We carried out an unannounced focussed inspection at Cygnet Hospital Sheffield on both of the child and adolescents mental health wards: Peak View ward and Haven Ward. Since September 2017 we became aware of a number of incidents and safeguarding concerns on Haven and Peak View wards which gave us concern about patient safety. We requested further information from the provider about how these incidents and safeguarding concerns had been managed. The information we received did not give us sufficient assurance to ascertain whether patients were suitably protected from harm. As a result, we undertook this focussed inspection to review the areas of safeguarding and incident management on the child and adolescent wards in further detail. This inspection was not rated.

During the inspection we found:

• The majority of staff on both wards were up to date with mandatory safeguarding training and staff were in the process of undertaking additional training. Staff reported knowledge and confidence about identifying and reporting safeguarding concerns. Contact with the local authority and actions to help safeguard patients were documented in patient records. From a review of seven patient’s care records, we found one instance where a disclosure had not been reported and documented as required.
• Staff discussed safeguarding issues and incidents in a number of forums. These included staff meetings, specific safeguarding training and development meetings, multidisciplinary meetings and staff handovers. Patients with ongoing safeguarding concerns had safeguarding care plans in place. These were reviewed regularly but did not always contain details of ongoing safeguarding incidents on the ward.
• The hospital had recently introduced an incident review meeting so that managers had a daily discussion about all incidents which took place, any actions required and whether these needed to be notified to external organisations. We saw evidence of learning from serious incidents and staff told us about changes that had been made as a result of these. Managers had introduced new measures to improve information sharing about incidents and any associated learning.

However:

• The hospital held a safeguarding tracker to log progress of all safeguarding referrals centrally. This was incomplete in some areas and the data did not coincide with incident data recorded on the central tracker. Following our inspection, the provider told us this had been in the process of being updated due to being a recent implementation

• Staff meeting minutes included evidence of some discussion of incidents, but did not demonstrate that learning from incidents were reviewed as a matter of routine. Some staff felt they did not get feedback or information about other incidents at the hospital which may be relevant. An investigation of a serious incident had exceeded the provider’s own recommended timescales.

We carried out an unannounced focussed inspection at Cygnet Hospital Sheffield on Haven ward. The inspection took place to establish whether the hospital’s systems and processes were suitably robust at night following a recent serious incident that occurred. We did not rate this inspection.

We found that:

• The hospital had suitable systems in place on Haven ward to enable staff to help manage risks to patients using the service. Staff were aware of known risks to young people and the hospital had processes in place to enable staff to escalate any concerns.
• Patients’ care and treatment records on Haven ward had current risk assessments in place which staff regularly reviewed. However, we did see an instance where staff had not updated one patient’s risk assessment in response to an incident.

We found that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. People told us that they felt well cared for.

We found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We found that there were enough qualified, skilled and experienced staff to meet people’s needs.

We found that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We found that the provider had an effective system to regularly assess and monitor the quality of service that people receive.

This inspection included checking that improvements had been made to the management of medicines, assessing and monitoring the quality of service provision and records, as the provider was non-compliant following our inspection on 4 June 2013.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. All the patients we spoke with told us they felt they could engage well with staff and felt supported by them. For example, one patient said, “It was the anniversary of my dad’s death and staff were available for one to ones to make sure I got support”. Another patient said, “Patients shout and threaten people, but staff are good and calm”.

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

There were enough members of staff to keep patients safe and meet their health and welfare needs. All but one patient felt there was enough staff on duty to meet their needs, both during the day and night. All staff told us that the staffing levels were sufficient to meet people’s needs.

Although improvements had been made, the provider did not yet have effective quality checking systems in place to manage risks and assure themselves of the health, safety and welfare of patients and others.

Patients records were kept safe to maintain their confidentiality and included appropriate information about them.

This inspection included checking that improvements had been made to records as the provider was non compliant following our inspection on 28 January 2013. The provider remained non-compliant.

On this visit we spent time on both Spencer and Shepherd ward.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. Comments by patients included, “I have a named nurse and I speak to her when she is on shift. We discuss the side effects of my medication and the monitoring of my physical health. We discuss any issues that have arisen and any changes” and “my progress is discussed at Care Programme Approach (CPA) reviews.”

Patients who use the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. All the patients we spoke with felt the restraint that had been applied to them was appropriate and justified.

Patients were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

The provider did not have an effective system to identify, assess and manage risks to the health, safety and welfare of patients and others.

Patients were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

Patients experienced care, treatment and support that met their needs and protected their rights. Patients told us they received activities and particularly enjoyed the activities on the Haven, but that they would like more groups to aid their recovery, such as drugs and alcohol, eating disorders, looking at personality disorders and anger management.

There were enough qualified, skilled and experienced staff to meet patient’s needs. Patients told us there was no concern about activities getting cancelled regularly because of a lack of staff. We were told there was now an activities co-ordinator who worked in the Haven every day. One patient was particularly pleased as she said it also ran at the weekends now.

The provider had an effective system to identify, assess and manage risks to the health, safety and welfare of patients and others. This included the re-establishment of the audit committee, with an audit programme for the next year being developed, clinical governance meetings and communicating with patients and staff.

We found there was a lack of proper information about patients because their care records were not accurate and did not include appropriate information and documents in relation to the care and treatment they were receiving. We also found that information and documents held about patients could not always be located promptly.

This inspection was to review improvements at the service. This was because a visit to the service on 17 April 2012 resulted in a compliance action being made against outcome 4, ‘care and welfare of people who use services’.

At this inspection we also covered outcome 7, ‘safeguarding people who use services from abuse’, outcome 12, ‘requirements relating to workers’, outcome 13, ‘staffing’ and outcome 16, ‘assessing and monitoring the quality of service provision’. This was because we had received information of concern about these outcome areas.

Our inspection was conducted on the two low secure wards, Spencer and Sharman.

A new manager had been appointed and this was her fourth week of employment.

We spoke with four patients about aspects of their care and welfare. They felt staff at the hospital were ‘good’, ‘treated them with respect and dignity’ and ‘that they related well to their key worker’.

Patients told us that there had been some changes in recent months. For example, they could get a drink whenever they wished to and were able to keep their own snacks in their rooms. Patients told us that they were able to go outside more freely and this had made life much better. Patients also told us that some changes, such as access to the garden area and activities, such as going to the gym and section 17 leave, didn’t always take place because of a shortage of staff.

Patients said they were supported by the staff to retain contact with family and friends.

When describing their care, patients identified they had access to health care professionals and attended opticians and dentists if necessary.

We spoke with four patients about whether they felt safe on the ward. They all told us they felt at times it was unsafe on the ward. They said this was because of some incidents that had recently taken place between patients. All patients told us they felt safe with staff.

This follow up inspection was to review improvements at the service and the provider’s compliance with six essential standards. Since the last inspection a new manager had been appointed and his application to register had been submitted to the Commission.

On Spencer ward, patients raised no concerns about staff maintaining their confidentiality, but on Sharman ward it was still a concern to three of the six patients we spoke with.

Patients on Sharman ward spoke of the good facilities in ‘the haven’. 'The Haven' is a separate area off the ward that includes a good multi-faith room.

Patients told us staff were now completing searches in private areas, which afforded them more privacy and dignity. One patient told us that she had made suggestions to staff about improving the search area and that her suggestions had been incorporated.

Patients were supported in promoting their independence and community involvement. This was demonstrated by patients telling us about weekly meetings which took place on each ward where they could discuss activities, improvements and ward rules. We saw that there had been improvements to the recording of this information, to give a true reflection of what was discussed. Patients led the meeting and took their own minutes and a representative of the organisation also took minutes.

All patients said they were able to contribute to decisions about their care in ward rounds, which told us patients were able to express their views and were involved in decisions about their care and treatment.

We spoke with eight patients to ask them how they consented to their care and treatment including searches of their person and property.

Seven patients told us that they were asked to give consent to being searched. We asked what happened if they didn’t consent to being searched. One patient said, "You don't go out." Another patient said, "They'd do it anyway." Another said, "You'd be restrained, but it's not happened to me."

One patient told us that her search arrangements had recently changed as she presented a lower risk than she had previously. She saw this as a positive development.

Four patients told us they now had a folder containing a copy of their care plan and risk assessment for them to look at and check when they needed/wanted to.

We spoke with eight patients. All felt there had been a shift in the restrictions that were applied to them. However, one patient felt there was still a lot the hospital could do to improve this. They gave examples of this as cigarette breaks and access to the kitchen and garden. They eloquently described the impact of those restrictions on their mental health. They said, “If you’re not well and feeling tense and aggravated, it just adds to it and your own baggage.”

Another patient told us that because she had arrived late to the communal area, staff did not allow her to go out for a cigarette.

A further patient told us it would be better if they could go for a cigarette when they wanted to. They told us cigarette breaks were every two hours, you have to be in the communal area fifteen minutes before the break and come back inside after fifteen minutes.

Patients that we spoke with told us about weekly meetings which took place on each ward where they could discuss activities, improvements and ward rules. We saw that there had been improvements to the recording of this information, to give a true reflection of what was discussed. Patients led the meeting and took their own minutes and a representative of the organisation also took minutes. Patients told us decisions and feedback about issues raised in that meeting had improved, but there were occasions when subjects continued to be raised. The new manager was seeking to address this, by monitoring those minutes on a weekly basis. This told us patients were asked for their views about their care and treatment and they were acted on and that the provider took account of complaints and comments to improve the service. It also told us decisions about patient’s care and treatment were made by the appropriate staff, at the appropriate level.

In our discussions with eight patients, the overall picture was that patients were provided with information about how they could complain if they were not happy. On Sharman ward there was good feedback from a patient who was able to change their named nurse on request. However, another patient wasn’t happy with their named nurse as it was a permanent night nurse, which meant their 1:1’s were happening late at night, which they weren’t happy with. The provider may find this useful to note, so that they can address this at service level.

However, there was still a perception from three patients that there was no point complaining, as things never got resolved.

This follow up inspection was to review improvements at the service and the provider’s compliance with six essential standards.

When we spoke with patients, one told us that confidentiality on the wards was never good. This was because staff discussed information about patients on the ward.

All patients said they were able to contribute to decisions about their care in ward rounds.

Patients that we spoke with told us about weekly meetings which took place on each ward where they could discuss activities, improvements and ward rules. One patient said, they’re not always effective, because some things don’t always get recorded. On one ward some of the patients told us that they did not get effective feedback in these meetings.

We spoke with one patient who knew the multi-faith room was being implemented, but didn’t know they could use it now.

Patients told us searches were still taking place in public areas. This was despite the provider making structural changes to provide a search room in a passageway off the main entrance. This was confirmed because on the visit we saw one patient enter the corridor area off the ward and hold out their arms to be searched. The staff member accompanying them told them it wasn’t necessary any more to be searched on their way out.

One patient told us their search usually takes place in the corridor off the ward, but it’s never in a private place. Sometimes, they said they can use the recess off the corridor, to make it more private.

We spoke with patients to ask them how they consented to their care and treatment including searching of their person and their possessions. One patient said they’d never been asked to sign a consent form that they agree to being searched or be asked if they verbally agree. They said they are aware rooms should be searched randomly every month, but it doesn’t happen.

Another patient told us searches continued and they’d never consented or been asked their permission. They said they could understand random, but not every time. They felt it was easier to agree and go ahead rather than risk losing leave. On a different ward they said searches were more rigorous and included removing your shoes.

Patients told us they didn’t like being searched, but understood why staff needed to.

When we spoke with patients it identified there continued to be restrictions placed on patients, that were not all based on individual risk. For example, everyone had to have the majority of their own money and bank cards kept in the office safe. Some patients said they could only have snacks at 14:00 or 20:30. They said this was because some patients were on weight loss programmes.

Patients told us about zonal observations. They said everyone had to be up and in the main patient area by a certain time, and bedroom access varied between individual patients depending on which zonal observations you were on.

On this inspection one patient told us that they felt in the past couple of months, things seemed to be coming together. They said they had been disappointed because they had transferred from an enhanced medium secure ward and expected to continue with at least the same care plan when they came here, but they didn’t, they had to ‘start again’. They told us they were always searched on the way out of the ward until this morning and have always been searched on the way back onto the ward. They said this includes a ‘pat down’ and search of property. They said anything that’s sealed can be brought onto the ward, but there’s no consistency with applying this rule.

On the locked rehabilitation ward, patients were much happier. They felt changes had been made for the best. For example, they could have previously banned items such as mobile phones and pot crockery. They explained they don’t have searches and if they do they’re random or if there’s a reason. One patient said, “it’s improving and getting to be more like a rehabilitation ward. I’m really pleased with the progress.”

In respect of receiving their medication on time, one patient said there had been times when they had been without their medication, because of changes in dosage, but this had got better more recently. For other patients we spoke with, they described their routine for receiving their medication. This demonstrated different routines for patients to take their medication and that a person centred approach based on risk was in place for this.

When we asked patients what changes might improve the ward, one patient thought a beautician. We told them to raise this in the community meeting, which they said they had done. On the locked rehabilitation, one patient thought cooking for yourself.

We asked patients about whether there were enough staff at the hospital to meet their needs. One patient on Sharman ward said in the last two – three weeks there had been more staff, but it’s poor at night. Another patient said there is not enough staff for one to one talk time, which means you have to deal with your problems on your own. You also have to wait to put laundry in, because other patients are on observations. They said numbers of staff always get discussed in community meetings, but the hospital says they are the correct numbers.

During our discussions with patients they said in general staff were good and helpful.

Patients had different experiences of how complaints were dealt with dependent on the ward they were on, but there seemed to have been improvements more recently.

On one ward, one patient wasn’t clear how the complaints procedure worked and would only speak to certain staff, because one member of staff had said, “if anyone blogs on me, I’ll make life difficult”.

Another patient told us the procedure they would use to make a complaint. However, although their complaint had been listened to they didn’t think the provider had dealt with it correctly, because they’d just moved the problem elsewhere.

On the locked rehabilitation ward patients were much more confident that their complaint would be dealt with.

On this occasion we were carrying out a follow up inspection to look at the provider’s compliance with one essential standard, and we did not speak to patients. However, when we inspected this hospital in November 2011 we spoke with patients and found their views about receiving treatment at Alpha Sheffield were varied. Most of the patients that we spoke with on that occasion told us that they had the opportunity to be involved in their care planning and making decisions about their treatment. Patients told us that there were plenty of activities taking place within the hospital that they could participate in, although some told us there was little to do at weekends and that sometimes activities were cancelled due to short staffing. Some patients told us that they liked the staff and felt that they did a good job. Several of the patients we spoke with told us that they found there were too many rules in place. Some patients told us that when they make requests for things the hospital takes a long while to respond. Other patients told us about times when they have made suggestions for improvements and these have been implemented.

We found the following areas of good practice:

• Staff were up-to-date with their mandatory training and managers monitored this weekly. Staff received training in the requirements of the Mental Health Act and Deprivation of Liberty Safeguards. Overall, staff compliance with mandatory training was high.
• Staff carried out restraint and seclusion only when necessary and could show how they took into account patient preference.
• Patients had comprehensive risk assessments which staff updated following incidents.
• Patients had a single complete and contemporaneous care record which contained up-to-date care plans and physical health monitoring. Staff used outcome measures appropriate to the patient group.
• Patients had meaningful involvement in their care and staff had a collaborative approach to care planning and risk management. Patients could get involved in decisions about the running of the hospital.
• Staff kept carers up-to-date with their relatives’ progress and carers attended multidisciplinary reviews.
• The hospital had an improved complaints procedure. Patients and carers knew how they could complain and felt their concerns would be taken seriously.
• Managers had introduced new initiatives to improve the quality and safety of the wards. The hospital could show a reduction in the use of restrictive practices including restraint and seclusion.
• Staff had made improvements to the environment and to the overall of quality of care. Most patients and carers were happy with the care provided by staff.

We found the following areas the hospital needs to improve:

• Managers did not always ensure that records demonstrated staff monitored medication fridge temperatures consistently and correctly. 
• Some of the provider’s policies did not provide enough guidance for staff on the standards expected of them.
• Staff did not record when de-brief occurred with staff or patients following incidents.

Although the provider had made improvements and addressed all the areas we told them they must do following our previous two inspections, we were not able to change their ratings. This was because this was a focussed inspection and we only inspected those areas which we required them to address following our last comprehensive inspection in August 2017 and our focussed inspection in September 2017.