Cygnet Joyce Parker Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Leaders did not have the experience, capacity, capability and integrity to ensure that risks were well managed. We were concerned that the provider’s policies in relation to ligatures and resuscitation were not adequate to prevent potential harm to children and young people. Leaders were not always alert to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff. Managers did not ensure staff were aware of their responsibility to raise concerns, 12 staff observed the abusive incidents and failed to report them. Staff spoken with were not aware of the term closed cultures.

This service scored 46 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Following staff abuse of patients during incidents of restraint the provider reviewed closed circuit television footage to identify staff. As well as the staff directly involved there were a significant number of staff who observed the incidents. The provider has subsequently identified 12 staff who were ‘passive bystanders’ when the abusive incidents occurred; none of whom raised concerns about what they had seen. Staff spoken with had not heard of the term ‘closed cultures’. We identified possible indicators of a poor culture in minutes from the provider’s HR clinics that we reviewed. Staff used the word challenging to describe children and young people in 2 of these clinics. We reviewed an audit of the culture of the service completed by the provider on the 1 and 2 May 2024. The report stated, “there may still be areas that require addressing to avoid closed cultures forming” and highlighted that, “no staff members knew who the Freedom to Speak Up ambassador was.” The providers Freedom to Speak Up Guardian advised only one concern was received in the last quarter for Cygnet Joyce Parker. However, the provider had an action plan to address closed culture concerns with actions including increased local management oversight, Cygnet senior leaders input and increased input from external agencies including the local authority, police and advocacy. Most staff spoken with told us senior leaders at the hospital were supportive and approachable.

We reviewed the provider’s ‘Raising Concerns, Freedom to Speak Up (Whistleblowing) Policy’. It referred to PIDA 1998 and what constitutes staff speaking up and whistleblowing. It stated that staff have an obligation to speak up when they identify concerns and failure to do so may result in disciplinary action. The policy did not detail who local speak up ambassadors were for the service, nor did it state who other prescribed bodies – such as CQC – were, should a staff member wish to speak up or whistle blow externally. The policy did not identify how leaders should respond when incidents were identified and staff failed to report, or how to identify, explore, and remove barriers preventing staff from speaking up. We reviewed CCTV audits completed from 1 April 2024 to 5 July 2024. The service security lead completed audits monthly for each ward. These audits included a random sample of closed circuit television footage from incidents. All audits reviewed were scored at 100%. These audits cover the time that the incidents of abusive restraints took place and therefore we were not assured that this was a reliable audit process. We were concerned that the provider’s policies in relation to ligatures and resuscitation were not adequate to prevent potential harm to patients. We asked the provider how they ensured their policy for emergency bag use in ligature situations was in line with Resuscitation Council UK (RCUK) and National Institute of Health and Care Excellence (NICE) guidance. RCUK Mental Health inpatient guidance states, “Organisations must have policies and procedures in place for resuscitation in special circumstances (including ligatures)”. The provider advised that their procedures were in line with RCUK guidance, however a review of Cygnet policies identified there was no procedure for a ligature specific emergency. This significantly increased the risk of life saving equipment not being available when needed for children and young people.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Governance, management and sustainability during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.