The Care Quality Commission (Cqc) has rated Cygnet Views in Matlock, Derbyshire, inadequate overall and placed it in special measures following an inspection in June.
CQC undertook an unannounced inspection of the independent hospital which provides care for up to ten women with learning disabilities, behaviour that could challenge and complex mental health needs, as part of continual checks on the safety and quality of health care in hospitals.
Following the inspection, the hospital’s rating went down from requires improvement to inadequate overall. It was rated good for being responsive, requires improvement for being caring, and inadequate for being safe, effective and well-led.
As the service is in special measures, it will be inspected again within six months. If there is insufficient improvement, CQC will use its enforcement powers further to protect patients from the risk of harm and hold the service’s leaders to account.
Jenny Wilkes, CQC head of inspection for mental health and community services, said:
“When we inspected Cygnet Views, we were not assured all reasonable steps were being taken to protect women from avoidable harm.
“We were concerned that safety incidents were not well-managed at the hospital. Staff were trained in how to use restraint, but many were not confident about using these techniques which often resulted in the police being called to assist.
“Police have contacted us with their concerns about the safety and management of patients following several call outs to the hospital. Liaison meetings were set up with the local safeguarding authority to monitor police involvement at the hospital and are ongoing.
“In addition, risk assessments failed to identify significant ligature points across the hospital meaning vulnerable patients were at an increased risk of causing harm to themselves. Assessments inspectors looked at had missed several ligature points in bedrooms. This was despite similar risks being identified and actioned for improvement as part of Cygnet’s national review of ligature risks inside their hospitals.
“We did, however, see some examples of positive care for patients. For example, staff always treated people with kindness and respect and met the needs of all patients including those with a protected characteristic. Staff helped patients with communication, cultural and spiritual support.
“We spoke with Cygnet about addressing our findings as a priority and making the necessary improvements. We will continue to closely monitor the service and will return shortly to check on progress.”
Inspectors found areas where improvements must be made, including:
- All areas of the hospital must be assessed for ligature risks and staff must act to reduce risks to protect patients from harm.
- Physical health care risks must be being monitored and effectively mitigated.
- All staff must receive training to maintain necessary skills to meet the needs of the people they care for and support.
- Patients must receive appropriate treatment which meets their needs and where a person lacks the mental capacity to make specific decisions, their best interests should be considered and acted on.
- Patient's records must be complete and fit for purpose.
- Staff must support patients to understand the care or treatment choices available to them and discuss with a health professional the balance of risks and benefits involved in any particular course of treatment.
However, inspectors also found:
- Staff planned and managed discharge well and liaised with hospitals that would provide aftercare. Discharges were delayed only due to clinical reasons.
- Staff followed infection control policy well. This was an improvement from CQC’s previous inspection when a warning notice was served in relation to infection prevention and control practices to keep people safe during the COVID-19 pandemic.
- The hospital staff worked well together as a multidisciplinary team and with those outside the hospital who have a role in providing aftercare.
- The hospital team included and had access to the full range of specialists required to meet the needs of patients.
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