This was a follow-up inspection from November 2013 to check whether the outstanding compliance action had been completed at the hospital. Specialist advice/support was provided for the above inspection by a specialist advisor and Mental Health Act Commissioner. A separate Mental Health Act Commission report will also be produced.

We also looked at the service provision on the adolescent unit also known as a children and adolescent mental health services (CAMHS) and governance because concerns had been identified at our previous visit. We visited Lower West, Upper West and Madison wards on the adult side of the hospital. We visited the CAMHS unit and saw positive improvement in the care of young people.

There was evidence to show that learning from incidents and investigations took place and appropriate changes were implemented.

We saw the new registered manager had introduced a lot of changes, which was commented on positively by staff. Prior to the inspection we had several whistle blowing enquiries about the introduction of zonal observations and staffing levels. The provider at our request did a thorough investigation into the concerns and this included visiting all wards and departments and speaking to patients and staff at all grades during the day, night and at the weekend. No further concerns were raised during the inspection.

At our inspection undertaken in November 2013 we issued the provider with three warning notices and two compliance actions in relation to our findings on the adolescent service. An immediate and interim action plan was put into place by the hospital director and the registered manager at that time, which was monitored by us. This inspection was undertaken to check compliance.

The director of nursing who was also registered with us to manager the service and identified in this report had recently resigned. A new director of nursing was in post and was in the process of registering with us.

We were informed by the new manager for the adolescent service that a triage system was now in place to help ensure that the adolescent service could safely and effectively meet the young patient's individual needs. A review of parental access to the adolescent wards had been carried out.

Young patients were protected against the risk of unlawful or excessive control or restraint because the provider had suitable arrangements in place to monitor what was happening.

Young patients were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We were told by the new service manager for the adolescent service and the staffing co-ordinator that there had been a review of the staffing arrangements to ensure that there were enough qualified, skilled and experienced staff to meet young patient’s needs at all times of the day and night.

Young patients were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained and could be located promptly when needed.

On 19 November 2012 we received an anonymous concern from a staff member telling us that the staffing levels at Alpha Hospital Bury were very low and were affecting patient care.

We saw that the information gathered by the contract compliance team based at the hospital showed that wards were above the agreed set core hours by between 29 – 45 shifts a week between 14 November 2012 and 11 December 2012.

One nurse said that at the time of our visit the ward was “over run” with staff and another told us that the shift had started with three staff down due to sickness and had ended with one staff member over due to a person coming back onto the ward following a seclusion review.

Although we spoke briefly with some people living on each ward we did not ask them about staffing levels. We observed that wards were generally calm and relaxed and interactions between people and staff were seen to be warm and friendly. We saw that there was a significant number of staff on some wards we visited.

We spoke with four people about how they received support from staff on the wards. They told us that if they were upset then staff would take them to a quiet place and talk or communicate with them to try and calm the situation down. One person said that sometimes they might ask for additional medication to help them calm down. They said they could not see the point of seclusion and it made them feel claustrophobic like “being in a mouse trap.”

One person told us that they were not happy about the new activities structure being put in place and would prefer to be able to go to their bedroom and sleep when they wanted. However they also said that they enjoyed taking part in the activities provided. Another person said that they were not happy about having a structured day and getting involved in activities. They told us that they could see the benefit of the changes because they were not as withdrawn and they were talking more to people. They said they enjoyed the activities being provided for example the beauty room, using computers and making cards. A young person told us that they enjoyed going to education classes everyday and this would help them when they went back to school once they returned home.

We spoke with four people on two wards about their medicines and the care they received. People we spoke with confirmed that their medicines and any changes to them were discussed with them. We heard that they usually had enough privacy and support when taking their medication. However, one person felt that other patients were sometimes “quite near” when they were taking their medicines at the clinic. One person self-administered their own medication. We saw that suitable arrangements were in place to support this.

People told us that they could see the GP to discuss any physical health needs. Nurses confirmed that a GP visited each week and the hospital also employed a nurse practitioner to help ensure any minor ailments could be promptly treated.

We asked people whether all their medicines were always available. Two people told us that although it was usually okay, they had experienced one of their medicines being out-of-stock, but this was not for long. Senior staff explained that they had recently started to capture information when medicines were out-of-stock so it could be measured and addressed as appropriate.

People who used sign language said that they found it difficult to lip read staff were English was a second language. People we spoke with said that they had not noticed staff speaking in their native language.

We rated Cygnet Hospital Bury as good because:

• During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe, responsive and well led as requires improvement following the May 2016 inspection.
• The hospital was meeting Regulations 10, 11, 12, 17 and 20 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
• The required policies of the Mental Health Act code of practice were in place and complied with the code.
• The hospital had created and implemented an action plan following our last inspection to address the concerns we had raised.
• The registered manager held monthly team briefs with all managers to share learning and changes within the hospital.
• The hospital shared learning from incidents via team meetings and monthly lessons learnt bulletins.
• Managers ensured staff received regular supervision, team meetings and annual appraisal.
• Care plans were accessible for patients.
• Staff were aware of the Mental Capacity Act, Mental Health Act and duty of candour and their responsibilities in relation to these.
• New staff received a comprehensive two-week induction.
• We observed caring and supportive interactions between staff and patients, staff knew the patients well.
• The hospital had made real progress to ensure the care plan documentation was accessible for deaf patients, including recording patients’ aims and goals from their reviews to DVD for patients to watch.
• There was a variety of activities available for patients including those that were rehabilitative in focus.
• The hospital was managing complaints well and patients knew how to complain.
• The governance structure was fully embedded with clear lines of accountability and reporting.

However:

• The hospital had not fully achieved the actions in relation to Regulations 9 and 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
• Staff working on Bridge Hampton ward, a ward caring for patients, most of whom had a learning disability, had not received training in learning disability.
• Staff working on Columbus and Madison ward, specialist wards for patients with a personality disorder had low levels of attendance at personality disorder training with Columbus 32% and Madison 37%
• British Sign Language training levels for staff working on the four wards caring for deaf patients was low and meant there would be times where staff could not effectively communicate with patients. This included when deaf patients were secluded on Upper West ward.
• There were inconsistencies in the opportunity for patients to have access to mobile phones that had not been individually assessed.
• Bedrooms on the female wards were locked off for seven hours a day; this meant all patients had to be in the communal area together.