Our rating of this service is 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; 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:

• Staff did not ensure patient privacy and dignity whilst they were in the bedrooms and when they were using the bathroom, for example by not ensuring doors were closed. Staff were observed talking about patients care in front of other patients.
• Do not attempt to resuscitate forms were not always easily found in the patients notes.
• Although staff received Safeguarding Individuals at Risk E-Learning which was equivalent to Safeguarding Training Level 2, the provider had identified that this level of training was not adequate and had enrolled staff on Safeguarding training Level 3 including safeguarding children.
• Managers did not ensure that appraisals were individual for each staff member. We saw one record contained two staff members names’ in the same record.

This was a short notice announced re-inspection to determine what progress Cygnet Hospital Taunton had made since being rated inadequate at the previous Care Quality Commission inspection in February 2016.

During this inspection (February 2017) progress had been made and we were able to amend the ratings for safe from inadequate to good, caring and well led from requires improvement to good and effective from inadequate to requires improvement. Overall we were able to re-rate the hospital from inadequate to good.

At this February 2017 inspection we rated Cygnet Hospital Taunton as good because:

• Some work had been carried out to improve the environment within the hospital since our inspection in 2016, for example wards had been redecorated and carpet had been replaced with vinyl flooring.
• Wards were clean, and free of odour.
• The senior management team within the organisation had supported new managers at the hospital to make a range of service improvements. The new managers provided strong leadership and staff that we spoke with had embraced the drive to improve the service.

• Patients and relatives commented positively on the care they and their family members received. Care records contained up-to-date, personalised, recovery orientated care plans.

• The provider had reviewed their medicines administration systems to ensure that medicines were administered to patients in a timely manner and followed safe practice.

• Required staffing levels had been achieved regularly. There was appropriate use of bank and agency staff. Staff had completed a thorough risk assessment for each patient. Records indicated that staff were carrying out the required level of patient observations.
• The provider had a pro-active approach to reporting safeguarding incidents. The provider had demonstrated learning from serious incidents and displayed an open approach when liaising with external agencies.
• Eighty-eight percent of staff were up-to-date with mandatory training.
• Staff from all disciplines participated in audits. Audits were reviewed at a monthly team meeting, actions were generated at the meeting in the form of action plans.
• We saw evidence of good discharge planning throughout the hospital.
• Staff told us that they felt able to raise issues through their managers and that their concerns were responded to appropriately. Staff told us that morale was good and teams functioned well.

However:

• Some staff were unable to tell us about the needs of the client group and how best to support them. Psychological interventions were delivered by the psychologist only. Ward staff did not describe using psychologically informed approaches in their interaction with patients. This was relevant as many patients displayed challenging behaviour and it was not clear how this was being addressed.

• Staff on an upstairs ward told us that often they could not facilitate patients going outside due to staff availability. Staff told us that when patients said they did not wish to go outside they would respect this.  We did not see staff distracting two patients who were becoming agitated.

•  Some patients had rooms that had been personalised by relatives or staff but not all. Staff that we spoke with on the wards about this did not appear to see this as their role. There was more work to do on the wards to make them appropriate for the needs of the client group, this included consideration of appropriate furniture and decoration.

• Staff had difficulty telling us how they might apply the principles of the Mental Capacity Act on a day to day basis in their interactions with patients. We found that in most care plans reference to mental capacity was completed with standard phrases. In some files we saw that assessments of capacity had not recently been completed and it was not clear if they had been reviewed or updated to ensure their ongoing validity.

• Whilst some changes had been made to the environment since the last inspection, it still lacked some resources for people with dementia such as items in the environment to cognitively stimulate patients. Some wards had features or furniture that was not appropriate for the client group such as bookcase wallpaper. Furnishings were in good condition but some were not appropriate for the safety of the client group. For example there were small side tables in patient lounges, some were located next to armchairs. On the day of the inspection we saw that two patients had difficulty manouevering around a small table to sit down in an armchair. 

• There was no training for staff on mental illness.

We rated Cygnet Hospital Taunton as inadequate

because:

• All wards had blind spots which meant staff could not respond immediately to defuse potential assaults between patients or respond to a fall. Falls were not always recorded and falls plans put in place. Patients with a history of falls were not assessed by either a falls nurse or physiotherapist. Whilst the staff used observations to mitigate risk, we found some observation records incomplete. The provider acknowledges that line of sight could be improved in order to mitigate the risks posed.

• Risks to patients health such as pressure areas, nutrition and other health problems were not always monitored effectively. Information from discussions about patient care was not always recorded in records in a timely way. Pressure areas were not always checked and care records updated.

• We saw one patient who was left in bed until 12:30 despite asking to get up. Staff told us as the patient was mobile and that the patient had to stay in bed as staff were too busy delivering care to other patients.

• Staff did not follow best practice when administering medication. Medicines were not always administered at the correct time and important information was not always recorded on the prescription chart. Staff did not give patients information about what medicines they were about to receive. Directions for the administration of covert medication were not documented on the medication administration sheets. There could be long delays in obtaining medicines.

• Incidents were not always reported. We found incidents recorded in patients’ notes but no incident form completed. During our visit we witnessed a patient fall. That evening the same patient fell again. We looked in the patients care records the following day and could find no record of the first fall.

• Patients' physical heath was not always assessed on admission or regularly reviewed thereafter. Important regular physical health checks were not always carried out.

• Assessments and care plans were not routinely reviewed and updated. There was little evidence of patient involvement in developing their own care plans. There was no system in place to support patients with dementia to make choices.

• The ward environments were stark and not suitable for those patients living with dementia. Bedrooms were not personalised nor decorated unless a family member came in to do this with a patient. There were restrictions on access to outdoor space.

• The hospital did not deliver any rehabilitation services and access to physiotherapy, occupational therapy and psychology to support rehabilitation was minimal. Patients with challenging behaviour had no psychological input and there were no systems in place to develop any behaviour support plans.

• There were 38 staff leavers between Feb 2015 and Feb 2016. Of these 38 leavers only one member of staff, a Health Care Assistant, was dismissed for gross misconduct in July 2015.

• Staff training was low in some areas and the induction of new staff was not always fully completed. Staff did not receive supervision in line with the provider's policy.

• There was a generally poor service for women at the hospital. Women on Willow ward had very limited space and could not be protected from a noisy environment. There was insufficient communal space on the ward and access to fresh air was via the male dementia ward.

• The provider had a governance system in place, however it had failed to identify and address serious shortfalls in care across the hospital. There was no effective system of audits in place to identify areas needing improvement.

However:

• The hospital maintained good health and safety checks.

• There was availability of equipment to assist with poor mobility.

• Staff were caring, respectful and attentive to patients. Patients were complimentary about the staff. Patients were clean and tidy and relatives told us that this was always the case.

• Staff reported they felt well supported by their managers. There were regular integrated governance meetings and improvements had been made to hospital systems. Sickness and absence rates were low. There was good morale in the team. There were opportunities for career development for staff at all levels.