This was a focussed inspection based on concerns we had received about the safety of Fairfax ward. Ratings have not been given for this inspection.

We found the following issues that the provider needs to improve:

• The management of environmental risks was poor and we had concerns about the management of medication. Not all staff were trained in areas, which would help to ensure that patients were cared for safely and which reduced the risk of harm. There was not a clear process in place for staff to assess and manage patients’ risks in areas such as their mobility, eating and drinking and in relation to needs for the use of restraint. When risks were identified, staff had not taken action to reduce risks and prevent harm.

• Staff did not record whether they had used de-escalation techniques with patients prior to the use of restrictive physical interventions. Staff did not record exceptional circumstances for the use of prone restraint.

• The governance systems in place did not ensure the delivery of safe and high quality care. Staff did not always follow guidance and procedures set by the provider. Internal audit and governance systems had not highlighted concerns we identified on inspection such as the poor recording of restraint and the increased falls taking place on the ward. We had made previous recommendations to the provider, which they have not acted upon to improve, the safety and quality of patient care.

However, we also found the following areas of good practice:

• The provider responded quickly to our concerns and made immediate improvements to enhance patient safety.

• Patients were engaged in activities during our inspection.

We inspected the safe domain on Fairfax Ward at Cygnet Hospital Wyke

We also inspected the seclusion facilities in relation to the previous Care Quality Commission inspection on the 22 – 25 June 2015, where we found Cygnet Hospital Wyke to be in breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because the seclusion room did not fully meet national guidance requirements. At this inspection, we found that improvements had been made at Cygnet Hospital Wyke.

We also reviewed the incidents of restraint, including the use of face-down floor (prone) restraint on Fairfax Ward at Cygnet Hospital Wyke. This was because at the previous Care Quality Commission inspection on the 22 – 25 June 2015, we found Cygnet Hospital Wyke to be in breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because they had not introduced measures to reduce the use of face down floor (prone) restraint by staff on all three of its wards. Face down restraint can put patients at risk of asphyxiation. We found that improvements had been made on Fairfax Ward where we completed this inspection.

Our expert by experience talked with five patients on Bronte ward and four patients on Shelley ward. Six patients told us they had attended meetings with the health professionals (multi-disciplinary team and community programme approach meetings) where they had been able to contribute to how they would like their care and treatment planned. One said “I put my own points of view forward”.

Seven patients told us they were aware of the advocacy service and were able to provide us with the name of the worker who came to the wards. One said “yes, talk to them quite a lot but still cannot get out”.

We asked seven patients if they felt their needs were met, four said “yes” and three told us “fifty, fifty’’. Six told us staff responded promptly if they needed help.

Four patients told us there was enough staff and four told us there was not enough staff to meet their needs. When we asked why one patient told us “there are not enough staff to take us out on visits”, and another patient told us “today at dinner time there were no staff around”.

Despite the positive comments people made, we found improvements needed to be made to ensure the records were maintained to a sufficient standard to ensure patients received the care and treatment they needed.

We carried out a visit to Austen ward at Cygnet Hospital in Wyke on 29th February 2012 to follow up compliance actions made following our last review of compliance at Cygnet Hospital in November 2011. 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.

We carried out a visit to Cygnet Wyke on 24 November 2011 to follow up compliance actions made when we last visited this service in August 2011. The compliance actions related specifically to Austen ward. 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 ward.

Three people were spoken to who use the services and none had any complaints about their care.

The inspection of Cygnet Hospital Wyke commenced on 8 November 2018 and was unannounced. The inspection was prompted by notifications of seven incidents following which two patients using the service sustained serious injuries. These incidents may be subject to criminal investigation by the Care Quality Commission and as a result, this inspection did not examine circumstances of the incidents. However, the information shared with CQC about these incidents indicated potential concerns about the management of risk such as falls from height, ligature risks, environmental risks, observation and engagement and staffing, this focussed inspection examined those risks.

We found the following issues that the provider needs to improve and have already taken urgent enforcement action to ensure improvements are made to the safety and management of the hospital. The service has begun to work on these improvements, and are engaging with the Care Quality Commission in this process.

• People were not safe and were at high risk of avoidable harm. This was because the safety systems, processes and standard operating procedures in place were not fit for purpose. This had caused unacceptable levels of serious incidents and incidents of harm to patients. There was limited measurement and monitoring of safety performance. Staff did not recognise concerns, incidents or near misses and missed opportunities to prevent and minimise harm.
• Staffing levels were not adequate, agency staffing was not well managed, staff had not completed all mandatory training, did not assess risk adequately, and did not carry out observations of patients as prescribed, which had all had a direct impact on patients
• The service did not give sufficient priority to safeguarding patients. Staff did not report all incidents to the local safeguarding authority and did not notify the Care Quality Commission of all incidents as per their registration regulations. This meant that other professionals could not be aware of the risks and issues to enable them to protect patients from harm.
• The hospital was not well led. The governance systems and process were ineffective because they had not identified the issues and risks for the service. There was a lack of ward level clinical leadership, this meant that the expectations of senior managers were not being met but there were no checking processes in place to identify this. There was little evidence of learning from events or action taken to improve safety. The culture of the hospital was poor, staff had low levels of morale and were highly stressed, they felt unable to raise concerns. The provider had failed to act on early indicators of this

.