Cygnet Hospital Harrow

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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

We assessed 3 quality statements in the well-led key question and found areas of good practice. The scores for these areas have been combined with scores based on the rating from the last inspection, which was inadequate. Though the assessment of these areas indicated areas of good practice since the last inspection, our rating for the key question is requires improvement. We found that the provider had clear and effective governance and management systems in place. The service was implementing a few remaining improvements following its previous inspection in May 2023. Leaders were visible, knowledgeable, passionate and experienced and had the capability to ensure the service’s vision and improvement plan was managed and implemented in a timely manner.

This service scored 43 (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.

Since the last inspection, new senior leaders had been recruited. Leaders were knowledgeable, experienced and capable. All staff we spoke with, spoke highly of leaders and felt supported to be able to carry out their roles. Leaders were visible in the service, inclusive and cared about the patients they looked after. During our assessment, we observed the ward manager to have a good rapport with patients on the ward. We observed them to be directly involved in coordinating patient’s care.

Staff were providing more activities for patients. This included visiting cafes, movie nights and accessing the community. However, most of these activities were not specific for patients undergoing rehabilitation. Patients could make suggestions for activities at community meetings. Staff were also reviewing restrictive practice with patients at community meetings. The ward had a plan for reducing restrictive practice. This was reviewed at weekly community meetings and restrictive practices were lifted where appropriate. For example, access to the gym was restricted as there was no gym instructor, however the service had managed to recruit a gym instructor so this restriction could be lifted.

Documentation showed that leaders have the capability to ensure that the organisational vision can be delivered, and risks are well managed. Leaders were responsive to the concerns raised in the last inspection and have worked methodically and at great pace to make the necessary improvements.

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.

During our last inspection, Springs Centre did not have effective governance systems in place, and the systems which were in place, were not tailored to the individual needs of autistic people. The service has improved. There were clear and effective governance, management and accountability arrangements. Leaders could account for the actions, behaviours and performance of staff, and where there were concerns, there were clear plans in place to support and upskill staff. The ward had integrated a daily governance meeting which looked at patients’ physical health, patients’ rights, equipment, restrictions and audits. The quality assurance lead was planning to review the ward during 3-night shifts. When incidents occurred, learning was shared in handovers and staff meetings.

In the previous inspection, the provider had the following breach: The provider must ensure governance processes operate effectively and that local procedures and policies are met. We found the ward had implemented sufficient improvements to comply with the requirement notice we issued at the last inspection. The provider had a clear and comprehensive service improvement plan to ensure current and future performance and risks were managed well. It detailed all breaches and recommendations from the previous CQC report. All areas but one, were now complete and implemented. Some areas were ongoing and removed, due to the wider environmental plan and ongoing renovations of the service. Staff had access to the risk register and could escalate concerns when required. This was updated monthly or when required.

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.

In the previous inspection, the provider had the following breach: The provider should ensure that the wards for people with learning disabilities or autism takes part in opportunities to improve the quality of care for people such as involvement in quality improvement projects and accreditation schemes. We found the ward had implemented sufficient improvements to comply with the requirement notice we issued at the last inspection. At this assessment the ward was working on some internal quality improvement projects. The ward was converting 2 patient bedrooms into a new sensory room. Leaders told us this was expected to be completed by September 2024. Leaders told us the ward was creating a carer’s handbook for the ward. Staff told us the ward was providing more feedback to families and speaking to them on a weekly basis. Carers were invited to attend ward rounds that occurred every fortnight, however their input in care planning was no documented in care records. Staff were supported to prioritise time to develop their skills around supporting patients with autism.

The service does not participate in any accreditation schemes; however, leaders told us this is part of their plans after the renovations on the ward are complete later this year. On 28th March 2024, a variety of staff from the provider Cygnet, raised awareness and funds for the National Autistic Society. They carried out a 100km communal trail from Lourdes to North of Spain.