Archived: Cygnet Thors Park

Updated 15 September 2020

Cygnet Thors Park operated as an independent hospital that provided support for up to 14 men. The provider is Cygnet (OE) Limited. The hospital in Thorrington, North East Essex, Cygnet Thors Park provided support and treatment for men with learning disabilities and complex needs. The provider accepted patients who had additional mental and physical health needs, and those who are detained under the Mental Health Act. The service comprised of three elements:

• Thorrington Ward had eight-beds that provided assessment and intervention for men with learning disabilities, complex needs and behaviours.
• Brightlingsea ward had four-beds for men who required more intensive support. There were also four self-contained, bespoke apartments.
• The provider also had two bespoke single person apartments that provided a more independent living environment.

This location was registered with the Care Quality Commission on 1 October 2010 for the following regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983
• Treatment of disease, disorder or injury.

The hospital did not have a registered manager. The previous registered manager was not available from December 2019 and they left in March 2020. The provider arranged for their two regional managers to act as the hospital's manager in the interim. The provider appointed a new hospital manager who submitted a registered manager application 8 July 2020.

The hospital was placed in special measures after a comprehensive inspection 5 February 2019. The CQC took enforcement action and issued a warning notice under section 29 of the Health and Social Care Act 2008. This related to a breach of Regulation 12 safe care and treatment: regarding medicines management, environmental issues including the medicines clinic, the staff alarm system and also staff observation of patients. Regulation 17 good governance: regarding the provider’s oversight and mitigation of risks. Regulation 18 staffing which related to staff training, supervision and appraisal.

We carried out a follow up inspection visit on 24 and 30 September 2019 to check on the provider’s actions and issued a notice of decision to urgently impose conditions under section 31 for a breach of regulation 12 safe care and treatment, regulation 17 good governance and regulation 15 premises and equipment. The conditions restricted the admission of patients, related to having suitably competent and skilled staff and ensuring staff’s observation of patients were in accordance with patient care plans and the provider’s policy. Since this inspection, the provider sent the CQC information outlining how they were addressing the breaches of regulation relating to the conditions.

The provider applied 9 July 2020 to cancel their registration of regulated activities at this location. They had transferred all their patients out of the hospital by 18 June 2020.

Updated 15 September 2020

We rated Cygnet Thors park as inadequate because:

• The service did not provide safe care. Staff were unable to call for help when they or a patient needed protection from violence or aggression. Staff personal alarms did not work when we tested them and the display panel which helped staff to find the emergency, displayed an inaccurate location.
• The provider had not identified or sufficiently mitigated blind spots in the ward environment. This meant that staff and patients were unable to observe all parts of the ward to ensure their safety.
• Managers failed to ensure there were enough staff on duty to provide the required levels of patient observations in a safe way. Staff were completing patient high level observations from two to 12 hours continuously (on rotation) without a change of activity or alternative task. The provider did have a protocol in place which stated that staff should not undertake close observations for longer than two hours without a break but this protocol was not adhered to during the inspection. The records for the patient’s care plan, their daily risk assessment, and their observation plans did not always match.
• Managers failed to complete bi weekly CCTV reviews for three weeks during September 2019. The CCTV was not working effectively during this time and was not identified by the provider. This was an action from the November 2018 inspection. We found the closed-circuit television (CCTV) system was not working and the manager was not aware of this until the inspection.
• Staff did not plan sufficiently for patient discharge. Patients stayed at the service for longer than they needed to with the average stay being 1423 days. One transition plan for a patient’s discharge had action points which staff had not completed and it was not clear why their discharge was delayed.
• The registered manager did not have enough oversight of all the safety concerns and risks at the service and had not acted to correct all the concerns raised at previous inspections or from enforcement action.

However;

• The ward environments were clean. Staff assessed patient risks regularly, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability and autism and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• 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.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

Updated 6 December 2019

Brightlingsea Ward

Thorrington Ward