We rated Cygnet Hospital Bierley as good overall, we were unable to re-rate the service overall as we did not carry out an inspection including all of our key lines of enquiry. However, during this inspection, we found breaches of regulation in all domains other than caring and responsive. Due to this, we have suspended the ratings of good in the effective and well–led domains.

• Following our inspection in August 2016, we rated the service as good for caring. Since that inspection we have received no information that would cause us to re-inspect this key question or change the rating.
• We also rated responsive as good at the last inspection but we received information prior to this inspection in May 2017 raising concerns related to levels of activity and discharge planning. However, at this inspection we found that patients accessed a range of activities throughout the week, including weekends, and the services continued to discharge patients following discharge planning.
• The service had addressed the specific issues that had caused us to rate safe as requires improvement following the August 2016 inspection. All wards were clean and furniture had been replaced on Bowling ward (female specialist personality disorder service). Patients told us that staff always kept the hospital clean. The service was now meeting regulation 15 of the Health and Social Care Act (Regulated Activities) Regulations 2014: premises and equipment. The provider had created a system of mapping ligature points to reduce the risk to patients and increase staff awareness. The system was working well and staff were aware of the risk and mitigated it via observations.
• There was a range of rooms where patients could take part in activities such as art therapy, using the gym, computers, outside activities and therapy sessions. Wards and communal areas contained information for patients. Patients told us that they knew how to complain and that staff took their concerns seriously when they raised an issue. This had improved following the actions we reported the provider should improve at our visit in August 2016.
• Patients told us that ward rounds were more consistent and this was an improvement following our recommendation at our visit in August 2016.
• The provider had conducted a corporate risk assessment following guidance from the resuscitation council UK which mitigated the requirement for keeping the reversing agent with emergency drugs and so had addressed the action recommended at the last inspection in August 2016.
• The service had begun work on building a specific spiritual room for patients (as recommended at our inspection in August 2016). Patients and staff were involved in the planning and design of the room.

However:

• Despite the work by the provider to risk assess, eliminate and mitigate ligature points, this location remained in breach of regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014: safe care and treatment. Staff carried out seclusion and rapid tranquilisation with patients and they did not always ensure they had done this safely. We reviewed specific episodes of both interventions and found that physical health observations were not always completed and recorded as per the provider’s own policy. This increased the risk of harm to patients and on one occasion had resulted in a serious incident. The providers own governance system had not identified this issue.
• Although we did not receive information prior to this inspection in order to change the rating of ‘good’ in the well-led domain, during this inspection we found that systems and processes were not operating effectively or sufficiently embedded to ensure the service was safe.
• Staff had not always updated patient risk assessments after a significant incident of harm.
• The service had a high turnover of staff at 31% at the end of December 2016, but at the time of inspection this was 13%. This had led to a vacancy rate of 46% of nursing staff and 17% of healthcare support workers. This had caused significant use of bank and agency staff.
• Staff did not adhere to internal policies and procedures and did not follow the Mental Health Act Code of Practice when using restrictive practices with patients.

When we last inspected this hospital in September 2013 we identified concerns. We issued compliance actions and commenced enforcement action which required the provider to ensure they became compliant with the Essential Standards of Quality and Safety. After our inspection the provider wrote to us to tell us how they would improve and reach compliance with the required standards.

At this inspection three inspectors were assisted by three specialist advisers from National Health England.

Two patients on Bowling ward told us the hospital had improved, and that there was now a structured programme of meaningful activities for them to take part in. They told us were involved in the development of their care and treatment plans and felt they were being helped by the staff towards recovery. They told us they felt “safe” on the ward.

At this inspection we found systems were in place to protect patients from the risk of abuse. Improvements had been made to patient records and patients were now protected from the risks of unsafe or inappropriate care and treatment because accurate care records were maintained.

We continued to find evidence that patients were not always protected against the risks associated with medicines.

We found that although improvements had been made since our last inspection visit, the provider did not had an effective system in place to regularly assess and monitor the quality of service. This was specific to management of risk, policy updates and learning from audit and clinical incidents.

We carried out an inspection on the 20 July because we had received information of concern that on the 21 June 2012 on the psychiatric intensive care unit (Denholme ward), staff called for police assistance, and this had resulted in a taser being used by the police to subdue a patient. We therefore visited only Denholme ward and looked specifically at how the staff were managing patients when they became a risk to themselves or others.

During our inspection on the 20 July 2012 we reviewed outcome four (regulation 9) to assure that the patients experienced care, treatment and support that met their needs and protected their rights.

We talked to one person using the service and we used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not always able to tell us their experiences. The person using the service and our findings indicated to us that the systems in place did not fully protect people’s rights.

Following our inspection on the 7th February 2012 we issued a warning notice because there were concerns that patients' were not provided with sufficient information to ensure their rights and best interests were being properly protected. Also because some patients' care records were incomplete, inaccurate and illegible, and patients were at risk of not receiving the care and treatment they require.

At our inspection on the 4th April 2012 we talked with nine patients and reviewed four patients care and treatment records. We found the records were maintained and patients were protected from the risks of unsafe or inappropriate care and treatment. Also patients were being informed of their legal rights and informed about their care and treatment.

We talked to nine patients who told us they were now provided with the information they needed and that they did have access to an independent mental health advocate (IMHA). They met regularly with their named nurse, and they were able to contribute to the weekly ward rounds, where their care and treatment was discussed. However all did say they did not feel fully involved in the development of their care and treatment plans.

We carried out a visit to Cygnet Hospital Bierley on 07 February 2012 to follow up compliance actions made when we last visited the service in September 2011.

In view of the major concerns identified in two outcome areas the Care Quality Commission served Warning Notices on the Registered Provider and the Registered Manager on 2 March 2012.

During the follow up inspection, because we needed specific information from the management to demonstrate their compliance with the essential standards, we did not need to speak directly with patients from the wards.

Overall, the people spoken who use the services felt safe at the hospital, well supported by staff and adequately involved in their own care planning.

Due to the nature of this review, we did not speak to people who use the service on this occasion.

We rated Cygnet Hospital Bierley as ‘requires improvement’ because:

• The hospital did not always provide safe care and treatment. We had concerns about the safety of the environment. Not all ligature risks had been appropriately risk assessed and those risks mitigated. The ground floor seclusion room had a viewing panel that could be obscured from the inside to prevent the use of staff viewing points, which could compromise patient and staff safety. Staff sometimes transported patients in restraint holds whilst using stairs, and there was no risk assessment for staff to follow for this procedure. On the psychiatric intensive care unit, the use of planned prone restraint was not always in line with national guidance. On the specialist personality ward patients did not have risk assessments, which staff regularly updated following every incident. There were some blanket restrictions in place on the specialist personality disorder ward and low secure forensic wards which were not included in the blanket restriction audits undertaken.

• The hospital was not always providing effective care. The monitoring of patient’s physical health did not always take place according to best practice guidance or the provider’s own policy. This included patients who the service had newly admitted to the psychiatric intensive care unit, patients who had received rapid tranquilisation and patients with long term physical health needs. Staff did not always monitor patients’ potential side effects when they prescribed medication to patients. Staff did not always ensure patients gave consent and that staff recorded this in line with the Mental Health Act. When patients lacked capacity to make specific decisions, staff did not act in accordance with the Mental Capacity Act. Staff told us that they did not always receive monthly formal supervision.
• The service was not always responsive to the privacy and dignity of patients on the psychiatric intensive care unit, because staff brought patients through communal areas of the hospital when they were admitted to the unit. The ward was on the first floor of the hospital and did not have a separate entrance.
• There were elements of the governance processes across the whole service, which were not entirely effective. Audits taking place such as in physical health monitoring, ligature risk assessments and blanket restrictions audits did not ensure that all areas of risk and concern were monitored to ensure the senior managers were aware of all areas of concern. The service did not have written protocols or risk assessments in place for staff to follow when transferring patients to seclusion using stairs, or for admitting patients through communal areas, and using stairs to the psychiatric intensive care unit.

However:

• The hospital provided care, which was compassionate, and empowered patients to be active partners in their care. Patients described staff as kind and caring and we witnessed this behaviour during our inspection. Patients had access to advocates, and were able to make complaints and give feedback about the service they received. The service was routed in patient involvement and the feedback of patients was important to the leaders of the service.
• The hospital had a high quality therapy service, which encompassed a focus on patient recovery. The therapy service had received national recognition, and staff were proud and passionate about its achievements.
• Patients had access to therapies and activities, which were high quality, and met their emotional, spiritual and cultural needs. The services were discharge focussed and the length of patient admissions was appropriate to their needs. The service had made adjustments to meet the needs of patients with mobility needs, and was able to ensure person centred care for patients with specific cultural and religious needs.
• The senior leadership team were knowledgeable, qualified and experienced. They were passionate about improving the quality of care and treatment at the service. Staff felt valued and supported by managers and the service continued to request feedback from staff.
• The service was committed to quality improvement and innovation and had been involved in a number of projects and awards all of which involved the support of patients.