The Care Quality Commission (CQC) has taken action after it identified risks to patient safety at a Durham mental health hospital.
CQC carried out an unannounced inspection of Cygnet Appletree, Meadowfield, on 5 and 6 August 2020, following allegations from whistleblowers regarding patient safety, culture and incident monitoring.
The 26-bed hospital cares for women, including those detained under the Mental Health Act, requiring acute and psychiatric intensive care. It had nine patients at the time of the inspection.
Inspectors found that the service was not ensuring patient safety, leading to patients being exposed to the risk of harm.
Ligature points had not been identified, and blind spots in the ward’s layout impaired patient monitoring.
Staff did not always receive necessary training, including for resuscitation.
Inspectors also found that the service was not compliant with Public Health England’s guidance on personal protective equipment (PPE), including in respect of the use of face masks and gloves, to reduce the spread of COVID-19.
Following the inspection, CQC used its enforcement powers to ensure people’s safety and hold the service’s leaders to account. This includes requiring the hospital to report on its progress with improvements it must make to ensure people receive safe care and treatment.
Dr Kevin Cleary, CQC deputy chief inspector of hospitals and lead for mental health, said:
“Our latest inspection of Cygnet Appletree found that the hospital was not ensuring its patients’ safety.
“A lack of oversight from managers and a failure to implement Cygnet’s own policies was behind many of the shortcomings. This included failing to identify and learn from incidents where patients had been exposed to the risk of harm, and ensuring staff had the right training.
“We were also concerned that staff were not always compliant with guidance to protect people from COVID-19.
“Following the inspection, we used our enforcement powers to ensure patient safety.
“The service’s leaders know what must be done to ensure people receive care and treatment that meets standards that patients should be able to expect.
“We continue to monitor the service, including through future inspections, and will use our enforcement powers further if satisfactory improvements are not made.”
Following the inspection, CQC told the service it must make the following improvements:
- All clinical staff must complete immediate life support training
- Staff must follow policies and procedures to monitor patients’ physical health, and ensure that referrals to specialists are made when needed
- Staff must receive regular supervision and appraisal
- Systems must be implemented to ensure that concerns are taken seriously, investigated fully and used to drive change
- Complying with the conditions imposed on its registration, in line with the enforcement action detailed in the inspection report.
Although CQC suspended its routine inspections in March 2020 to support care providers to deliver safe care during Covid-19 pandemic, inspections are still taking place where there is evidence suggesting people may be at risk of harm.
CQC continues to collect insight and intelligence about services from its data sources – including providers, healthcare staff, stakeholders, and the public – and it is working closely with its partners to ensure additional support is in place where needed. If there is evidence that people are at immediate risk of harm, CQC is taking action to ensure that people are safe.
People can give feedback to CQC by:
- telephone - 03000 616161
- give feedback on care webform (www.cqc.org.uk/give-feedback-on-care)
ENDS
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