The Care Quality Commission (CQC) has taken action after it identified serious risks to patient safety at a West Yorkshire mental health hospital during a focused inspection in September.
As a result of this inspection CQC has placed Cygnet Woodside, Bradford, in special measures and suspended its current rating of Good for caring.
CQC carried out this unannounced inspection following allegations of abuse by staff towards a patient. There is an ongoing police investigation into this incident.
CQC rated the safety, effectiveness and whether the service was well-led as Inadequate, with the responsiveness of services rated as Requires Improvement. This gives an overall rating of Inadequate for Cygnet Woodside.
Dr Kevin Cleary, CQC deputy chief inspector of hospitals and lead for mental health, said:
“Our latest inspection of Cygnet Woodside found that the hospital was not ensuring its patients’ safety. We have placed the service in special measures and also suspended its current Good rating for being a caring service until it is able to demonstrate improvements in this area.
“The service showed warning signs that increased the likelihood of a closed culture developing. This would have put people at serious risk of coming to harm if we didn’t take action.
“There wasn’t always the right number or skill level of staff looking after people, which compromised their care. A high turnover of staff coupled with carers not always following risk assessments, meant people weren’t always treated as individuals - putting them at risk.
“We have told leaders at this service what they must do to improve and will continue to monitor Cygnet Woodside closely. Should we see insufficient improvement, CQC will not hesitate to take further action to keep people safe.”
The service had inherent risk factors and warning signs that increased the development of a closed culture:
- Although there was information in an accessible format which enabled people to communicate their needs, people using services were not able to give feedback about the care they were receiving. This meant people were less able to speak up for themselves, without good support.
- Senior leaders were not always fully aware of concerns in the service and this included the concern relating to the allegations of abuse toward patient a which is being investigated by police.
- Senior leaders were visible in the service and staff felt they could raise concerns about poor behaviour with them without fear of consequence. However, some staff told us that they had not done so when there were allegations of abuse, because they felt intimidated to not do so by other staff, and that their concerns were ignored by managers.
- There was no seclusion room at the hospital. However, there was evidence that staff had secluded a patient in another area of the hospital which was against their own policies to protect people.
- People were highly dependent on staff to meet their basic needs and were not able to access drinking water by themselves.
- The service has a high turnover of staff. Even though most care plans were written to a high standard, including comprehensive behaviour plans, they were not always filled in or followed, meaning staff didn’t always know people’s individual needs or risk assessments. For example one patient could only be restrained for a specific time period due to health reasons, but this was not documented in their care plan and staff provided different lengths of time they recalled the patient could be restrained. This ranged from five minutes to 15 minutes. Not having up to date and comprehensive risk assessments could lead to avoidable harm.
Inspectors have told the service what it must do to keep people safe from contracting COVID-19 as staff were not always wearing face masks and those that did were not always wearing them properly.
On the ward areas, inspectors found a strong odour of urine, damaged walls, and peeling paint as well as intermittent issues with the television. However, the service provided inspectors with a programme of works that are to be completed by January 2021 including new flooring in parts of the service and a full refurbishment of the shower room, bedroom corridor and the quiet room.
The inspection report is available on the CQC website here.
Ends
Cygnet Woodside is an independent mental health hospital providing care for up to nine male adults with a primary diagnosis of learning disability. At the time of the inspection there were eight patients using this service.
For enquiries about this press release please email regional.engagement@cqc.org.uk.
Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here (Please note: the duty press officer is unable to advise members of the public on health or social care matters).
For general enquiries, please call 03000 61 61 61.
Throughout the COVID-19 pandemic, the CQC’s regulatory role has not changed. CQC’s core purpose of keeping people safe is always driving decisions about when and where we inspect. As the risks from the pandemic change, we are evolving how we regulate services to reflect what we have learnt during this time. You can read more about our approach here.
CQC listens to what people say about services to detect any changes in care. If there is evidence that people are at immediate risk of harm, CQC can and will take action to ensure that people are safe. People can give feedback about their care to CQC via the details below:
- Give feedback via website
- Telephone - 03000 616161