We rated Cygnet Alders Clinic as good because:

• Staff provided safe care and treatment for patients using a recovery focused model that followed best practice guidelines. Staff completed thorough assessments of patients which were holistic and used these to inform individualised care plans. Staff empowered patients to make decisions and engage in their care and treatment. Staff ensured that all assessments, including risk assessments and care plans were updated regularly. Records were clear, up-to-date and easily available to all staff providing care.

• Staff supported patients with their physical health and encouraged them to live healthier lives. The service had an on-site gymnasium and beauty therapy room. A range of psychological therapies were on offer and staff ensured that patients received a minimum of 25 hours of therapeutic activity each week. Staff supported patients with activities outside the service, such as work, education and family relationships.

• The service was accessible to all and took account of patients’ individual needs. Staff supported patients to develop skills and prepared them for life in the community following discharge. The service had a high percentage of successful discharges when patients had completed their rehabilitation at Alders clinic.

• The environment was spacious, clean and well maintained. Patients had their own bedrooms which they could personalise and keep personal belongings safely. Patients felt safe at the service and well supported by staff. Patients were involved in informing change in the service, such as menu choices and the choice of therapies on offer.

• Staff treated patients with compassion, kindness and supported their individual needs. Staff empowered patients to make decisions about their care, treatment and changes to the service. The service treated concerns and complaints seriously, investigated them, learned lessons from the results, and shared these with all staff. Staff felt supported and respected by managers. Staff worked well together as a team.

• The team included or had access to the full range of specialists required to meet the needs of the patients. Staff had appropriate training that enabled them to meet the needs of patients and keep them safe. Staff understood their roles and responsibilities under the Mental Health Act 1983, the Mental Health Act Code of Practice and the Mental Capacity Act (2005).
• The manager of Alders Clinic was enthusiastic, proactive and focused on quality improvement for both patients and staff. There was a positive working culture between colleagues and staff to ensure important decisions were given careful consideration. There were robust governance systems in place to support staff development, reflection and practice.

However:

• The external windows of all the bedrooms allowed anyone in the outdoor space to look in and therefore compromised patients’ privacy.
• The Automated External Defibrillator (AED) was due a service check in July 2018 but this had not been completed at the time of the inspection.

This was a focussed inspection. We inspected Cygnet Alders Clinic following concerns raised to us by local GPs and others about the model of care being used at the service. In response to this we took with us two specialist advisors with expertise in working with people with a personality disorder. We have not changed the ratings and the services remains ‘good’ overall.

We found that:

• Staff worked to ensure patients were kept safe. This was achieved through regular and timely risk assessments and the handover of relevant risk information. The service had good lines of sight, and staffing numbers were adjusted to meet patients’ needs. For example, where patients needed enhanced observations extra staff were on shift to do this, and where patients were deemed to be too high risk to visit a GP practice, a registered general nurse was sourced to meet the patients need.
• Where incidents did happen, staff knew how to report these. They demonstrated learning from these events, could explain how learning was shared within the team, and with other services across the provider. Patients said they felt supported and safe when cared for by substantive staff. Permanent staff numbers had increased over the year before this inspection to reduce the need for bank or agency staff.
• Patients had their needs assessed in a holistic way, and staff updated care plans in a timely way. There was a range of recovery focused psychoeducational groups and therapeutic activities. A clinical psychologist had recently been appointed to help improve patients’ access to therapies recommended by the National Institute for Health and Care Excellence.
• There was an increasing network of care available to patients, improved by the relationships that staff had with other local services. This included good relationships with safeguarding and local A&E departments. A memorandum of understanding was being drawn up to help strengthen relationships with local GP practices.
• The service had recently been taken over by a new provider organisation and some systems were still being embedded. However, we saw that staff benefitted from present and strong leadership from managers in the service, and that there were systems in place to ensure performance was tracked and improved. Staff could explain how they had made suggestions to improve the service, and these had been implemented. The service was also applying for accreditation with the Royal College of Psychiatrists under it’s Accreditation for Inpatient Mental Health Services scheme.

This was an unannounced focused inspection. We undertook this inspection to review the progress the provider had made regarding the breaches of regulations identified at the previous inspection in July 2016.

During our inspection in July 2016, we found that the provider was not monitoring the physical health of patients in line with organisational policy and national guidance following the administration of rapid tranquilisation. We found that while some attempts had been made to monitor physical health symptoms post-administration, this was poorly and inconsistently recorded.

During this inspection we found that the provider had reviewed their policy and practice with regards to the monitoring of physical health and rapid tranquilisation. There were systems in place to ensure that staff monitored the effects of rapid tranquilisation on patients post administration. Therefore the requirement notice had been met. 

We rated Cambian Alders as good because:

• Risk assessments were being completed on admission and regularly reviewed, including on a daily basis. Safeguarding procedures were followed and incidents were reported. Learning from incidents was evident. Ligature audits were completed and were done in partnership with patients.
• Staffing levels and retention of staff was good. Access to statutory and mandatory training was good. Role specific training was available for staff. Where relevant, training was available to all staff, regardless of profession. Staff were receiving supervision regularly and staff had completed annual appraisals. Staff were receiving role specific training and were taking in part in regular reflective practice sessions.
• Morale was high and staff told us that they felt supported by the head of care, the hospital manager, the consultant psychiatrist and the wider multi-disciplinary team. There was a good sense of team spirt and staff felt empowered to deliver good care. All staff without exception felt that their contribution was valued. Opportunities for career progression were encouraged and available.
• Despite challenges faced by staff caring for patients with complex mental health needs, seclusion was not used. Staff interventions were underpinned by least restrictive principles and practices. Patients were lawfully detained and mental health act arrangements surrounding filing, security and organisation of records was very good.
• Care plans were person centred, up to date, holistic and recovery orientated. Patients were receiving physical health screening on admission and were subject to general medical care regularly.
• Medicines management practices were good and well monitored. There were separate clinic and treatment rooms for the administration of medicines and examinations of patients.
• Staff were patient and kind despite the challenges and unpredictability of patients with complex mental health needs and personality disorder diagnosis. Due to the therapeutic relationships and the strong sense of relational security, staff were able to recognise early signs of distress and intervene before situations became critical. Staff were proactive, empathic, good humoured and calm, taking pride in the work that they do.
• Patient’s recreational, educational, psychological and emotional needs were well met through a comprehensive programme of activities, treatments and interventions. There was access to a range of space including a sensory room, a beauty parlour, gymnasium and private interview space. Patients were able to take paid employment within the hospital. This involved watering plants, recruiting staff, collecting newspapers and cleaning. Patients would have to submit an application and be interviewed for jobs. This helped build confidence and independence.
• Family members described admission to the hospital as an ‘opportunity’ and had seen improvements in their relative’s recovery as a result of their stay at the hospital. Family members we spoke to felt involved and informed and most said that there was access to a variety of activities that enabled recovery and independence. The hospital paid travel fares for relatives who were unable to make journeys to visit patients due to certain personal circumstances.
• There were good working relationships with other agencies and goods relations with the neighbouring community.
• There were no delayed discharges and the admission process and pathway was informative and structured. Bed occupancy levels were low. Admissions were considered in relation to existing acuity levels and with regards to staff and existing patient’s wellbeing.
• There were governance arrangements in place to monitor staff and service performance. Learning from incidents and complaints was evident and new practices introduced as a result. The local risk register was up to date and owned by all staff.
• There were regular team meetings. Sickness and absences were well managed and staff performance issues addressed. Duty of candour arrangements were well embedded in the service and evident during our visit.

However

• Rapid tranquilisation procedures were not always being adhered leaving patients at risk of developing life threatening physical health complications.

• Fridge temperatures on three occasions had not always been monitored and recorded, potentially reducing the efficacy of medications that required refrigeration.