We carried out this inspection to check whether the service had taken action following concerns identified during our previous inspection in February 2014 where we found that they were non-compliant with outcomes 4 (care and welfare of people who use services), 9 (management of medicines) and 21 (records).

During this inspection, two inspectors visited Meridian and Tyler wards. We met and spoke with people who used the service, relatives of people who used the service, members of staff and managers on each of the wards as well as the hospital and clinical manager. We found that records relating to the care of people who use the service were up to date and comprehensive. We saw medicines were appropriately monitored and recorded. The hospital had systems in place to audit the records at ward level, hospital level and organisational level.

People told us that they were involved with their care planning processes and had copies of their care plans. Risk assessments were completed thoroughly and people had current risk management plans. The hospital had ensured that when higher levels of observation were needed for people who used the service, that these were recorded comprehensively.

We found that the action plan which had been submitted to us after the inspection in February 2014 had been effective.

We carried out this inspection to assess if the service had taken action to rectify issues found at our last inspection in August 2013.

At that inspection there were gaps in recording, both in general care records for people using the service and in medication records.

On this visit we found that there were still a number of gaps in care records; There were also several gaps in medication recording, and we found that one person did not have a current care plan.

This was a follow-up review of compliance, during which we undertook on-site inspection of Tyler ward only, to ensure that the hospital had complied with the requirements made after our previous compliance reviews in July and September 2011, at which we found that Cygnet Wing Blackheath was not meeting three essential outcomes and that improvements were needed. We also reviewed outcomes where we had suggested that improvements were made to ensure that compliance was maintained.

On this particular occasion we did not talk to people who used the service.

We inspected Cygnet Wing Blackheath as part of a review of compliance on 18 July 2011. At our inspection, people using the service told us that they did not know who their primary nurse was and that they did not get one to one time with a specific person; they felt that more staff were needed and that staff were too busy. We also found that many staff had left or been moved to different wards since April 2011, that there were staff vacancies and overall that there were not sufficient staff available, on Tyler ward particularly, to work with people in a personal and therapeutic manner. We placed a Compliance action on the provider, Cygnet Health Care Limited, under Outcome 13, Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010 requiring the provider to take action to ensure that, at all times, there were sufficient numbers of suitably qualified, skilled and experienced staff. The provider sent us a report telling us how it would become compliant with Outcome 13 by 15 August 2011.

However, following this Cygnet Wing Blackheath notified us of a serious untoward incident, leading to a safeguarding alert, which had taken place on Tyler ward on 19 August 2011. The incident highlighted concerns about the numbers, skills and mix of staff available on the ward, which had impacted not only about the personal and therapeutic care and treatment of people using the service but also on their safety and wellbeing. The provider's own investigation found that there had been insufficient numbers of staff at the time of the incident, and to a lack of skilled, experienced and poorly inducted and supported staff.

People on the low secure ward, Meridian, said the ward was clean and well-looked after, and they were content with their bedrooms. They felt that nurses tried to escort their leave at mutually agreed times, as far as was possible.

People we spoke to on Tyler ward said they did not know who their primary nurse was, that they did not get one to one time with a specific named person, and some were not aware that they had a care plan. Two people said that staff had not explained their rights under the Mental Health Act to them.

People were aware of organised activities at the hospital, but they felt that, in general, there was not much to do except sit, sleep, watch television and talk. Books were in short supply and on Tyler ward people had not been able to help themselves to a hot drink for some days.

Generally, people felt that their privacy and dignity was promoted and observed by staff. One person felt his one to one observation was intrusive and upsetting as staff watched him from the corridor through his open bedroom door and anyone else who was passing could also see into his room.

Almost everyone said staff were too busy and that more staff were needed.

We rated Cygnet Hospital Blackheath as requires improvement because:

• Ward staff did not have opportunities to learn from incidents and improve the safety of the care provided to patients. On Tyler Ward, there were no discussions in team meetings about the frequent incidents involving actual assault, attempted assault, verbal threats and disruptive or aggressive behaviour.
• Supervision sessions did not support staff to discuss the care they provided for individual patients in order to reflect on and develop, their professional practice. Records of supervision sessions were very brief.
• There were a high number of medication errors on Tyler Ward, particularly errors relating to compliance with the Mental Health Act 1983. These errors had resulted in doctors prescribing medication unlawfully.
• High use of agency staff on Tyler Ward was potentially impacting on the consistency and quality of care as these staff did not have access to team meetings or supervision to support them with meeting the challenges of patients with complex needs.
• A majority of patients we spoke with on Tyler Ward said they did not feel safe on the ward or that they had experienced aggression from other patients.
• Staff on Meridian Ward did not receive specialist training in relation to the complex needs of many patients such as learning disability, autistic spectrum disorders or epilepsy.
• Staff morale was poor. Whilst staff felt well supported by managers within the hospital, they did not feel that senior managers in the organisation listened to and responded to their concerns. Staff were unhappy about changes to their terms and conditions linked to changes in the organisation.

However,

• Senior staff within the hospital had a good understanding of the wards. This team met every morning for a daily planning meeting. During this meeting they discussed staffing, incidents, safeguarding admissions and discharges.
• Managers had clear information that enabled them to compare their performance with other similar wards within Cygnet Health Care.
• Most of the 15 patients we spoke with said that staff were kind, caring and respectful.
• Carers spoke very positively about the improvements that the people they cared for had made whilst on Meridian Ward and the level of stability they had achieved.