We did not rate wards for people with learning disability or autism or long stay/rehabilitation mental health wards for working age adults at this focused inspection. We found the following areas of good practice:

• The provider had reduced the risk of patients accessing the security fence and roof by improving the physical environment of the garden area on Oak Court. Staff completed risk assessments for patients and updated these regularly, including specific risk assessments in relation to accessing the security fence and roof.
• The provider deployed sufficient staff to maintain the safety of patients on all wards and to undertake enhanced observations for patients. Managers ensured they offered regular breaks to staff. The provider had established systems to provide accurate information about staffing levels and monitor this across the service.
• The provider had reviewed the paperwork for allocating enhanced observations and monitored how managers allocated staff to work with patients. The provider had established a clear protocol and rationale to explain why staff worked outside the therapeutic engagement and observation policy on Larch Court to meet the needs of patients with autistic spectrum disorders. Managers had also applied this rationale to some of the staffing arrangements on Oak Court where staff supported some patients separately due to the closure of another ward.
• The provider had ensured that staff admitted patients to the service within their referral and admissions criteria.

However, we found the following issues that the provider needs to improve:

• The therapeutic engagement and observation policy did not always accurately reflect the working arrangements across the service. On some occasions, managers recorded that they had allocated staff to enhanced observations for longer than stated in their policy.

From our inspection we found:

• Patients were not always monitored in line with the provider’s policy after receiving rapid tranquilisation.

• Some risk assessments had not been updated within the provider’s timescales. This included assessments for patients with epilepsy and at risk of choking.

• Handover discussions took place in environments which made it difficult to convey information effectively. Rooms were small and there was a lack of other facilities.

• Some handovers took place in communal areas which lacked confidentiality and did not maintain patients’ privacy and dignity.

• Care records were difficult to navigate and it was difficult to access information about patients quickly. Some care plans had not been updated in line with the provider's own policy.

• There was no systematic monitoring of physical healthcare for those patients receiving high doses of antipsychotic, antidepressant and anticonvulsant medication.

• The provider did not demonstrate that it was following NICE guidance for challenging behaviour and antipsychotic medication by identifying target behaviours and stopping at six weeks if there was no response.

• As required medication protocols were not individualised and lacked clarity.

• Mental capacity assessments were not person centred, did not evidence family involvement and did not show how decisions had been reached in relation to patients’ capacity.

• The provider had not conducted an audit of positive behavioural support plans to ensure their quality and that they had been updated regularly.

• Six carers said that communication from the hospital was minimal, poor or inconsistent and that they often had to ring the hospital to get information about their relative.

However:

• Restraints across the hospital had reduced since the last inspection in February 2017, showing a downward trend.

• The provider ensured patients had a behavioural support plan and had taken steps to put this approach at the centre of its care planning. Staff received training and the psychologist and behavioural therapist offered support to staff on the wards.

• Staff were caring and treated patients respectfully and showed understanding of patients’ needs.

• The provider had developed a robust and clear system to monitor the performance of staff and the hospital through key performance indicators.

• The provider had appointed a safeguarding lead to ensure the quality and timeliness of safeguarding information to the local authority, police and the CQC.

From our inspection we found:

• The provider’s governance systems and processes for sharing learning from incidents with staff as part of risk management were not robust.
• Staff investigation reports were not detailed and information was lacking as to if action plans were completed to reduce further risks.
• Staff had not updated six patients’ risk assessments, care plans and positive behaviour support plans to reflect a change in risk management following safeguarding incidents.
• We found incidences where staff had not adequately observed patients when they posed a risk to themselves or others.
• Staffing rotas were not always updated to reflect staffing levels.
• Management and leadership was not consistent as there were several changes to head of care posts who managed the wards. Three staff expressed concerns about the effectiveness of management support and the lack of feedback on issues raised.
• Staff meetings were not regularly taking place and minutes did not always detail how decisions were taken to evaluate and improve the service.
• Staff were not achieving mandatory training targets identified by the provider, for example relating to safeguarding adults.

• A staff member said they had not had restraint training and had been involved in restraint.

• We found examples where the provider’s policies and procedures had not been improved to reflect current national guidance.
• The provider had not improved their practice, responding to feedback from the CQC regarding notifications and providing updates in a timely manner.

However:

• Patients told us they felt safe on the ward living with others and were able to tell staff if they had any concerns.
• We saw good examples of positive staff and patient interaction and individual support.
• Staff knew how to report incidents and safeguarding concerns. Managers had systems for reporting and tracking safeguarding referrals to the local authority, police and CQC.
• Managers told us that they had identified problems with their governance systems and communication with staff. They had contacted the provider’s quality team to improve processes.
• The provider had consulted the National Autistic Society to improve their service.

We last inspected this service on 06 and 07 November 2013 and we identified areas where the provider needed to take action. The provider sent us a report detailing the actions they had taken. This included an updated action plan dated 20 June 2014. We carried out this inspection to check on the actions taken.

During this inspection we found that overall improvements had been made by the hospital that ensured the provider was now compliant with the relevant regulations.

The service was safe. We found the provider had policies and procedures in place to protect people from abuse or harm. Staff had received relevant training. People told us that they usually felt safe in the service.

The service was effective. We noted that clear assessments and care plans were in place for each person using the service to ensure people’s needs were being effectively met.

The service was caring. Most people gave us positive feedback about staff and the service given. However the provider may find it useful to note that some people expressed concerns about access to Section 17 leave and activity provision.

The service was responsive. We saw that staff gave support to people to ensure individual choice and the records seen demonstrated that people received support from an effective independent advocacy service.

The service was well led. Robust management systems were in place and the provider had taken steps to address the areas of previous non-compliance.

We gathered evidence of people’s experiences of the service by talking with people, observing how they spent their time and noting how they interacted with other people living in the hospital and with staff.

During our inspection we visited three areas and on two of the units we were shown around by people who use the service. They told us about the things they liked to do and what it was like to live at Cambian Fairview Hospital.

One person told us about their interest in monitoring the weather and that they had enjoyed a visit to the BBC weather centre. Another person told us that they enjoyed playing football and listening to music.

There was a wide range of activities for people both on site and in the wider community and records confirmed that people were encouraged to take part in activities and pastimes they enjoyed.

We saw good interactions between staff and people using the service. Staff spent time with people supporting them with activities such as working on the computer and making arts and crafts.

We found that staff received the training they needed to provide care and support safely and were able to demonstrate that they understood the needs of the people using the service. We saw that staff had good communication skills and it was evident that they knew people well and understood their needs, likes, dislikes and preferences.

During our visit we were able to meet with six people who were receiving care and treatment at this hospital. Other people greeted us throughout our visit to their individual unit

People with whom we spoke confirmed that they were listened to and respected by staff. There were no reports of any bullying or harassment of anybody within the hospital.

People confirmed that they were involved in their own care and treatment programmes. For example some people had just attended their individual clinical review and as part of this process were granted section 17 leave at the weekend. Two people told us that they were being transferred to services closer to home and were looking forward to this happening.

People told us that they were generally satisfied with the care and treatment provided by staff. They said they felt able to approach staff if they had any concerns and were confident that these would be addressed appropriately.

We rated Cygnet Hospital Colchester as requires improvement because:

• Safety was not a sufficient priority. The provider had not ensured all ward environments were safe. Managers had not identified, rated and mitigated against all ligature risks on all wards. The provider did not ensure the environment on Oak Court was clean, that maintenance issues were repaired, or the décor was updated. There was little evidence of learning from events or of action taken to improve safety.  Managers completed investigations of incidents but did not record the outcome of investigations on their incident recording form. Managers did not share lessons learnt with staff in team meetings which posed a risk that similar incidents could reoccur.

• Staff on Flower Adams wards did not consistently assess, monitor or update risks to patients. Four out of six records either did not identify needs, had incorrect information within them, were a repeat of assessment information or information had been copied and pasted from a previous placement. Staff did not always update care plans across all wards, with the exception of Ramsey ward which meant staff were not aware of the changing needs and risks of patients.

• The provider made last minute changes to the service specification for Flower Adams 1 ward, immediately prior to opening. This had impacted on safe care and treatment for patients. Originally planned to be a long stay rehabilitation ward, the decision to change to an acute admission ward, had caused anxiety amongst the staff. The majority of staff told us they did not feel suitably skilled or trained to manage the complexity of needs and risks of this patient group. Patient care records showed high numbers of incidents across both Flower Adams wards since opening. Staff did not receive regular supervisions or appraisals. The provider did not ensure that minutes of team meetings were available for staff reference on all wards except Oak and Larch Court.

• Staff across all wards said moving away from a learning disability service to a service with wards for people with a personality disorder had been challenging and they were still in the process of adjusting to this change. Staff were often moved between services to cover vacant shifts including on both Flower Adams wards. Some staff did not feel adequately trained to meet the specific needs of these patients. We were concerned that continuity of care for patients was disrupted when staff moved between services.

• Staff did not involve all patients in their care plans. We reviewed 23 care plans and eighteen of these were not person centred and lacked the patient voice. Not all patients had signed or had access to a copy of their care plan. Some patients said they were not involved in developing their care plans and said they did not receive a copy.

• Patients on Flower Adams 2 ward were not receiving care and treatment in line with best practice for rehabilitation wards. Staff did not provide patients with training or work opportunities that would enable patents to acquire living skills. No patients had unescorted leave or were responsible for managing their medication as part of gaining independence to move out of hospital. Patients on Flower Adams wards did not all receive psychological formulations and the psychological model had not yet been fully embedded on the wards which meant patients were not receiving all their required treatment in line with National Institute for Health and Care Excellence guidelines.

However:

• Staff were discreet and respectful when caring for patients. We observed staff interacting with patients in a way that was responsive to their needs. Staff described the needs of their patients and how they worked with patients to support them.

• Patients on some wards had access to work opportunities. This included car washing and cleaning jobs. The provider was installing computers in their activity centre for patients to use and were due to open a tuck shop for patients to promote patient socialisation and employment experience. Staff were developing a career skills and Curriculum Vitae writing group on Ramsey ward to support patients with seeking employment. Patients were encouraged to attend a local college to develop their educational knowledge and develop skills and confidence in seeking employment. Patients on Flower Adams wards did not access these opportunities.