Our rating of this service stayed the same: We rated it as outstanding because:

Patients were protected by a strong and comprehensive safety system and a focus on openness, transparency and learning when things go wrong. Cygnet Cedars had a genuinely open culture in which safety concerns raised by staff and patients who use the service were highly valued as integral to learning and improvement.

Staff took a positive approach to risk management. Patients and those close to them were actively involved in managing risks. Positive risk taking and least restrictive practice was embedded within the culture of the unit. Patients were actively involved in managing their own risks using risk assessments, positive behavioural support plans and worked collaboratively with staff.

Staff understood and focussed on least restrictive practice. Cygnet Cedars had a least restrictive practice group, completed restrictive practice audits and sought to use the least restrictive approaches when managing challenging behaviour. Patients were involved in shaping least restrictive practice through governance and community groups. We found no evidence of blanket restrictions. The providers had a transparent policy on the use of restrictive interventions, with an overarching restrictive intervention reduction programme with a board-level lead.

Staff supported the national STOMP pledge to reduce the long-term use of anti-psychotic medicines without the use of appropriate clinical justification. All patients at the hospital who were on anti-psychotic medicines had a care plan in place with the prescribing rationale, reduction plan and side effect monitoring.

Staff used a truly holistic approach to assessing, planning and delivering care and treatment to patients. The staff were actively supported by management to use innovative approaches to care. The model of care promoted patients’ recovery, comfort and dignity. Staff worked with patients to create excellent care plans that were holistic, recovery focussed, and person centred. They wrote these care plans in the voice of the patient. Staff reproduced care plans and other documentation in easy read formats for each patient. The multidisciplinary team provided a clear care pathway through the service from admission to discharge. Care plans fully reflected individual circumstances and preferences.

Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients, families and carers in care decisions to make sure patients were active participants in their care and treatment. We saw positive, professional and respectful interactions between staff and patients during our inspection. Staff showed patience and warmth. Staff and patients shared humour and were relaxed with each other whilst maintaining professional boundaries. Patients knew the staff well and were complimentary about all the staff at Cygnet Cedars.

The continuing development of staff skills, competence and knowledge was recognised as being integral to ensuring high quality care. Staff were proactively supported to acquire new skills and share best practice. All staff engaged in clinical audits to evaluate the quality of care they provided and learned from these to improve their practice.

We saw evidence of best practice in the application of the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA). All staff we spoke with had a comprehensive understanding of the Mental Health Act, the Mental Capacity Act, Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice. Staff had excellent understanding of capacity. They fully involved patients in decisions about their care. All patients had a file that documented what reasonable adjustments to communication should be considered when assessing the patient’s capacity. This ensured staff undertaking the assessment clearly understood the patient’s communication needs and was aware of any communication tools needed to support the patient.

The staff team were committed to providing active support to patients. Staff helped patients to be actively, consistently and meaningfully engaged in their own lives regardless of their support needs. One example of this was staff supporting patients to exercise their civil rights to vote and become active members of society. They supported patients to get involved with projects at the hospital and in the wider community. For example, helping staff with clinical audits and undertaking voluntary work in the local community.

Staff empowered patients to have a voice and to realise their potential. They showed determination and creativity to overcome obstacles to delivering care. Staff ensured that patients’ individual preferences and needs were always reflected in how care was delivered.

There was a holistic approach to planning people’s discharge, transfer or transition to other services, which staff started on admission. Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason. The service took patients that had already spent a long time in care and enabled them to move into lesser dependant services in a reasonable time frame. This is the aim of Transforming Care

Governance structures were clear, well documented, followed and reported accurately. There were controls for managers to assure themselves that the service was effective and being provided to a high standard. Managers and their teams were fully committed to making positive changes. We saw changes had been made to maintain improvements in quality using audits. The service had clear mechanisms for reporting incidents of harm or risk of harm and we saw evidence the service learnt from when things had gone wrong.

The staff team were committed to improving and taking part in innovative practice. We saw excellent evidence of learning and developing projects within the hospital and throughout the provider region, staff shared ideas and good practice across sister units. Staff were supported to undertake research and present findings at national conferences.

We rated Cambian Cedars as outstanding because:

• The hospital were creative and innovative in their approach to rehabilitating patients while following National Institute for Health and Care Excellence (NICE) guidelines. They were patient focused and they used strategies to enhance understanding and expression through individualised care planning. They used evidence based risk assessment models to inform clinical interventions and assist in treatment and risk management plans.
• The lead consultant psychiatrist for the hospital was involved in research aimed at reducing the use of medication and section. The psychiatrist actively worked with patients to reduce their medication and patients came off their medication and section during their stay, which was empowering and helped patients stay out of hospital.
• There was a strong commitment to developing the skills, competence and knowledge of all staff. There was strong emphasis on embedding learning and quality improvement. There was a thorough induction for new staff and a training programme was developed for all staff on communication and working with people with autism.
• All staff had regular, protected time for facilitated, in-depth reflection on clinical practice through supervision and reflective practice sessions. The aims were to enable the supervisee to achieve, sustain and creatively develop a high quality of practice through the means of focused support and development.
• There was a schedule of audits that involved staff at all levels to help improve the quality of the service being offered and opportunities for developing staff.

• All new staff had a probation period, which could be extended if needed. The organisation supported new staff with a good induction programme and mandatory training. Those staff unable to fulfil the obligations of their role were dismissed.
• There was a good multi-disciplinary team (MDT) available to enhance the care and treatment for patients and support staff in working effectively with patients.
• The hospital promoted activity in a fun and therapeutic way to rehabilitate and help patients back in to the community. They supported healthy living through exercise and there was a range of indoor and outdoor activities that patients could access. The hospital supported individual projects with a view to developing small business enterprises. 

• The vision and values of the hospital were embedded.  There were clear team objectives, high levels of participation, commitment to excellence, and support for innovation. 

There were 15 people using the service on the day of our inspection. We spoke with five people who used the service, seven members of staff and the manager.

People who used the service were supported to ensure their physical and mental health needs were met.

People told us and we saw that each person had an activity plan. People were offered regular opportunities to develop their independent living skills and take part in leisure activities.

People were encouraged to bring their personal possessions with them to personalise their bedrooms. One person said, “I love my room, I have all my own things in it.”

Systems were in place to ensure that people using the service were safeguarded from harm. One person told us, “It’s nice here; the staff are good to me.”

People had their medicines as prescribed to ensure their health and well being.

People who used the service were supported by staff who had the skills and knowledge to meet their individual needs.

People were asked for their views about the home and audits of the quality of care that people received were completed. Where needed, improvements to the service were made as a result of these.

We visited the service because we had concerns about the number of incidents that were reported to us about people living there hurting or attempting to hurt each other. We were also concerned about how an allegation of abuse had been investigated, which may have impacted on the safety and well being of a person living there.

There were 11 people living there on the day we visited. We spoke with two people living there, looked around the premises, spoke with five members of staff and looked at one person’s records and sampled the provider’s records.

We asked people what it was like to live there and if they felt safe. One person said, “It’s nice here and better than the last hospital I was in.”

We saw that allegations of abuse had been reported appropriately to ensure that people were safeguarded from harm.

Staff received training in safeguarding and knew how to report any allegations of abuse. Staff were confident that concerns would be listened to ensure that people were safeguarded from harm and abuse.

We saw that the atmosphere was calm and people were engaged in activities and talking with staff. One person told us. “They help you to do things here and you can talk to staff about what you want to do.”

Staff spoken with said and records showed that restraint was used only as a last resort to ensure people’s safety. Staff received training in how to manage people’s behaviour and minimise the need for restraint.