items included challenges, safety concerns, advocacy referrals, environmental issues and activity planning. Actions from the meetings were logged and we saw evidence that these were actioned promptly. The service also offered patients the opportunity to provide feedback via a patient satisfaction survey. The most recent survey had been completed between October and December 2023. Responses that indicated lower satisfaction rates were added to the service’s overarching local action plan (OLAP) and progress monitored by leaders. There were positive changes made as a result of survey feedback, such as a new social hub set up off the ward and an additional activity coordinator recruited to address dissatisfaction with the quality of evening and weekend activities. However, the 4 actions in relation to environmental improvements were mostly incomplete. Issues we found with the environment will be discussed elsewhere in this report.

Staff and leaders spoke positively about the proactive culture of safety and learning at the service. They reported positive developments and improvements to how the ward was run since the new ward manager started in their role. Staff said they had safe spaces to share their ideas to improve services, and that lessons learnt were cascaded regularly and through a variety of forums. Staff stated they had access to professional training and development, attended debriefings following incidents, shared learning during reflective practice sessions, and had regular supervision. However, 2 regular agency staff we spoke with felt they were not always involved with discussions about how to improve the service and were not involved in most team meetings. Staff showed an improvement in their awareness of ligature risks on the ward compared to the last inspection, and leaders informed us of work that had been completed to improve in this area. Staff gave examples of where changes were made as a result of safety incidents or feedback, such as weighted furniture being introduced in the dining room following concerns raised by patients about safety of existing furniture. Hospital leaders said they had identified themes and trends around patients going absent without leave (AWOL) from the ward and had responded by increasing provision of evening and weekend activities.

Lessons were learnt from safety incidents, but this did not always result in changes that improved care for others. For example, leaders requested a cultural assessment of the ward in response to complaints from patients about staff attitudes. This assessment was completed in December 2023, and 3 recommendations were made in response to issues found. These issues were documented as having been closed in February 2024. However, at the time of inspection 2 of 3 actions were yet to be completed. Given leaders felt it necessary to conduct this review, and given some of the negative feedback patients told us about staff attitudes, we were concerned to find out these had not been actioned promptly. Furthermore, there had been an incident on the ward between 2 patients, and 1 recommendation was for a new standard operating procedure (SOP) relevant to the incident to be completed by December 2023. This action had not been completed at the time of inspection and we did not see it featured on the service’s OLAP. The service shared learning from the incident internally and with the wider provider, but this did not contain all the relevant details for staff to learn from. This meant that the service was not always acting promptly on lessons learnt to make the changes required to improve care for patients. However, the service had processes for staff to report incidents, near misses and safety events. We saw evidence that lessons learnt were shared with the staffing team via email, through printouts on the ward, and reflective practice. Some learning was shared with the wider organisation and reflected in the provider’s learning bulletins.

The most recent patient feedback survey results demonstrated patients felt the care and treatment they received was helping them progress towards discharge. They felt involved in decisions about their care and treatment. Independent mental health advocates visited the ward regularly to support patients in communicating their wishes and concerns with the ward’s multidisciplinary team. However, 2 of 7 patients we spoke with did not know what an advocate was, and 2 other patients did not know how to access the advocacy service.

All 17 beds on Juniper Ward were contracted by a local NHS trust. The service worked collaboratively with partners to prioritise safety and continuity of care. We spoke with a clinician from the NHS trust employed to oversee the care and safe discharge of all patients on the ward. The clinician and Cygnet Churchill leaders both reported positive and effective working relationships. They met twice a week to review the care of all patients and discuss any areas of concern, treatment plans, and barriers to discharge. There were also regular contract meetings between senior leaders from the NHS trust and Cygnet.

As well as the representative from the NHS trust, we also spoke with an independent mental health advocate who visited Juniper Ward 3 times a week. They described the collaborative and joined up approach to safety and care they had with leaders, ward staff and patients. This included helping patients with any issues and concerns they had about the ward, being made aware of safeguarding issues, and supporting patients to contact external organisations such as banks, community mental health teams and benefits offices. The advocate said the ward staff and patients were very engaged with the advocacy service and reported a positive and engaging environment. The trust representative was very complimentary about the daily communication from the ward manager and responsible clinician and said patient flow and length of stay was consistently excellent. However, they said that because patients from all London boroughs could be admitted to the ward, some patients were not close to relatives and did not always have easy access to their community mental health teams. This meant contact was often conducted virtually.

We attended a ward round which included representatives from the NHS trust, the advocacy service, and a community support worker who joined via video link. Staff identified and managed risks proactively prior to discharging patients. Care and support was planned and organised between the service and partner agencies to ensure continuity. We observed the clinical team and the trust representatives working together to ensure a patient’s home environment was suitable for them prior to discharge. The teams worked together to put a plan in place for the patient’s treatment in the meantime. The average length of stay for patients on the ward was 27.5 days. There were 2 delayed transfers of care (above 56 days) at the time of inspection, which were due to delays in finding suitable accommodation.

Most patients we spoke with said they felt safe on the ward. This was consistent with patient survey results conducted between October and December 2023. Three of 5 carers we spoke with said their relative felt safe, but 1 carer said it depended on how settled the ward was, and another did not think their relative felt safe. People were supported to understand safeguarding and to raise concerns when they did not feel safe. We reviewed the 3 most recent community meeting minutes during the inspection and saw evidence patients were supported when they told staff they felt unsafe. However, most patients we spoke with said it often took staff a long time to respond to their requests due to being in the office a lot. Representatives from partner organisations said they were always informed of any safeguarding matters.

Staff we spoke with knew the safeguarding processes and procedures and knew who the safeguarding lead was. They said safeguarding incidents were discussed during meetings and handovers. 81% of staff had completed their mandatory safeguarding e-learning training, which was below the provider’s target of 90% compliance. Only 43% of eligible staff had completed their virtual classroom training on safeguarding. Leaders informed us the reason for this low figure was because the course was new. Leaders had contacted staff who still needed to complete the training to improve compliance rates. The safeguarding lead described improvements in staff reporting safeguarding incidents. They had implemented additional face to face safeguarding training and group safeguarding supervision, and felt staff understanding had improved. Leaders had clear operational procedures on dealing with safeguarding matters and worked closely with other agencies to protect patients.

We saw posters displayed on the ward which provided information about how to contact the ward’s advocates, as well as details for the restrictive practice lead, and rights for informal patients. During our onsite assessment, we observed a patient assault another patient. Staff responded to the altercation and put a protective plan in place, but we were concerned to find out the incident was not reported as a safeguarding matter until 1 week later. Leaders conducted a review and found another incident that had happened in the same month which had also not been referred to the local authority as expected. In response, managers introduced a new auditing process where all incidents were reviewed so leaders could assess if any required safeguarding referrals if not already completed.

As outlined above, the systems, processes and practices did not always ensure patients were consistently protected from abuse and neglect. However, when raised with leaders, new processes such as the audit were introduced. Prior to our assessment, leaders had already developed other oversight methods in response to identifying shortfalls in practices and staff knowledge. For example, the service had introduced a safeguarding tracker which was reviewed during daily operations meetings. This allowed leaders to have improved oversight of safeguarding incidents, which showed the actions that had been taken and actions that remained outstanding. Referrals to the local authority safeguarding team were embedded in the tracker. However, although there was a column to embed copies of CQC notifications, we did not see any evidence of these. This meant leaders could not be certain whether notifications were always submitted or not. Leaders demonstrated a commitment to taking immediate action to keep patients safe from abuse and neglect. For example, leaders notified CQC of disciplinary action against 4 staff following inappropriate physical or verbal behaviour from staff towards patients. This demonstrated positive action from leaders, but raised concerns about the attitudes and behaviours of some staff members employed to care for patients. As mentioned elsewhere in this report, some patients we spoke with expressed concerns about the attitudes of some staff. Leaders monitored the numbers of safeguarding incidents across the hospital during monthly clinical governance meetings. However, we did not see evidence that themes and trends or lessons learnt from these incidents were consistently discussed or documented. This meant we did not see evidence that leaders discussed how to reduce safeguarding incidents.

Patients were invited to attend their ward rounds along with ward staff and external partners. Care records contained notes written in the patient’s voice. We observed a ward round for 1 patient and saw they contributed to their care plan. The independent mental health advocate for the ward told us patients’ views were listened to and responded to proactively. The most recent service user satisfaction survey showed all 8 patients who responded felt involved in decisions about their care and treatment. Most felt treated as an individual when it came to rules and restrictions. Patients could make their own drinks and had access to snacks between meals. However, 4 out of 5 carers we spoke with did not feel involved in decisions to do with their relative’s care. One of these carers said they tried to be involved but felt staff did not listen to them. It should be noted we do not know whether these relatives had been given consent by the patients to be involved with their care and treatment.

Staff showed an improvement in their awareness of how intermittent observations should be conducted compared to the last inspection. Staff we spoke with knew times they checked on patients should be randomised. We reviewed intermittent observation records for 1 patient over a 1 week period and found staff completed checks at unpredictable intervals and noted clear descriptors of what they observed. Observation levels were reviewed daily, and staff updated patient records when observation levels changed. Staff debriefed patients after an incident and had a review with a member of the team within 72 hours of an incident. Staff described balanced and proportionate approaches to risks that respected patient choices. For example, a new social hub had been created off the wards and patients had been involved in choosing activities for this space. Leaders explained plans to embed DIALOG+ after a successful pilot to improve the care plan approach on other wards at the hospital. DIALOG+ enables patients to rate their satisfaction with various life domains and their treatment and co-produce a plan of action to improve their satisfaction in lower scoring areas. Leaders confirmed there were audits of care plans, but that these audits did not focus on quality. Leaders said this would improve with planned changes to the care plan approach, which included moving over to a new care system.

Risks to patients were not always managed appropriately. Risk assessments were completed on admission and risks were identified, but these were not always updated following incidents. This meant clear and updated records of risk mitigations were not always in place for staff to follow. We also found shortfalls in physical health management. For example, 1 patient’s notes stated they should have vital signs taken daily, but we found a 2 week gap where vitals were not recorded via the national early warning signs (NEWS) form. This form is used to assess and record the physical health of a patient with indicators that tell staff when a patient’s health may be deteriorating and needs to be escalated to a doctor. Two patients’ records stated they had diabetes, but there were no physical health interventions around the management of this within their care plans. One of these patients was due to have vital signs taken 3 times a day but the NEWS chart showed a gap of a week. 64% of eligible Juniper Ward staff had not completed their physical health training. The shortfalls in risk management plans and physical health interventions meant some patients were being exposed to health and safety risks unnecessarily. Following our feedback, managers provided training to staff on documenting incidents and updating clinical records. However, leaders discussed incidents and safeguarding matters during daily staff operations meetings. Patients attended weekly community meetings and ward rounds where they could raise any challenges or safety concerns. Staff handover documents detailed current risks related to each patient and ways for staff to meet individual’s needs. Restraint was used as a last resort. Staff tried verbal-de-escalation and other least restrictive options first. We reviewed 4 records where rapid tranquilisation (RT) had been administered and found staff usually carried out post RT monitoring and debriefs in line with best practice guidance.

We spoke with 7 patients and 5 carers. Three patients and 2 carers we spoke with said the ward was dirty and tired. One patient said they had a damp patch in their bedroom. This meant patients were not being cared for in an environment that promoted comfort and dignity. A service user satisfaction survey was completed between October and December 2023. Only 25% of respondents said they were satisfied with the ward environment and bedrooms. Some patients had complained about the ward temperature, and that it was either too hot or too cold. The ward being too hot was noted as an issue during our last inspection in 2022. Most patients we spoke with and in the survey said they felt safe on the ward. We saw evidence that patients were asked during weekly community meetings if they felt safe or not, and actions were taken if there were any concerns.

Staff acknowledged shortfalls with the ward environment and said patient complaints were predominantly around the ward temperature. The untidiness of the ward environment had been raised during ward staff meetings in December 2023 and January 2024. A hospital wide staff survey conducted between October and December 2023 showed 31% of staff did not think the environment was clean and well maintained for patients and staff. Leaders explained plans to refurbish the entire hospital throughout 2024 which would see improvements to the environment. However, although a positive change for the hospital in the long term, it did not negate the fact that in the meantime patients and staff were living and working in an unclean and poorly maintained environment. The service had improved staff knowledge around ligature risks on the ward since the last inspection. Most staff we spoke with were able to identify ligature risks and were aware of how to mitigate the risks. Managers had introduced standalone ligature risk reduction training for all new staff as part of their inductions. Staff had annual refresher training and managers said ligature risks were discussed in supervision, meetings, and via randomised knowledge checks. Staff informed us that when patients had raised concerns about safety in the dining room, staff responded by changing the furniture for the safety of patients and staff.

We observed the ward was unclean and poorly maintained. We observed stains on the walls and ceilings, the floor was sticky, there was a presence of fruit flies, and there was an unpleasant smell in some parts. We also observed damage to some of the walls and some cupboards did not have working lights. The ward was hot and stuffy. There were alarm call bells on the ward and in patient bedrooms and staff wore alarms.

In response to the negative feedback about the ward environment in the patient survey, leaders had added actions to the OLAP. However, at the time of our onsite assessment in March 2024, only 1 of 4 actions was marked as completed. The action marked as completed was recruitment to housekeeping vacancies, but during the assessment we found there was still a housekeeping vacancy. Managers promptly recruited a new cleaner and maintenance manager following onsite feedback. The service noted maintenance issues on a log. In the 6 months prior to the assessment, 10 entries were made on the log in relation to heating issues on Juniper Ward. Some of these were shown as completed, others did not have any details about whether the issues had been resolved or not. However, the service had improved their ligature risk assessment. The ligature risk assessment clearly detailed the ligature points and blind spots on the ward. The service had a business continuity plan which outlined responses to unexpected emergency or disaster situations to ensure business processes could continue. This included plans related to the ward environment, such as if there was a water leak, loss of heating or infection outbreak.

Five patients we spoke with said they had to wait a long time for a nurse to address their requests on the ward, 4 of these commented that staff were in the office a lot. Two members of staff we spoke with said they would like nurses to have fewer office-based tasks so they could spend more time on the ward with patients. Most carers we spoke with felt some or all staff had the training required to meet the needs of their relative. Four carers said they had seen a positive change in their relative since their admission to the ward. However, 2 carers we spoke with felt some staff were better trained than others, and that some staff just opened doors or did not interact with their relative. The independent mental health advocate said some patients had mentioned delays with their section 17 leave due to staffing issues. However, the advocate said they had successfully raised the matter with staff and noted improvements since the new ward manager started in post. When we spoke with patients and relatives, they did not raise any specific concerns about delays with section 17 leave, but some did say they had to wait a long time for staff to help them with general support requests. The clinician from the NHS trust described significant disruption to the staffing team over the past 6 months but said the concerns had been addressed and the medical team had worked hard to reduce the impact of changes to the nursing team and ward management.

Staff and leaders described recent staffing challenges on the ward. There had been 4 different ward managers over 5 months and a high turnover of staff. However, staff spoke highly of the current ward manager and the positive impact their leadership had on patient care and staff wellbeing. The new ward manager had the skills and knowledge to perform their role and could explain the challenges as well as priorities for improvement. At the time of our onsite assessment, there were vacancies for 1 clinical team leader, 2 nurses, and 4 support workers. In May 2024, the hospital director confirmed there were no vacancies as another ward had closed for refurbishment and those staff were able to fill the vacancies on Juniper Ward. Most staff we spoke with felt staffing levels were sufficient. The service had 3 medical staff, with an on-call rota system at weekends. The service had low usage of bank and agency registered nurses. Between September 2023 and February 2024, the highest use of bank nurses was in October and November where 5% of the month’s shifts used them. Bank and agency support worker use was higher, with 26% of shifts in February 2024 requiring agency support workers. Staff reported this was to support with observations and acuity and said most bank and agency staff were familiar with the service. Staff completed anonymous surveys and managers monitored trends and actions from these via the OLAP. For example, survey results showed some staff were dissatisfied with the amount of non-mandatory training they received. In response, leaders aimed to promote learning opportunities through team meetings and supervision. The Medical Director was also about to restart monthly learning sessions for staff, using role play to review incidents and teach improved responses. Staff we spoke with said they had access to reflective practice sessions, supervision, debriefings, professional training and development, and said learning was shared following incidents.

The onsite team observed that additional agency and bank staff were sought to cover enhanced observation levels due to the varying acuity of patients on the ward. We had some concerns about the effectiveness of some staff communication with patients, which we have outlined in more detail under the caring key question.

Staff received training appropriate to their roles and leaders monitored compliance rates. We found some lower compliance figures, including the physical health care course as mentioned above. The clinical services manager acknowledged this and said managers were working to increase compliance. They explained other low compliance figures, such as intermediate safeguarding and tier 2 autism and learning disability training, was because the courses were new. Managers said they regularly reminded staff to complete their training. Leaders managed staffing levels according to patient acuity and could adjust these where necessary. Staffing levels were discussed daily during operational meetings which was attended by leaders and members of the MDT from across the hospital. New staff had to complete an induction. The induction pack contained a checklist of all job specific tasks new starters, including ad hoc agency staff, had to complete prior to starting their roles. Following the previous CQC inspection, leaders had introduced standalone ligature risk reduction training for new staff. Staff completed good quality handover documents. Leaders carried out disciplinary procedures and took appropriate action when necessary. Supervision and appraisal figures showed most staff had received this. Staff stated that they had regular supervision and attended debriefings.

Some patients and carers we spoke with described the ward as dirty and tired

Some staff we spoke with described the environment as unhygienic and said it needed cleaning. A staff member described a high level of acuity on the ward which contributed towards cleaning issues. The service had regular cleaners, but leaders said there had not been a full complement for a while. They promptly recruited an additional cleaner following our feedback.

During our inspection, we found the ward to be unclean and observed fruit flies, unpleasant smells, a sticky floor and stains on the walls and ceilings. Poor levels of cleanliness and hygiene meant leaders could not be assured that patients were protected as much as possible from the risk of infection. However, we saw that staff followed handwashing guidance and had access to appropriate personal protective equipment.

Cleaning staff completed a daily checklist of areas they had cleaned. Some patients’ bedrooms were deep cleaned. However, the checklist was not fully effective as it marked areas as cleaned the day prior to and the day of our onsite assessment, but we found shortfalls with cleanliness. Staff completed monthly audits for hand hygiene compliance and quarterly infection control audits. The audit completed in January 2024 had found that not all food stored in the patients’ fridge had an open date and expiry date. Staff were reminded to consistently check this and inform patients of the need to date food. This audit noted that the ward was clean and in a good state of repair. The service had an infection, prevention and control (IPC) policy. There were clear responsibilities around IPC and arrangements in place for infection related incidents. Most staff had completed their IPC training .

The patient satisfaction survey completed by Juniper Ward patients between October and December 2023 revealed positive views around care and treatment. For example, all respondents felt enough care was taken of their physical health problems and all felt they were involved in decisions about their care and treatment. We spoke with an independent mental health advocate who said clients wishes and views were heard and acted on proactively.

Staff we asked about medicines management were confident with the process and felt comfortable asking for help if they needed it. One staff member described having attended medicines competency training as well as having in person training and meetings with the external pharmacist. Staff and leaders said the pharmacist visited once a week, and patients were encouraged to speak with them about their medicines. This was due to increase to twice-weekly visits in the summer of 2024, due to the pharmacy provider changing. However, some staff we spoke with felt unsure whose responsibility it was to complete actions identified within the pharmacist’s audits. This was discussed on site with the clinical services manager.

Medicines, including controlled drugs, were stored safely. Equipment and technology were well-maintained and stored securely. The first aid box was in date and checked regularly. Staff usually completed weekly checks of emergency equipment, although we found some omitted or incomplete checks between 2 and 15 March 2024. We found 2 bottles of medicine which did not have the date of opening and/or correct day of opening on them. This meant the date of when the medicines could safely be used was unclear to staff.

We reviewed 7 medicine administration records for completeness, legibility and inclusion of relevant client-specific information, such as allergies. Records were legible and prescriptions signed by a doctor. Staff had signed the record when administering medicines. Staff did not always document two staff signatures in the drugs liable for misuse (DLM) book when medicine was administered. We found one record with only one signature and shared this with staff during the assessment. Some staff felt that 2 signatures were only required prior to the end of the shift and not at the time the medicine was administered. We shared staff views with the clinical service manager who stated the expectation of staff was for there to always be 2 staff available on each shift to sign the book at the same time. They said this reflected the training staff had on DLMs. The service had trained senior support workers so there were additional resources to assist with the process. Staff monitored and recorded the drug fridge temperatures to ensure medicines were stored safely and remained effective, and these were in range. However, there were 2 days in February 2024 where staff did not record the fridge temperature, which meant they could not be assured that medicines were always stored at suitable temperatures. Leaders monitored numbers of medication incidents during monthly clinical governance meetings. Medicine and clinic room audits were completed by staff and the visiting pharmacist. We noted that one of the audits, which was undated, stated 22% of queries and interventions made by the pharmacist were not acknowledged by the service. As mentioned above, some staff felt unsure of the process. We did not see any action plans around how this would be improved.