We have rated services as good overall because:

• The hospital acted to meet the requirement notices we issued after our inspection in April 2016.
• We found the service had made changes to keeping their electrical equipment up to date with safety stickers and Cambian (the provider) had updated and published the Mental Health Act Code of Practice (2015) policies
• We also found safe staffing levels that allowed staff to care for the patients.
• The staff kept care plans that reflected the involvement of the patient and care records were up to date, well written and detailed.
• Regular audits were taken in areas such as ligature risk, environmental risk and medicine management.
• Staff used relevant guidance from the National Institute of Health and Care Excellence when providing therapies.
• Specialised training was available to help staff understand the patient group better.
• A local GP ran a well persons clinic weekly at the hospital.

We spoke with 14 patients who were detained in the hospital at the time of our inspection. We spoke with nine patients on the downstairs ward and five patients on the upstairs ward. Patients gave differing feedback about their involvement in the care planning process. Patients in the upstairs ward indicated they were given the opportunity to be involved in their care plan. However, the patients we spoke with on the downstairs ward reported that they did not have the opportunity to be involved in the care planning process.

We asked patients for their opinion of the care and treatment they received. One patient said, “They have turned my life around.” Another patient told us, “I am nearing the point where I can be discharged. I would never have thought that possible.” All of the patients we spoke with indicated they felt safe at the hospital.

The downstairs ward was not of an appropriate standard of cleanliness. There were not effective systems in place to ensure the cleanliness of the hospital.

There were not effective systems in place to regularly monitor the quality of the service being provided. The patients we spoke with were frustrated that they were repeatedly raising the same issues and did not always receive a response in a timely manner. One patient said, “We are always raising the same issues. We never hear anything back so we don’t know what’s happening.”

Records relating to patient's care and treatment were not always of the required standard.

There were 21 people living in the hospital. We looked at the medicine administration records for eight people and how the service stored and managed medicines.

We were told that improvements had been implemented to ensure medicines were stored securely. We found medicines were stored safely and securely in the two units with access restricted to the person in charge of the unit.

We spoke with one person who told us ‘’I don’t get given my medicines on time." We found that the Medicine Administration Record (MAR) charts documented that people were given their medicines at the prescribed times. We observed nursing staff giving people their medicines at the times that they were prescribed. However, we also found that when a medicine was not given the reason was not always recorded.

We spoke with a pharmacist from the supplying pharmacy. They explained about the support provided to the service to ensure medicines were handled safely. We were shown a folder called ‘Pharmacy Audit Medicine Management’. These contained medicine audits which were undertaken every week by the visiting pharmacist. The pharmacist detailed specific action points to improve medicine management. We found that some of these action points had not been undertaken by the service.

We found that appropriate arrangements were not always being undertaken in order to manage the risks associated with the unsafe use and management of medicines.

We visited this service as we had not been since their registration under the Health and Social Care Act. We wanted to be sure the people detained at the service received good, safe care, treatment and support and to check that the service was compliant. Throughout this report we will refer to the people detained at the service as "service users" or "people using the service." This is because this is their preferred term.

We spoke with three people using the service. They said they had seen their care plan, and said that the staff went through this with them and agreed it. One person told us the plans were reviewed roughly every two months.

People told us that many of the staff who worked at the unit were good at their jobs. One person told us that their co-ordinator had helped them prepare for their Mental Health Review Tribunal and had written down what they wanted to say and the issues they wanted to discuss. A person using the service told us there had been improvements in the consistency of the staff group. The person said that the manager tried not to use agency staff. One person commented, "there’s lot of good staff in here. Some are like family to me."

People told us that restraint and seclusion were not used very often. One person explained that restraint had never been used with him, "because the staff know how to calm me down."

One of the people we spoke with told us he (along with another service user) was a patient representative. He told us they spoke to the unit managers to bring about improvements to the service. People using the service also told us that an ex service user came in every week to advocate of behalf of the people who use the service. We were told he saw people individually or in groups. The advocate attended the weekly 'community meeting' on both units.

Another person told us that the new unit manager was very good and had made significant improvements to the service. He told us, "he has turned this place around and he’s turned me around too. Everyone knows where they stand with him which is good. He’s always gone out of his way to come and talk to me and find out what I think about this place."

We rated Cygnet Hospital Clifton as requires improvement because:

• Staff did not always treat patients with kindness and compassion. This was confirmed in interviews with patients and our review of hospital records. We frequently saw staff responding to patients requests for assistance, rather than approaching patients to initiate contact and support.
• Staff practices did not ensure that risks to patients were always minimised. This was demonstrated in failures to maintain checks of emergency equipment, undertake prescribed observations, and monitor patients following the administration of rapid tranquilisation.
• Communication practices were poor. This was confirmed in interviews with staff and patients. We saw an example of how information poorly communicated between staff led to gaps in care. Patients reported that staff did not keep them informed of changes occurring in the service and inform them of planned visitors to the wards.
• Staff did not always keep accurate and complete records of the care and treatment provided to patients. This included patients being cared for in seclusion. 
• Staff reported short staffing, low morale, and an unhappy staff team. Staff were concerned about high staff turnover rates, the suitability of training provided for their roles, and maintaining professional staff and patient boundaries. Patients reported experiencing delays when they required staff support to move around the hospital.
• Staff completion rates for Mental Health Act and Mental Capacity Act training were low. Some staff identified a need to receive training in these areas, and others believed the training offered was not sufficient for their roles.
• Management systems were not embedded to ensure that all staff were aware of, and understood lessons learned as the result of the investigation of incidents and complaints. Staff reported their experience of this was poor, and examples of good practice were not embedded in the service.
• Despite the new providers improvement plan, transition to existing governance structures, and additional senior and multi-disciplinary staff, change at the service had not sufficiently embedded to demonstrate safe and effective care.

However:

• There was evidence of investment into the service from the new provider. This included changes to the hospital environment to improve safety, establishing a new senior staff team, the recruitment of additional staff, and an overarching action plan of improvement in all clinical areas.
• Staff completed risk assessments for the hospital environment and individual patients. Resulting plans from these assessments contributed to reducing restrictive practices for patients.
• Staff assessed the physical and mental health of all patients on admission. Interviews with patients confirmed that staff supported them with their physical health and encouraged them to live healthier lives.
• Staff supported patients to access activities inside and outside of the hospital. This included voluntary work, education, and community support for patients with protected characteristics. Patients could also contribute to decisions about the service by contributing to staff recruitment practices and a People’s Council.