Cygnet Joyce Parker Hospital

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• 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

Children and young people did not always feel safe at the service. Managers did not ensure young people were safeguarded against restraint that was not necessary to prevent, or not a proportionate response to, a risk of harm. Staff did not demonstrate a strong understanding of safeguarding. Systems, processes and practices to make sure people were protected from abuse and neglect were not effective. Leaders did not always demonstrate a commitment to taking immediate action to keep people safe from abuse and neglect and did not always work with partners in a collaborative way. Staffing was not always safe and effective. The provider was using high levels of agency staff at the location. Although we saw evidence that agency staff received training relevant to their roles, we were not assured that agency staff were competent, skilled and experienced to care for young people safely.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

People did not always feel safe at the service. We spoke with 7 young people across the 4 wards. Four young people told us they did not always feel safe. We reviewed community meeting minutes from 3 June 2024 to 12 July 2024 for Mermaid and Pixie wards. Of 17 community meeting minutes reviewed children and young people expressed not feeling safe in 7. Most children and young people expressing this were on Dragon ward; they expressed feeling unsafe at 3 of the 5 meetings we reviewed for Dragon ward. However, the advocate told us the provider had tasked them with developing questions for children and young people in relation to safeguarding and feeling safe. The advocate had spoken with the 3 children and young people subjected to abuse by staff and they have all said they now feel safe.

Not all staff spoken with demonstrated a strong understanding of safeguarding processes. Whilst staff spoken with were able to describe how they would report safeguarding concerns internally, they were unaware of how external safeguarding processes worked. We fed this back to the provider, and they advised they have since introduced safeguarding quizzes to check staff knowledge.

We observed Closed Circuit Television (CCTV) footage of three incidents where staff dragged young people during restraint. Two of the incidents occurred on Dragon ward and 1 incident occurred on Mermaid ward. For all 3 incidents reviewed there was no apparent risk requiring restraint presented by the young person. There was no evidence of staff attempting de-escalation prior to restraining the children and young people. In one incident staff escalated the situation by refusing the young person access to their bedroom.

The provider had a policy for Safeguarding Children and Young People. Although the policy was detailed, thorough and supported staff in understanding their role in safeguarding, it had not been personalised to Cygnet Joyce Parker Hospital and did not contain links or contacts for local safeguarding arrangements. We identified an incident of abuse that staff did not report to the local authority until 11 days after the child or young person disclosed it. Managers did not ensure staff received safeguarding supervision as required by their supervision policy. The provider’s supervision policy refers to separate safeguarding supervision taking place on an ad hoc basis in relation to specific issues and incidents. The supervision record forms reviewed onsite did not demonstrate examples of reflective or restorative safeguarding supervision in relation to individual children or young people. We were not assured that the service always took immediate action to keep people safe from abuse and neglect, including working with partners in a collaborative way. Partners spoken with advised they were not always informed of safeguarding incidents involving young people at the service. Partners shared concerns that managers at the service were not proactive in taking action to identify and prevent further incidents of abuse.

Staff did not always ensure they used restraint that was lawful, for a legitimate purpose, safe and necessary. One young person on Pixie ward shared with a CQC inspection team member that staff (usually agency) sometimes bent their wrist during episodes of restraint. Another young person on Dragon ward told us that staff sometimes hurt them during episodes of restraint, including twisting their knee on one occasion. The provider reported 3 injuries to young people during episodes of restraint between 1 April 2024 and 30 June 2024. The independent advocate for the hospital told us that the hospital director had taken action to ensure the handover from day to night staff was better. The advocate advised that the daily risk assessment meetings they had attend were improving. This includes staff taking positive risks, for example with section 17 leave. Staff enable the children and young people to take control for themselves and make their own choices and ensure they understand the impact of their choices. Children and young people told the advocate that there were inconsistencies with staff following their positive behavioural support plans.

Staff spoken with told us they only used restraint as a last resort and would try de-escalation techniques first. We spoke with 5 staff on Mermaid ward who told us this. They told us seclusion was rarely used. We spoke with the nurse in charge on Dragon ward, they described de-escalation techniques they used, for example, keeping the de-escalation room cooler. They said if a child or young person was distressed, they would ask them if they wanted to take a walk to the de-escalation room as the change of environment and lower temperature helped them to de stress. They would ask the child and young person what would help them. They described offering distractions, for example, fidget toys, ice, as required medication or a drink. One young person has a shower to help them to de-escalate. We reviewed a report by the provider’s restraint lead. This report looked at 13 incidents of restraint that occurred in July 2024 across all wards. The report concluded all restraints reviewed were ‘lawful’ and staff were observed to use least restrictive practices before restraint and used restraint for the shortest time possible. The provider told us that the quality lead and clinical manager complete spot checks of incident reports and children and young people’s care records to check staff are following positive behaviour support plans and using appropriate de-escalation techniques. The provider advised debriefs have increased recently and are checked at the daily sit rep meetings to ensure staff are following positive behaviour support plans. The provider reported watching over 300 hours of closed circuit television footage from May- June 2024 and said they observed staff using positive de-escalation practices and only restraining children and young people as a last resort. However, we saw CCTV footage that evidenced staff did not always try to deescalate first and the provider only took some of these actions after concerns were raised by CQC and partners.

The service reported a high use of safety interventions, which included physical restraint. The hospital reported 2,456 incidents between 5 March 2024 and 5 July 2024. Of these, safety interventions were used in 943 incidents. Children and young people complained about the use of safety interventions in six of these incidents; 3 on Dragon ward, 2 on Mermaid ward and 1 on Pixie ward. The provider told us they admitted children and young people with higher acuity than at the provider’s other CAMHS inpatient services. Following concerns raised by children and young people we checked a random sample of agency staff profiles which evidenced they completed the same safety intervention (including physical restraint) training as permanent staff. We reviewed 20 staff debrief forms from across all 4 wards. There was limited evidence of discussion around whether the incident outcome was the least restrictive or in line with children and young people’s positive behaviour support plans. We observed staff restraining a patient on Pixie ward after they tied a ligature. We did not see staff checking the patient’s vital signs during this incident. Two staff used an incorrect restraint technique on the patient’s legs. There were no spare staff to provide additional support, for example, the retrieval of the emergency bag. The patient tied a ligature around their neck with a towel. Staff required ligature cutters to remove the towel which took 10-15 seconds. We observed closed circuit television footage of another ligature incident on Pixie ward. For both ligature incidents staff attending the incident did not retrieve the emergency bag, this would have delayed potentially lifesaving interventions, were they needed. We reviewed a sample of 9 debriefs recorded between May- June 2024 on Mermaid ward. Staff promoted a least restrictive approach in 5 of the debriefs.

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

People’s experience suggested agency staff did not always have the right experience and skill mix to meet their needs. Feedback from children and young people and carers indicated that agency staff were used predominately at nights and weekends. We reviewed minutes of 17 community meetings across three wards (Dragon, Mermaid and Pixie). Children and young people expressed issues with agency staff at 2 of these meetings (both on Mermaid ward) and issues with night staff at 2 of the meetings (both on Dragon ward). A young person on Pixie ward told us that there are sometimes staff shortages, and the ward ends up with a lot of agency staff, they are often staff young people don’t know. We spoke with 5 parents, the majority said they felt their child or young person was safe during the day, but the big issue was during the night when most of the support workers were agency staff. Parents told us agency staff were not well trained, had no clue how to approach the children and young people and instead of helping to defuse and listen they challenged the children and young people.

Staff on Mermaid ward told us they have weekly group supervisions and any concerns from this were escalated to the hospital director. They advised agency staff are used more at night and at weekends and managers try to use the same agency staff to provide consistency. They said the ward can get additional staffing when needed. We spoke with a group of multi-disciplinary staff on Pixie ward, they told us that incidents happen mostly during evenings and weekends when agency use is higher. Staff on Mermaid said it would be good for new staff to get some training in how to use verbal de-escalation and how to communicate with children and young people when they are distressed. However, the senior on site (senior staff supporting 24/7) was now an additional member of staff, rather than being part of the ward shift. This allowed them to review staffing levels and mix, including agency staff use, and move staff around if required to balance out use of agency.

During our evening site visit on 24 July 2024, we reviewed staffing on Dragon, Mermaid and Pixie wards for the night shifts, out of a total of 39 staff on duty, 11 were from the agency. This equated to 28% of staff. Dragon ward had the highest number of agency staff, 6 staff were agency out of a total of 15, this equated to 40% of staff on duty. The 3 abusive incidents we reviewed on closed circuit television occurred during night shifts and involved 4 agency staff. Two of these incidents happened on Dragon ward, which reported the highest use of agency staff.

We reviewed staffing data from the provider covering 1 March 2024 to 30 June 2024. Across all wards qualified agency staff filled 25% of shifts and support worker agency staff filled 27% of shifts. Dragon ward reported the highest use of agency staff with 30% of qualified shifts and 46% of support worker shifts filled by agency staff.

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 did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.