Cygnet Hospital Harrow

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

We looked for evidence on how the service provided safe care and treatment. At the last inspection in 2023, we rated this key question as inadequate. At that inspection, the service was in breach of regulation 12 (safe care and treatment), regulation 9 (person centred care), and regulation 10 (dignity and respect). At this inspection, the rating has changed to good. This meant that the service had taken action to minimize risks of avoidable harm. We found no breaches of regulations in relation to this key question.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons learned to continually identify and embed good practices.

During an inspection in May 2023, the provider had the following breach: The provider must ensure that all incidents are recorded and that these are reviewed and where needed measures taken to address patient safety. During this inspection, we saw this had been improved. Staff now knew what incidents to report and how to report them. Since the ward opened on 16 October 2024, staff had reported 21 incidents. Of these, 13 had been classified as relating to violence and aggression. There have been three incidents of self-harm and two incidents relating to security. Other incidents relate to a disclosure of abuse, an injury and a medicines error. All these incidents have been classified as low or no harm.

Staff reported serious incidents clearly and in line with provider policy. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed and signed-off by the ward manager. Incidents with a severity of moderate harm or above were escalated to more senior managers.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. For example, the ward manager wrote to both the patient and their family after a medicines error had been identified. The letter included an apology and an assurance that the error had not been sufficient enough to cause any harm.

Managers investigated incidents thoroughly. Each month, the ward manager and the safety and security lead reviewed closed-circuit television (CCTV) recordings of incidents. The safety and security lead had been in place when the service previously provided forensic services and now supported general safety of the environment. During the review of one incident, the ward manager noted that the body language used by staff appeared confrontational. They discussed these concerns with staff and agreed ways to avoid appearing aggressive.

Staff met to discuss the feedback and look at improvements to patient care. Staff said they were always involved in discussions about incidents. Staff were aware of recent incidents, such as a patient having recently swallowed batteries for a vape. Following this incident, they were aware of the need to be extra vigilant around this patient.

The service worked with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. The service ensured continuity of care, including when people move between different services.

The service received referrals from NHS trusts across England. The decision to accept a referral could be made by a registered nurse or doctor. The ward manager or clinical team leader was required to respond to any referral within an hour. Managers were confident that they met this target. A doctor had developed a screening document that staff could use to assess the appropriateness of referrals. Staff said this had helped them in deciding whether a patient should be admitted or whether they should be referred to an intensive care ward.

Staff ensured that people did not stay in hospital for longer than was necessary. Seven of the eleven patients had been in the hospital for less than ten days. Two patients had been on the ward for over six months. Both these patients had complex needs and there were plans in place for them to move on. Patients usually had a period of trial leave before they were fully discharged.

Staff ensured that patients discharge to their local mental health teams was managed safely. Staff ensured that patients were only discharged if they had a crisis plan, including contact details for their local community mental health team. The service had introduced a discharge checklist to ensure that all tasks relating to discharge were completed.

The service worked with people to understand what being safe means to them as well as partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff received training on how to recognise and report abuse, appropriate for their role. During 2024, staff had referred 34 concerns to the safeguarding lead for the hospital. Nine of these concerns related to violence and aggression. Other concerns related to physical abuse, financial abuse, medication errors and an allegation of domestic violence.

Staff received safeguarding training in levels 1, 2 and 3, in line with the intercollegiate document which identifies competencies required for all healthcare staff. Staff compliance with safeguarding was 100% in level 1 and level 2, 94% in level 3 for online learning and 80% for level 3 classroom learning.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. For example, the ward manager said that they referred a matter to the safeguarding lead after staff had become concerned that a patient may have been exploiting another patient. They had also made a referral after an audit had identified a medicines error.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. The safeguarding lead for the hospital worked closely with the local authority. They had created robust systems for tracking the progress of safeguarding referrals. The local authority had advised the hospital that its key priorities were referrals relating to medicines errors and potential neglect.

Staff followed clear procedures to keep children visiting the ward safe. Children were not permitted to visit patients on the wards. Visits from children took place at other areas in the hospital.

Managers took part in serious case reviews and made changes based on the outcomes. During 2024, two safeguarding referrals had reached the threshold for investigation by the local authority. Both these investigations related to medicines errors. Staff at the hospital worked alongside the local authority in conducting these investigations.

The service worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that matter to them.

Assessment of patient risk

Staff completed risk assessments for each patient on admission using a recognised tool, and reviewed this regularly, including after any incident. A nurse and a doctor conducted a risk assessment of all patients on admission. Risks were reviewed by the multidisciplinary team each day.

Staff used a risk assessment tool and risk assessments rated the level of risk on a scale of red, amber and green. Actions to address these risks were reflected in patients’ care plans.

Management of patient risk

Staff knew about any risks to each patient and acted to prevent or reduce risks. All patients indicated a reasonably high level of risk. Potential risks for patients typically included self-harm, suicidal ideation, self-neglect, non-compliance with treatment, absconding or risks to other people. Some patients were vulnerable and were at risk of exploitation from others. Staff also had a good understanding of patients’ histories and significant risk incidents that had occurred in the past.

Staff identified and responded to any changes in risks to, or posed by, patients. The multidisciplinary team discussed incidents and changes to patients’ risks at their daily handover meeting. Staff responded to risks by reviewing medication, increasing observation levels and suspending leave. At the time of the inspection, one patient was assigned to two-to-one constant observations. Two patients received constant observations. A further four patients were subject to observations four times an hour. When patients presented a high level of risk for a prolonged period of time, the service sought to transfer the patient to a psychiatric intensive care unit.

Staff followed trust policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. Staff said they conducted room searches when they suspected that a patient had prohibited items. Staff routinely searched patients when they return from leave. On some occasions, staff ensured that patients opened items delivered to the ward in the presence of a member of staff. This was to prevent patients ordering prohibited items through online delivery services.

The service had outside space that patients could access. Patients did not have direct, unrestricted access to outside space. However, staff facilitated access to the garden during each shift.

Use of restrictive interventions

Levels of restrictive interventions were consistent with other similar services. Between 16 October, when the service opened, and 4 December 2024, there had been 39 instances of restrictive interventions. Of these, 13 had been resolved without a physical intervention. There had been nine instances of rapid tranquilisation. Oral medication had been administered on five occasions to address the patient’s agitation. There had been nine instances of restraint, including two instances of patients being restrained in the prone position, which means facing the ground. Although we saw that staff completed information in the forms diligently, we noted that the forms did not support the most thorough recording of details. The provider should review the incident reporting forms to ensure all details are captured clearly and consistently.

The ward did not have access to a seclusion room whilst building works were ongoing at the site but would do so when the psychiatric intensive care unit opened. There had been no episodes where a patient had been secluded in any area and if the service could not meet a patient need, they referred to a more appropriate service.

Staff participated in the provider’s restrictive interventions reduction programme. The security lead for the hospital trained staff in preventing and managing violence and aggression. Care plans indicated that restrictive interventions should only be used as a last resort. When staff recorded an instance of restrictive intervention, they were required to record what alternative interventions they had used before initiating the restraint or use of medicines.

Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe. Patients’ care plans stated that additional medication (prescribed pro re nata (PRN)) and medicines used for rapid tranquilisation should only be used as a last resort.

Staff now followed NICE guidance when using rapid tranquilisation. During an inspection in May 2023, the provider had the following breach: the provider must ensure that patients’ physical health is checked appropriately and recorded consistently after they have received medicines via rapid tranquilisation, in line with national good practice guidelines and the provider’s own policy. During this inspection, we found that the service had made some improvement in this area. The hospital’s policy stated that staff must monitor the patient’s vital signs every 15 minutes for the first hour after the medication was administered. If these observations were normal, observation should continue every hour until this patient is fully alert. We reviewed two recent records of rapid tranquilisation. We found staff were consistent in recording observations for the first hour. However, staff did not clearly record that the patient was fully alert when they took the decision to end the observations, which they should have done to be in line with their policy. This is an area the service should focus on improving. We spoke with two patients who had received rapid tranquilisation. One patient said that staff had not explained the reasons for this.

Staff completed thorough risk assessments of all ward areas and removed or reduced any risks they identified. For example, the service had completed a ligature anchor point and blind spot risk assessment. This included a form for recording risks and an associated action plan. This was a comprehensive document, covering all areas of the ward and external areas. The security lead for the hospital conducted daily environmental checks of all the wards.

Staff could observe patients in all parts of the ward. Overall, there was good visibility. Bedrooms were situated along two corridors. Staff sitting at the centre of the ward were able to see along both corridors. During an inspection in May 2023, the provider had the following breach: the provider must ensure that staff understand how they will manage blind spots on the ward and maintain oversight of the patients across the whole environment in order to keep them safe. During this inspection, we saw this had been addressed and the service had installed convex mirrors to improve visibility at blind spots.

The ward complied with NHS guidance Delivering same-sex accommodation, there was no mixed sex accommodation. The hospital only admitted male patients.

Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Patients’ bedrooms were designated as safe rooms. They were fitted out to a high standard with anti-barricade doors and anti-ligature features. The service had produced a ‘heat map’ showing the location of high, medium and low risk areas. Closed circuit television (CCTV) was installed in communal areas.

Staff had easy access to alarms and patients had easy access to nurse call systems. Call buttons were installed throughout the ward. The service provided alarms for staff and visitors. Some members of staff also carried a radio.

Ward areas were clean, well maintained, well-furnished and fit for purpose. The ward had opened in October 2024. It was clean, bright and well-maintained. There was a high standard of furniture and equipment. All cleaning records were up to date.

Clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff now checked regularly. During an inspection in May 2023, the provider had the following breaches: the provider must ensure equipment used to monitor patients’ physical health is properly maintained and calibrated, the provider must ensure staff complete weekly checks of resuscitation equipment in line with national good practice guidelines. During this inspection we saw these areas had been addressed. The clinic room had a couch for examining patients, along with equipment to measure weight, height and blood pressure. Equipment had a sticker to indicate when it had last been cleaned and calibrated. All the equipment was in date. Emergency equipment was stored in a ‘grab-bag’ in the nurses’ office. The contents of this bag were checked every week. Emergency drugs were all in-date.

Facilities that promote comfort, dignity and privacy

Each patient had their own bedroom, which they could personalise. Bedrooms were clean and bright with ensuite facilities. Whilst patients could personalise their rooms, none had chosen to do so, mainly because most patients stayed on the ward for short periods of time (usually less than one month). All bedrooms were fitted with double beds to enable patients to sleep more comfortably.

Patients had a secure place to store personal possessions. All patients had a safe in their bedroom to store valuable items.

Staff used a full range of rooms and equipment to support treatment and care. The ward had a clinic room, rooms that could be used for interviews with staff, a meeting room, a de-escalation room and an activity room.

The service now had appropriate areas and a room where patients could meet with visitors safely and in private. During an inspection in May 2023, the provider had the following breach: the provider must ensure all patients risk assessed as safe to have visitors are allowed visits from families, friends and/or carers, whether on or off the ward. Staff must be clear on the provider’s protocol on visits. During this inspection we saw the service had made improvements. Visiting hours were between 2pm and 7pm during the week and 9am to 7pm at weekends. Patients could meet with visitors in the quiet room or the dining room. Visits from children took place off the ward, in another area of the hospital.

The service made sure there were enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

The service had enough nursing and support staff to keep patients safe. The ward had capacity for 18 patients. The core staffing when the ward was working to full capacity was two registered nurses and four health care assistants. On the day of the inspection there were 11 patients on the ward. The staffing establishment for this number of patients was two registered nurses and three healthcare assistants. Additional health care assistants were assigned to the ward to cover enhanced observations. Both staff and patients agreed that there were always sufficient staff on the ward.

The service had no vacancies. The hospital was due to open a psychiatric intensive care unit shortly after the inspection. Staff who had been recruited to work on the new ward were assigned to West Ward. This meant that the ward had more staff than it would usually employ. The service had very low usage of bank and agency nurses. The high number of staff assigned to the ward meant that use of bank and agency staff was very low. However, the service still occasionally used temporary staff to cover short-notice absence such as sickness.

The ward manager could adjust staffing levels according to the needs of the patients. Whilst building work was taking place, the ward assigned additional staff for security and to escort people between the ward and the entrance to the ward. Additional staff were assigned to the wards when there were high levels of acuity.

During an inspection in May 2023, the provider had the following breach: the provider must ensure that patients have regular one-to-one sessions with their named nurse to ensure they can develop therapeutic relationships and express any individual needs they may have. During this inspection, we saw that patients now had regular one-to-one sessions with their named nurse. At this inspection we found that daily discussions with named nurses were a key part of the care plan. These sessions allowed patients the opportunity to vent any concerns they may have.

Patients rarely had their escorted leave or activities cancelled. There were sufficient staff on the ward to facilitate these activities.

The service had enough staff on each shift to carry out any physical interventions safely. The hospital assigned staff from all the wards to form a response team who could attend any area of the hospital if a physical intervention was needed.

Staff shared key information to keep patients safe when handing over their care to others. Nurses and health care assistants attended a hand over meeting at the start of each shift. Other members of the multidisciplinary team had a daily hand over meeting.

The service had enough daytime and night-time medical cover and a doctor available to go to the ward quickly in an emergency. Two specialty doctors and a consultant psychiatrist were assigned to the ward. The service operated an out-of-hours rota for consultants and specialty doctors. On-call doctors were required to be onsite within an hour of the ward calling them. Managers could call locums when they needed additional medical cover. For example, the hospital used locum doctors to cover the out-of-hours rota for specialty doctors. These doctors had worked at the hospital for many years and had a good understanding of the service.

Mandatory training

Staff had completed and kept up-to-date with their mandatory training. Overall, staff compliance with mandatory training was 96%. The lowest compliance was in courses on dealing with concerns at work, 75%, and infection prevention and control, 78%. The mandatory training programme was comprehensive and met the needs of patients and staff. The mandatory training programme comprised of 12 training courses including immediate life support, infection prevention and control, preventing and managing violence and aggression and safeguarding.

Managers monitored mandatory training and alerted staff when they needed to update their training. Managers received a regular report showing compliance with mandatory training. This report included details of training that was soon to expire.

Skilled staff to deliver care

The service had a full range of specialists to meet the needs of the patients on the ward. The service employed a ward manager, doctors, nurses, health care assistants, occupational therapists and psychologists.

Managers gave each new member of staff a full induction to the service before they started work. All new staff attended a week-long induction programme, facilitated by the human resources department. The hospital set up an email account for new staff and arranged for new staff to be able to access online training. New staff received an orientation to the ward. They spent at least two shifts shadowing experienced staff before they were fully incorporated into the staff numbers.

Managers supported permanent staff to develop through yearly, constructive appraisals of their work. Fifteen of 18 staff (83%) had received an appraisal in the year before the inspection and appraisals had been scheduled for the remaining three members of staff. Appraisal meetings involved reviewing objectives, a review of knowledge and skills, training, professional registration, a summary of performance and setting objectives for the following year. Managers supported staff through regular, constructive clinical supervision of their work.

During an inspection in May 2023, the provider had the following breach: the provider must ensure that all staff have access to regular good quality supervision. Improvements to supervision was required at the last comprehensive inspection of the hospital. During this inspection, we saw that the service had made improvements since the last inspection and was no longer in breach of regulations. The hospital’s policy stated that staff should receive managerial and clinical supervision each month, and this was taking place. Staff said they found these sessions helpful. During supervision sessions, staff typically discussed their health and well-being, follow up from appraisals, workload, clinical care and training and development needs. For most staff, managerial and clinical supervision took place within the same meeting with their manager. The service should ensure enough time is dedicated to clinical supervision in these meetings and discussion about specific patient care can take place. Managers made sure staff attended regular team meetings or gave information from those they could not attend. Staff held team meetings each month. During these meetings staff discussed lessons learned from incidents, admissions and discharges, safeguarding, security matters, health and safety matters and administrations of the ward.

Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. Some staff explained that they had moved around the hospital between different types of services. For example, some staff said they had moved to the acute ward from a secure ward for patients with autism. They said the hospital had supported them to make this transition.

The service assessed and managed the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

Staff made sure cleaning records were up-to-date and the premises were clean. Equipment was labelled to indicate when it had been clean and calibrated.

Staff followed infection control policy, including handwashing. The service displayed hand washing instructions in toilets. The service conducted handwashing audits.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Staff followed systems and processes to prescribe and administer medicines safely. Staff kept a record of all medicines dispensed on a medicines administration record. A specific record keeping system was in place for controlled drugs, although none of the patients were prescribed controlled drugs at the time of the inspection. Similarly, a specific procedure was in place for the management of medicines that were liable to be misused.

Staff reviewed each patient’s medicines regularly and now provided advice to patients and carers about their medicines. During an inspection in May 2023, the provider had the following breach: the provider must ensure patients are provided with information about their medicines and possible side effects. During this inspection, we saw that the service had made improvements. Patients’ medicines were reviewed as part of an overall review of their progress at ward rounds. Staff provided information about possible side-effects. Patients were involved in discussions about medication and care planning. One patient specifically said they had spoken to their doctor about their medication.

Staff completed medicines records accurately and kept them up-to-date. We reviewed the medicines charts for three patients. Records we looked at were clear, up to date and mostly accurate. However, we found one instance of regular medication that was not signed for and a further instance of a medicine being signed for in the wrong place. When staff made errors such as these, the ward manager followed a clear process. This involved a reassessment of medication administration competencies. A record of the medication error was also made on the incident reporting system.

Staff stored and managed all medicines and prescribing documents safely. All medicines were stored in locked cabinets, or in the medicine fridge, in the clinic room. The pharmacist conducted a weekly audit of medicines. However, there was an inhaler in the clinic room that was not labelled to say who it belonged to or when it had been opened. The inhaler had to be used within six weeks of opening and, therefore, may have expired. Similarly, an antifungal cream, opened in June 2024 was stored in the medicines fridge with no indication of its expiry date. The temperature range for the medicine fridge was 2-8 degrees centigrade. During our inspection, we found that the fridge thermometer was showing inaccurate temperatures. We raised this matter with the hospital. The service promptly addressed this concern by replacing the thermometer and recalibrating the equipment.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. None of the patients were receiving doses of medicine above the level recommended in the British National Formulary (BNF).