Cygnet Victoria House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The ward was safe and clean. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Although staff had completed and kept up-to-date with most of their mandatory training, there was only 28.9% compliance for the "Learning Disabilities and Autism Tier 2" , but this had increased from 14% since we had been on site as it was a new course and staff were completing when able. However, it was not clear on the ward where the fire door was located should it need to be used. Although there was a sign above the fire door, this door was not visible from main ward area and there was no signage on the ward to show where people would need to go in an emergency. The service did not have enough nursing staff to ensure patients were able to receive adequate therapeutic care as required by their own staffing matrix. Their staffing matrix had last been created in May 2016 and was due for review in 2019 but this had not been done. We reviewed 11 weeks of ward rotas from 1 Jan 2024 to 17 Mar 2024 and out of 154 shifts there were 51 that did not have more than 1 nurse on duty which was contrary to the services own matrix of having 2 nurses on every shift.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patient community meetings were held weekly, and a ‘people’s council’ meeting was held monthly within the wider hospital.

There was two Freedom to Speak Up Guardians at the hospital. Staff were aware of duty of candour and the process of informing patients and relatives when things go wrong. Staff told us that lessons learned are shared not only across the ward staff team, but on a larger scale through communications with other hospital sites.

The service had a thorough audit process in place and rectified any issues found within those audits. There was a whistleblowing (including Freedom to Speak Up) policy in place. The service completed lessons learned incident reports, applied appropriate mitigation to ensure they did not happen again and shared these with staff and patients at the service.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Care plans we reviewed captured individual care and support needs and patients we spoke with were aware of treatment goals which had been discussed with the wider multidisciplinary team in review meetings. Patients had access to an electronic device which enabled them to make video calls to family. Although there was no information on display within the ward, which had been due to a recent patient incident, we saw that patients were still able to share their views and request information when needed.

Staff were able to tell us the process for incident reporting and how to escalate to safeguarding. Staff were able to tell us the process for staff speaking up and where to find information on how to do this.

Although there was no information on display within the ward, which had been due to a recent patient incident, we saw that patients were still able to share their views and request information when needed.

The service had multiple policies in place, including a search policy, safeguarding adults and children policies, and Mental Capacity Act and Mental Health Act policies. The service regularly submitted safeguarding alerts to the local authority and notifications to CQC. Staff completed both e-learning and virtual classroom safeguarding training. Senior members of staff at the service had been designated as the safeguarding leads for the service.

Seclusion was used appropriately and in the least restrictive way and was ended at the earliest opportunity. Regular contact with external agencies for patients which included safeguarding meetings with the local authority and also other professionals. We saw in patient records that information on the role of the IMHA (Independent Mental Health Advocate) had been provided at the time of admission. Patients also confirmed that they had contact with the advocacy service, with 1 patient advising that they had recently discussed their upcoming tribunal with their advocate.

Staff told us the advocacy service contacted the ward regularly and we saw evidence of physical health screenings being completed on a regular basis within patient records and care plans for physical health issues were regularly updated. Staff also told us that patients are involved in managing risk and included in multi-disciplinary meetings that concern risk management, where appropriate. Staff were happy with the effective communication within the staff team about emerging risks which would allow the multi-disciplinary team to be responsive to changing presentations.

The service had a positive and safe care policy in place which included a reducing restrictive practice plan.

Seclusion area met the standards in the Mental Health Act Code of Practice. At the time of our visit there was 1 autistic patient admitted to the ward. Although there were limited readily available sensory resources for autistic patients, the ward was in the process of trialling a sensory project and it was hoped that additional sensory resources would be obtained soon. The ward could refer patients to external teams for further specialist support and advice and staff were also provided with autism awareness training.

Staff told us they were involved in decisions about the environment and they had seen improvements since our last inspection including additional dining space, but acknowledged this space needs to be used more effectively.

We reviewed the ward, clinic room, and seclusion area. There was no signage to show people in the main ward area where the fire door was should they need it in an emergency. All the information usually available on the ward walls had been removed due to a patient incident and there was no information leaflets available.

The service had a comprehensive audit plan in place which included a regular review of the environment and its potential risks. There was an up to date smoking policy in place.

Patients told us they were able to access agreed leave but that sometimes there could be a delay due to staffing issues.

Staff said they could not always facilitate patient leave off the ward or 1:1 time due to the low staffing numbers. Staff confirmed that at times there was only 1 nurse on a night shift.

During the assessment we observed minimal staff in the communal areas, with nurses largely located in the ward office.

In our previous report, in September 2022, the ward had used bank staff to cover 399 shifts and agency staff to cover 1,043 shifts in a 12 month period. From April 2023 to March 2024, assuming a 12 hour shift pattern, the ward had used bank staff to cover 722 shifts and agency staff to cover 1561 shifts. Most staff had completed and kept up-to-date with most of their mandatory training. However, only 28.9% of staff had completed their training for the "Learning Disabilities and Autism Tier 2" training, but this had increased from 14% since we had been on site as it was a new course and staff were completing when available. The Oliver McGowan training had a compliance rating of 96.9%. The service did not have enough nursing staff to ensure patients were able to receive adequate therapeutic care as required by their own staffing matrix. We reviewed 11 weeks of ward rotas from 1 Jan 2024 to 17 Mar 2024 and out of 154 shifts there were 51 that did not have 2 nurses on duty which was contrary to the services own matrix of having 2 nurses on every shift to ensure therapeutic levels of staffing. Their staffing matrix had last been created in May 2016 and was due for review in 2019 but this had not been done.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We saw evidence of capacity assessments being completed in respect of patients’ capacity to consent to treatment. We also saw the appropriate use of a treatment authorisation certificate in 1 of the patient records we reviewed.

Staff told us they have access to clinical support administrators and there is a comprehensive audit programme for medicines.

We completed a review of the ward clinic room with no concerns.

Patients were monitored regularly for potential levels of toxicity and for signs of extra-pyramidal side-effects associated with medication such as anti psychotics and mood stabilisers.