The Care Quality Commission (CQC) has rated Cygnet Bury Hudson in Bury, inadequate overall, following an inspection in June.
Cygnet Bury Hudson is a hospital that provides low and medium secure inpatient services for men and women. It has six wards and 78 beds.
The service was last inspected in July 2020 when it was registered as Cygnet Bury. Since April 2021, the location has been split into three and this is the first inspection as this location.
Following this inspection, the overall rating for Cygnet Bury Hudson is inadequate. Safe, caring and well-led is also rated inadequate. Responsive is rated as requires improvement and effective is rated as good.
The service is now in special measures which means it will be kept under review by CQC and re-inspected to check sufficient improvements have been made.
Brian Cranna, CQC head of hospital inspection for mental health and community services, said:
“During our inspection of Cygnet Bury Hudson, leaders had a good understanding of the service, however we found a number of very concerning issues.
“People told us they were being bullied and abused by other patients and staff members, and that they didn’t feel safe on the wards. They told us staff weren’t always discreet, respectful or kind, and sometimes made negative comments about them. This is totally unacceptable and no-one using health and social care services should experience this kind of treatment.
“Inspectors found safeguarding issues weren’t always recognised and managed effectively by staff, and patients’ needs weren’t always being put first. A security breach had led to a patient’s offence being disclosed to others and they had to be moved to another ward after receiving abuse. This must be addressed as a priority to keep people safe and protected from harm.
“Staff were also unable to find information we requested which meant they didn’t always have timely access to important information needed to deliver appropriate care.
“However, staff minimised the use of restrictive practices and used de-escalation techniques to minimise the use of restraint on the wards. Also, blanket restrictions were in accordance with identified risks and were reviewed regularly.
“We have told the provider to make improvements to ensure that people are safe, and we will monitor the service closely to ensure these are made and fully embedded. If they are not, we won’t hesitate to take the appropriate action needed to drive the necessary improvements.”
Inspectors found the following issues during this inspection:
- Staff did not always meet the communication needs of patients. A patient with a learning disability told us they were given information in a way they could not understand
- The ward environments were not always comfortable for patients. A problem with the central heating system was causing the heating to come on even though it was warm which was making the temperature in the hospital uncomfortable for patients and staff
- On East Hampton ward, patients’ sleep was being disturbed by slamming doors and lights from a sensor shining into their bedroom
- Governance processes within the service did not always ensure that wards ran smoothly, and clinical audits were not always effective. There were issues in relation to safeguarding, complaint handling, responses to feedback, staff not being able to access patient information in a timely manner, medicines management, staff attitudes to staff and carers, also blood monitoring machines not being calibrated
- Staff did not always actively involve or inform families and carers about their loved one’s progress.
However:
- Although staff turnover within the service was high, managers were taking steps to recruit more permanent staff and used bank and agency staff to cover staff shortages
- The ward environments were clean. The provider was taking steps to recruit more nursing staff to the service
- Staff provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice
- Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason
- The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.