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Independent mental health service in Chesterfield put into special measures

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The Care Quality Commission has rated Cygnet Acer Clinic, in Chesterfield, as Inadequate following an inspection.

CQC carried out a focused inspection at the service on 19, 20 and 28 August 2019 following a number of concerns and a serious incident.

The inspection highlighted further concerns. As a result, CQC placed urgent conditions on the service’s registration to stop admissions and it is now in special measures.                                                                                                                                                                                                           

In November 2018, CQC rated the service as Good overall. The most recent inspection looked specifically at whether the service is safe and well-led and, as a result, the service is now rated as Inadequate overall as well as for whether its services are safe and well-led.

The service provides care and treatment for female patients with personality disorder and who self-harm, some of whom also have a mental illness, learning disability, substance misuse problems or unrelated physical health condition.

CQC’s Deputy Chief Inspector of Hospitals (and lead for mental health), Dr Kevin Cleary, said: “The care provided at Cygnet Acer Clinic fell well below the standard that people should expect to receive. We found a number of concerns about the service being provided and the risks to patients during our inspection.

“We found that the service was not ensuring the safety of those in its care. The number of incidents of self-harm by patients had increased in the three months leading up to our inspection and almost half of the incidents involved patients using a ligature. Ligature risk assessments for wards were too generalised and did not include all ligature anchor points on the wards, meaning service leaders and staff were not effectively minimising the risk of serious harm to patients.

“Prior to our inspection a whistle blower had contacted the Care Quality Commission and during the inspection two further whistle blowers contacted us. They reported low staffing levels, a lack of support from managers, and a lack of action by managers when they raised concerns.

“We found that 75% of staff were not suitably qualified for the role they were doing and we found that staff were not always available to support patients when they needed them. On at least four occasions inspectors witnessed patients congregating on the ward, in front of the reception area, banging on windows to attract the attention of staff who were not on the ward.

“Observations on patients were not carried out as they should be and we found that risks to patients were not being managed effectively. The service being provided was not safe and that is why we have taken action to suspend admissions to the service and placed the service in to special measures.

“The leadership team at Cygnet Acer Clinic knows that it must take immediate action to address the problems we identified. We will continue to monitor the service very closely and if urgent improvements are not made to ensure people are safe, we will take action to prevent the provider from operating this service.”

The service has been told it must make a number of improvements, including:

  •  The provider must ensure there are sufficient numbers of suitably qualified, skilled, competent and experienced clinical staff at all times to meet the needs of patients.
  • The provider must undertake an assessment of the safety and well-being of each patient, which should include a comprehensive review of risk assessments, risk plans and levels of observation to ensure patient safety.
  • The provider must undertake a comprehensive review of the daily meeting system for discussing and recording patient incidents and risk management.
  • The provider must urgently address how lines of sight on corridors are mitigated by staff and ensure that convex mirrors in blind spots are introduced where appropriate, ensuring objects constituting a ligature risk are removed.
  • The provider must undertake a comprehensive ligature assessment demonstrating how the risks are being mitigated.
  • The provider must ensure all staff have completed training in personality disorder, suicide prevention and self-harm management, carrying out of observations and undertaking ligature assessments.
  • The provider must ensure that incident patterns and trends are analysed to show an individual and unit picture e.g. time, location, type, so staff can make managerial decisions.
  • The provider must ensure patients have therapeutic and meaningful activity and ensure that staff accurately record the uptake of activities.
  • The provider must ensure they review and manage staff shift patterns, monitor excess hours and ensure that staff have sufficient rest days built into shift patterns, including volunteer staff.
  • The provider must review and evidence learning from serious incidents and actions taken to improve safety within the unit and ensure that learning is shared with all grades of staff.
  • The provider must review the observation policy and audit how it is being implemented.
  • The provider must take steps to minimise infection control risks by patients sharing sharp objects to self-harm.

A spokesperson for the clinic said: "We are disappointed that the CQC has published such an inaccurate picture of the care currently provided.

"This CQC report is in fact from an inspection in the summer. Since then, there has been a further inspection in October and the CQC has recognised the progress made and given us positive feedback. We expect that report to be published shortly.

"We have implemented substantial improvements and all the measures called for have been introduced, including a renewed focus on recruitment and training for staff, strengthened observation and engagement policies and a full review of care plans and risk assessments.

"We have also adopted an open and transparent culture with our CCG and NHS partners who have visited the service to see the improvements made and have been instrumental in supporting our progress.

"The percentage of nursing staff who the CQC said were 'unqualified' is inaccurate, as it refers to the percentage of staff who are support workers as opposed to registered nurses. By September 100% of all staff had completed the required training.

 "We remain committed to working collaboratively to provide safe, supportive care for our patients and their families and where required we will continue to make rapid improvements."

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