CQC re-inspect services at Cygnet Hospital, Godden Green

The Care Quality Commission has today published another report on Cygnet Hospital Godden Green in Sevenoaks, Kent.

CQC undertook an urgent responsive inspection on Knole ward and Littleoaks on the evening of 2 November and 3 November. Concerns had been raised with us, including the number and severity of incidents affecting the health, safety and welfare of young people on the wards, the lack of reporting of incidents to relevant external authorities and the safety of the ward environment. CQC have previously inspected Cygnet Hospital Godden Green in July and August 2017, when inspectors took action to restrict admissions to the service and again in September 2017 to ensure improvements had been made.

Natasha Sloman, Head of Hospital Inspection (mental health) said:

“This is a very disappointing report and despite receiving assurances from the provider, I was concerned to read about the lack of improvement on both of the child and adolescent wards. During our inspection in September 2017, we were able to see the provider had put systems in place to reduce the risks to young people and we lifted a previously imposed restriction on admissions to Knole ward.

“We did however, take further enforcement action and issued a warning notice in relation to seclusion and segregation, which we were concerned was used to control and contain young people in the absence of other approaches. Following this inspection we have now issued a further three warning notices due to breaches in regulation. We have grounds to suspect the provider has committed a criminal offence of failing without delay to notify the Care Quality Commission of incidents. Currently in conjunction with NHS England we have taken action to restrict admission to services and only allow eight young people to be treated in these wards at any time.

“While the provider has given assurances to us that it now has oversight of the issues we have identified and are making the improvements necessary, we will continue to monitor and inspect the hospital to ensure the changes put in place are further embedded. I am hopeful that the Cygnet Hospital Godden Green will do what is required for the sake of people using its services, but if we find that the service remains unsatisfactory, we will consider taking steps to cancel its registration."

Inspectors found the following issues that still required further improvement:

Staff were not always found to be competent and skilled to provide care and treatment to young people. Staff had required the assistance of police at times to support and manage incidents on the wards that should not have required the support of the police.

Staff were not always supported to prevent, identify and report abuse or skilled in making safeguarding referrals to the local authority safeguarding team.

The quality of risk assessments for young people were poor. Staff did not update risk assessments following incidents. The risk of similar incidents being repeated was not mitigated or managed. We saw several examples where similar, preventable incidents reoccurred.

Staff did not fully investigate safeguarding concerns and not all safeguarding concerns were reported internally or to the relevant external agencies. Inspectors found a number of incidents that had not been appropriately reported.

Environment assessments for the wards did not always identify risks. Inspectors saw examples where incidents had occurred in the environment and assessments were not updated to prevent similar incidents being repeated.

The provider did not always support young people following incidents and provide feedback.

Ends

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