Following a comprehensive inspection of Cygnet Hospital Harrogate in June 2016, we rated the service as overall good. We rated the effective, caring, responsive, and well-led domain as good and rated the safe domain as requires improvement.

We issued one requirement notice, which related to a breach of Regulation 10 HSCA (Regulated Activities) Regulations 2014. Dignity and Respect. We told the hospital it must ensure it meets national guidelines for same-sex accommodation and provide a dedicated lounge that is always available solely for the use of female patients.

According to current national guidelines, where there are male and female patients on a ward, good practice requires a service to provide a day lounge for use by females only. Female-only environments are important because of the increased risk of sexual and physical abuse and risk of trauma for women who have had prior experience of such abuse.

We published the report from our comprehensive inspection in September 2016.

We inspected Cygnet Hospital Harrogate again on 12 December 2016. This was an unannounced, focused inspection to find out whether the hospital had made the required improvements since our last comprehensive inspection on the 14 and 15 June 2016.

Following this inspection we have rated the safe domain as requires improvement because:

• The hospital had not acted sufficiently to meet the requirement notice we issued after our inspection in June 2016 to meet the requirements for same sex accommodation. The hospital provided only one dedicated female only lounge, which was available for female patients from all two of the mixed wards to use at any time. Female patients on Sanctuary ward rarely used the lounge. This could be because the one female only lounge provided by the hospital was situated on Haven Ward.

However;

• On the day of our visit, the dedicated female only lounge was available for all female patients to use. Staff we spoke with were clear about the national guidelines for same sex accommodation on mixed wards and the need for a dedicated female only lounge. Female patients told us they felt safe on the ward and staff did all they could to protect patients’ dignity and privacy.

We observed that staff and patients had positive relationships and patients appeared relaxed and comfortable with their surroundings, staff and the activities they were engaged in. Patients had care plans and risk assessments in place which helped staff to understand and meet their needs. Staff had the knowledge and skills to meet those needs.

We spoke with five patients. All expressed satisfaction with the care and support they received. One person said “The focus here is very much around talking therapies and not just doing therapies.” Another said "I feel listened to and am involved in deciding my treatment plan.”

The hospital had developed positive links with other agencies which promoted a coordinated approach where a number of agencies were included in people’s care and treatment.

We saw that medicines were kept safely and that appropriate arrangements were in place in relation to the recording and administration of medicines.

There were sufficient staff available. We saw people being assisted promptly and we saw that staff had time to spend engaging with people.

The provider had effective system in place to regularly assess and monitor the quality of service that people received.

At the time of the inspection there were no Detox 5 admissions. Other patients had been admitted from NHS Trusts either detained under the Mental Health Act 1983 or informal patients with acute mental health needs and at risk to their own wellbeing.

We asked people if they would like to talk to us and only two patients elected to do so. We visited all three wards in the hospital even though the ward for Detox 5 treatment was empty. We spoke with four members of staff about understanding of patients’ needs; their training and support. In general we found staff to have good understanding of people’s needs and they all said that training and support from the organisation was good.

People told us that they had been involved in decisions regard their care and treatment. They explained that when they had first arrived at the hospital they had been included in an initial assessment of their needs. They described how they had been given information about individual restrictions for their own health and well being and had signed agreements to this effect.

People told us that they had a choice about whether they joined in group therapy sessions and this would be agreed as part of their treatment and recovery plan. One person said “the staff here are lovely, very supportive, I feel safe.” Another person said “I have been here before and returned because I knew I would get the support I need.”

Patient's told us they had received the care and treatment which met their needs and had aided their recovery. Examples of the comments they made were that they had found the unit a "haven".

Patients' explained how they and their families were informed about and had been involved in their care and treatment. They described how they had regular unit meetings, where they could express their views and how their views were responded to.

A group of patients told us they felt “safe" at the hospital, even when they were at their " worst”.

Patients' confirmed they had attended both multi-disciplinary team and care planning meetings where their treatment and care is reviewed by the medical and nursing staff twice a week.

The patients we talked with described how the choice and type of therapeutic groups as “Fantastic” and “Brilliant” and provided us with examples, such as, meeting with a nurse regularly to discuss any concerns, yoga and massages.

All told us they were listened to and treated with respect, they explained how staff knock on their doors before entering and are always very polite.

We rated Cygnet Hospital Harrogate as requires improvement because:

• The hospital did not deliver safe care. Staffing levels on the wards were unsuitable for the acuity and number of patients and staff turnover was high. The hospital used a high number of agency staff and this had an adverse impact on the safety of patient care. Staff did not use an individual risk assessment as the basis for the decision about which observation level each patient should be on. They did not consistently carry out observations in a safe manner nor did they record these accurately. Staff did not carry out physical health monitoring appropriately after they had given rapid tranquilisation. Use of restraint was high and some members of staff expressed the view that restraint was used more often than necessary when there was low staffing levels on the wards. Insufficient action was taken following serious incidents to mitigate the risk posed. The on-call system was flawed and there were delays in patients receiving medical support from doctors. Patients’ bedrooms were not always placed according to gender. Blanket restrictions were in place. Staff did not always promptly ascertain what medicines patients were taking for physical health conditions, or whether they had allergies, when they were admitted.

• Care was not consistently effective. The hospital did not have a multi-disciplinary team and care was not reflective of their statement of purpose. Patients could not access activities or therapies seven days a week. Documents such as section 17 leave forms were not correctly completed. Consent to care and treatment was not recorded in all patient files. Informal patients’ rights under the Mental Health Act were not upheld on admission as they could not leave the hospital unaccompanied.

• Staff were not always caring. They could be “abrupt” to patients when the wards were busy. Staff were heard discussing patient confidential information at the nurses’ stations. Patients did not feel informed of or involved in risk assessment and medicines decisions. Carers were not involved in care decisions or routinely contacted. Because of the absence of appropriate rooms or an examination couch, staff had to hold one to one meetings with patients and undertake physical examinations in patients’ bedrooms.

• The governance structures were not robust. The auditing processes were not always effective. Not all ligature risks had been recognised and paperwork errors were not identified. Staff morale was low and not all staff felt they could raise concerns with their line manager. Staff did not feel supported within clinical supervision. Mandatory training was not consistently enforced. The service was placed under financial restrictions that limited their ability to respond to concerns that they had identified.

However:

• There was good team working and respect between teams. Staff had access to opportunities not expected of their role; such as a health care support worker leading the Safe Wards implementation. The managers had created a staff representative group where staff could raise concerns anonymously without managerial presence and evidenced actions following this. Staff were complimentary of the clinical and hospital manager. Staff had regular appraisals and managerial supervision; engaged in de-briefs following incidents and encouraged reflective practice regarding improvements. Poor performance was investigated and appropriate support put in place.

• Shortly before the inspection, Sanctuary had implemented Safe Wards as an ongoing initiative to reduce restrictive practice. Patients were more complimentary of the staff approach on Sanctuary.

• Care plans were personalised and reflected the patient’s voice and that the service was discharge and recovery focused. Patients had a comprehensive assessment on admission.

• Duty of candour was embedded and patients were told when things had gone wrong. Patients felt safe to raise concerns; staff acted on patients’ concerns raised in complaints and community meetings. Patients had regular access to an independent mental health advocate who also assisted with social needs such as housing. The hospital was linked to an interpreter service for patients who required it and had good disabled access.