Our rating of this service stayed the same. We continued to rate it as good because:

The provider managed risks well. Staff completed regular environmental and patient risk assessments and had a good knowledge of individual patient needs. The hospital had an up-to-date risk register that highlighted key concerns and had plans in place to manage these. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

Patient records were person centred, up to date and overall were of a good standard. Physical health monitoring and care were well managed and staff were suitably trained and up to date with mandatory training requirements. The provider had clear processes for monitoring and investigating incidents and complaints and undertook a variety of audits to monitor and improve the quality and safety of the service. Systems were in place to learn from these and improve practice as a result.

Managers adjusted staffing levels to meet changing needs, utilising extra bank and agency staff who were familiar with the wards to cover any shortfall. The hospital ensured agency and bank staff were familiar with the wards and had access to the same induction, support and training as permanent staff.

Staff provided a range of care and treatment interventions suitable for the patients in line with guidance from the National Institute for Health and Care Excellence (NICE). Robust arrangements were in place to meet patients’ physical and mental health needs. Staff were compassionate, respectful, responsive and discreet; providing patients with help, emotional support and advice at the time they needed it.

The ward managers and senior leadership team provided strong and effective leadership and staff members had confidence in them. Managers within the service promoted an open and honest culture. Staff felt able to raise concerns, report incidents and make suggestions for improvements without fear of consequences. Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff felt respected, supported and valued by senior managers and leaders. They were proud to work at the hospital and felt positive about their work and the support they gave patients.

However

Information about patients was difficult to find in the care records. Although paper records had plenty of detail the notes were cumbersome to go through and was not user friendly.

There were no facilities in place to safely dispose of surplus or out of date medication on any of the wards. We found expired medication in a storage cupboard, this was stored separately from patients medication waiting to be disposed of on Knightstone ward. We raised this with the provider and they took appropriate action. The provider disposed of the expired medication and also checked other treatment rooms in the hospital to ensure this was not repeated.

Although care and treatment records showed that discharge planning was considered there were no detailed plans for discharge in any of the care records we looked at on Knightstone and Nash wards.

• Our last comprehensive inspection of Cygnet Hospital Kewstoke was on the 19 January 2016. At that inspection, we rated the service as good overall.
• We also gave ratings for the core services provided by the hospital. For acute wards for adults of working age and psychiatric intensive care units we rated effective, caring, responsive and well led as good. However, we rated safe as requires improvement. We told the provider it must ensure that on Nash ward the cleanliness and damage to interior walls, fixtures and fittings are addressed immediately and adequately maintained thereon.
• On 24 January 2017 and 16 March 2017 we undertook an unannounced, focused inspection to see whether the provider had made the required improvements. We found that the provider had generally completed all the required improvements but that the bath panel and skirting board in the communal bathroom was still damaged, the bolted down tables in the dining room needed cleaning and that there were still some offensive odours in some bedrooms where the provider had not replaced the carpets. As a consequence, the requirement notice stayed in place. The provider revised their action plan and informed us when it had addressed the outstanding issues.
• We undertook a further unannounced, focussed inspection on 3 October 2017 to see if the provider had made the required improvements.
• We found that the provider had replaced the carpet in all patient bedrooms on Nash ward and the ward was free of odour. The provider had replaced the dining room furniture on Nash ward; the tables and the base of the tables were clean. The cleaning team regularly deep cleaned the ward areas.
• The provider had replaced the bath panel and skirting board in the communal bathroom which was in good order, and had installed CCTV to promote safety on the ward.

• As a result of the improvements we lifted the requirement notice.

We rated Cygnet Hospital Kewstoke as good because:

• The environment was well risk assessed, adapted and both patients and staff told us they felt safe on the wards. Personal and hospital alarm systems were robust and well documented.

• There were enough suitably qualified and trained staff to provide care to a good standard. Staffing vacancies had been recruited to and the team were able to access increased numbers of staff easily.

• Medicines management was safe and regularly audited by an external agency. Medication errors were discussed in integrated governance meetings and ward rounds. Recent external audits from the hospital pharmacy had increased awareness around medication errors.
• Patients were involved in developing their own care plans and their views were clearly documented in their own words. Care plans we saw were personalised, holistic and recovery focused. The wards used the ‘my shared pathways’ (a programme to allow patients to chart their own progress through secure services and set their own agreed outcomes/achievements) approach for planning and evaluating care and treatment. Staff were well supported by the hospital to have training on the successful implementation of ‘my shared pathway’.
• Patients had access to regular physical healthcare checks and a GP was employed by the hospital to provide regular contact with patients. Occupational therapists worked as part of the multidisciplinary team.
• Staff showed patience and gave encouragement when supporting patients. We saw that staff showed warmth and acceptance towards their patients despite the very challenging situations arising, often involving high levels of distress and self-harming behaviours. We saw that staff were non-judgemental towards their patients and empowered them consistently to encourage their involvement.
• There were quiet rooms that patients could access during the day and a full range of therapy rooms and equipment. There was a varied, strong and recovery orientated programme of therapeutic activities available.
• Patients knew how to complain and had access to advocates who had assisted patients to make a complaint in the past. The hospital had a detailed policy and procedure about how they dealt with complaints.
• Staff told us that the senior management team regularly visited the wards and were well known amongst the team. Staff felt well supported by the senior management team.
• All staff had good morale and said they felt well supported and engaged with a visible and strong leadership team, which included both clinicians and managers. Staff were motivated to ensure they achieved the ward objectives.

• Governance structures were clear, well documented, adhered to and reported accurately. There was a robust audit plan and any actions resulting from the audit were completed in a timely fashion. The wards conducted several audits to ensure they were monitoring and improving the systems that supported the ward to achieve set standards and targets.

• Recruitment was value based, sickness and absence was well monitored and staff were well supported back into work.
• Staff received regular clinical, managerial and group supervisions. Appraisal rates were almost at 100% throughout the hospital and included 360 degree appraisals for clinicians.

However:

• The hospital’s medicines management and rapid tranquillisation policies were overdue to be reviewed.

• Staff had not been given any training in the changes to the MHA’s new Code of Practice and that the on-going Mental Health Act training did not address these changes either.
• Mental Capacity Act assessments were brief and needed more information about how best interest decisions had been made.

This inspection was carried out to follow up a compliance action made at the last inspection 21 February 2013. This related to how records were maintained within the service. During this inspecton we also looked at how the organisation was respecting and involving people, providing care, how they ensured people were protected by safe employment practices and how the provider assessed the quality of service provided.

We visited Redhill, Knightstone and Milton wards. Eight people who used the service agreed to speak with us and we spoke with seven members of staff

We found Cygnet Hospital was now fully compliant with the way they ensured records were maintained.

People spoken with told us they felt staff treated them with respect. One person explained that staff always knocked on the door before entering. They told us male staff would not enter their en-suite when in use.

We saw care plans were written following discussion with people who used the service. They contained sufficient information to ensure staff were informed of the care needs of people in the hospital.

We found staff recruitment was robust and protected people from the risk of harm or abuse.

We saw people were supported by staff who were suitably trained before they worked with people un-supervised.

The provider had a quality assurance system in place that ensured people were safe and changes could be made to improve the service provided.

We visited two wards as part of our inspection, Redhill and Knightstone. We were accompanied by a specialist advisor with clinical knowledge and expertise in managing patients detained under the Mental Health Act 1983 in a low and medium secure environment.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

We spoke with four people who used the service. Two of the four people were happy with the way they were supported by the staff at the service. Two other people we spoke with raised concerns with us about their safety.

We reviewed five care records and saw assessment of care needs was not always carried out as appropriate. Care planning was incomplete in some cases and care delivery did not always reflect good practice guidance.

We reviewed the arrangements for protecting people from harm or abuse. We saw that reasonable steps had not always been taken to identity the possibility of abuse and prevent it before it occurred. There were not adequate arrangements in place to ensure the prevention of the use of unlawful or otherwise excessive restraint procedures.

We looked at records relating to care planning and delivery, cleanliness, complaints and hospital policies. Records kept did not contain all appropriate information and documents.

We looked at respecting and involving people who used services, care and welfare, safeguarding people who used services, infection control, complaints and records.

We visited three wards as part of our inspection, Nash, Redhill and Milton. We were accompanied by the Mental Health Act Commissioner (MHAC) for the service who visited people on Knightstone ward. We spoke with nine people who used the service. They told us their views about the service. Seven of the nine people were happy with the way they were supported by the staff at the service. We received some very good comments about the support and care from staff.

During our visit we observed staff interactions with people. We saw interactions were friendly and respectful. People had opportunities to take part in activities or chose to stay in their room .They all said they were consulted about what they could do throughout the day.

At meal times people told us they were offered a choice and provided alternatives if they were not happy with the options available. One person told us “the food is excellent here, it’s like a hotel – I have salmon for my tea”.

The MHAC spoke with seven detained people. Six people we spoke with all raised the same concern. They gave several examples of how they felt their own care was being compromised as a result of one person’s behaviour. People told us they felt the ward was no longer a therapeutic place for them.

We revisited Cygnet Hospital Kewstoke on 23 November 2011 to review actions taken to meet compliance with Outcome 9 Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We had issued the hospital with a warning notice on 4 November 2011 which required them to ensure that people are protected against the risks associated with the unsafe use of medicines by means of making appropriate arrangements for the safe administration and recording of medicines used for the purpose of the regulated activity.

We found that the hospital had developed a new audit regime at ward and staff level and carried out thorough checks of medicines and treatment orders. The hospital is now compliant with Outcome 9 Regulation 13.

We did not speak to patients about their medicines on this occasion. The purpose of our visit was to check on a compliance action set in July 2011.

We visited Cygnet Hospital Kewstoke on 13, 14, and 15 July 2011. The hospital is a low-security psychiatric service with five wards, namely Milton (female, 15 beds, rehabilitation); Nash (male, 12 beds, psychiatric intensive care unit); Clifton (male, 15 beds, rehabilitation); Redhill (male, 15 beds, complex needs); and The Lodge (male, 12 beds, rehabilitation).

The first four wards above are in the main building of the hospital. The Lodge is a separate house which has been configured to accommodate people who are either preparing to move back to the community or people who have come to Kewstoke Hospital from the community as informal patients, for support.

We were able to meet and talk with several patients on each of the hospital wards, and many of the hospital staff members. This included consultants, senior management, nursing and care staff, therapy staff, administrative staff, and members of the housekeeping team.

Kewstoke Hospital is located overlooking Sandbay near Weston-super-Mare. Patients we met told us how much they value the views from the hospital of the sea and the beach. The hospital is built and configured so that many of the patient bedrooms overlook the sea. We saw members of staff and patients using the grounds, and a game of disc golf being enjoyed by a patient and members of the occupational therapy team. We saw other patients walking in the grounds and going out on visits to the local area. One patient was going home to visit family and friends, accompanied by a member of staff.

We saw a barbeque taking place for people from two wards. People told us that this happens regularly and the food served is “lovely”. We saw people sat in the secure gardens eating the barbeque food and talking with each other. We were told by patients that the food is “absolutely lovely” and “healthy, with plenty of salads”.

Patients said that members of staff treated them well and “have really looked after me”. One patient said that “staff are amazing and try to make everyone feel safe”. One person said that they got “a bit bored at times” but others said “there’s plenty of stuff going on, but you’ve got to be motivated at times and that’s not always how I feel”.

Patients said that the activities provided by the occupational therapy team and the service from the drug and alcohol team were “brilliant” and “not patronising and does not treat us like we’re a child or stupid”. We were told by patients that the hospital was making “lots of effort” to re-enable people to be able to go back into the community. The hospital was delivering therapy programmes where the focus was upon recovery and discharge.

Patients said that having The Lodge as part of the hospital helped to demonstrate that the hospital was committed to them getting better. Patients said that they hoped to be able to stay at The Lodge, and therefore put some of the things they have learned into practice and gain some independence before being returned to the community.

Kewstoke hospital has recently been part of an investigation carried out by Health Inspectorate Wales (HIW). HIW had criticised Kewstoke Hospital for the way that it discharged a patient back into the community when he had been released from his legal detention.

We talked with patients about any plans that had been made for their eventual discharge. We also looked at the pathway of a patient who was being gradually discharged back into the community. Patients and the records that we saw told us that discharge is carried out gradually and sensitively, but that the hospital is also in the hands of the commissioners of care and the patient’s local social workers. The patient being discharged gradually in a phased plan has the full support of the commissioning team and home team.

Other patients said that they were “very confident” that the hospital would not “just chuck anyone out, or expect them to just leave and not have anywhere to go”. Patients and members of staff said that they did not feel that anyone had recently been discharged from the hospital in any way that was not safe and supported. Staff members said that all patients were discharged as safely as possible into the community and the hospital would do everything that it was able to both proportionately, taking account of patient’s rights, and the views of others in the multidisciplinary team, to ensure that this was the case.

• In the previous CQC inspection of Cygnet Hospital Kewstoke in January 2016, we issued a requirement notice to the provider. This related to a breach of regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - the safety and suitability of premises. We found this breach to have occurred on Nash ward which was the psychiatric intensive care unit.
• The requirement notice required the provider to take action to ensure that on Nash ward the cleanliness and damage to interior walls, fixtures and fittings were addressed immediately and adequately maintained from there onwards.
• Prior to this January 2017 inspection we had also had some concerns raised with CQC regarding the provision of physical health care on Nash ward. We also reviewed physical healthcare at the hospital on this inspection.
• On this inspection we visited Nash ward to review the requirement notice and subsequent actions that the provider had taken.
• The provider had undertaken various actions to address the requirement notice. It had developed an improvement plan for the ward and had progressed a number of improvements such as maintenance requests being dealt with more promptly, painting and decorating and deep cleaning of ensuite bathrooms. However, we found there were still issues over a communal bathroom, cleanliness around bolted down tables in the dining room and slight odours in some bedrooms where carpet remained.
• The provider had taken action to strengthen its focus on physical healthcare in a range of ways. For example, it had recruited two ward doctors from a GP background, developed a training programme for nursing staff and was encouraging changes in practice in line with a revised physical health care policy.

However,

• Not every patient care record we saw was easy to follow or clear about how physical health care was monitored.
• Some patients were not able to access gender specific health screening such as smear test screening for cervical cancer and breast screening for women.