The Care Quality Commission
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Cygnet Health Care Limited

This is an organisation that runs the health and social care services we inspect

All Inspections

27 Jan to 4 Mar 2021

During an inspection looking at part of the service

The Care Quality Commission (CQC) carried out a follow-up reactive provider well-led assessment of Cygnet Health Care between 27 January and 4 March 2021.

The purpose of this inspection was to follow up on the areas where improvement was required by Cygnet Health Care at the previous well led assessment which took place from July to August 2019. It did not revisit areas that were covered in the previous assessment and where there were no concerns or significant changes to review. This assessment did consider additional concerns which had arisen at 13 services following inspections at 20 services which had taken place since the previous assessment and feedback from other stakeholders.

The CQC regulates health and social care providers in England and so this assessment did not consider Cygnet services in Scotland and Wales.

Overall we found that Cygnet had made progress in meeting the requirements from the previous well led assessment although there was more to do.

CQC has not published a rating as part of this assessment as this is not part of the current methodology for independent health care providers.

We found a number of areas where significantly more work was needed:

  • Cygnet Health Care did not have a longer term strategic plan. The organisation lacked an organisational development approach. Members of the senior leadership team were not able to articulate which groups of service users they were planning to support in the future and how they would ensure they had the appropriate estate and skilled staff to meet their needs. As a consequence of this Cygnet had continued to close and ‘repurpose’ services and at times this took place with short notice and in response to serious concerns. This could have an adverse impact on the care of service users with the distress resulting from moving to other services. In an organisation with a clear strategic direction service changes would largely happen in a predicted measured manner, reducing the unanticipated repurposing of services to a minimum. Cygnet Health Care also had a number of service users where they were struggling to meet their needs, sometimes where their condition had deteriorated, and where the placements were breaking down. While they had made positive progress in reducing this through the development of clinical models for different types of services with inclusion and exclusion criteria, this work still needed to embed further. Cygnet Health Care needed to further develop their strategic planning for learning and development, to ensure there were staff with the appropriate skills and experience to meet the needs of the service users.

  • Cygnet Health Care did not have a good balance between its assurance and improvement work. They had invested very heavily in assurance processes since the last well-led assessment. While it was positive to see that Cygnet Health Care was taking its responsibilities to identify and improve services seriously, there was also the unintended consequence of services being constantly checked, having action plan overload and potentially not having the time to identify and improve services for themselves. In contrast their work on quality improvement was still in its infancy and was poorly understood by the leadership team who described a methodology, but did not recognise that to effectively implement continuous improvement there needed to be a significant change in the culture of the organisation to enable front line staff and service users to drive this forward.

  • While leaders and managers from Cygnet were very proud and positive about their work, many also found it hard to be self-critical and reflective. For example, they struggled to answer questions about areas for further development or improvement. There were a number of risks associated with this, including a potential failure to identify areas for improvement; a potential disconnect between senior leadership and frontline services; a potential to create an environment where people are unable to be open and transparent; and the potential to create a culture where local ownership and empowerment is unable to flourish.

  • The performance of leaders and managers at different levels of the organisation was variable and so a more tailored approach to meet individual needs, including access to coaching and mentoring and where appropriate a talent management approach. The leadership and management apprenticeships currently in place may be suitable for some individuals, while others may benefit from an alternative arrangement.

  • While the new governance systems gave improved oversight of service user safety there were still a number of areas where further action was potentially needed to safeguard people using services. Cygnet Health Care was aware of these and they were on their risk registers but they still needed significant ongoing action. These included staff recruitment and retention with staff turnover of over 30% each year and some services really struggling to maintain safe staffing; use of restraint in social care services with around 500 restraint incidents recorded a month across the services; the need for further ligature reduction work where an environmental audit had taken place and some work completed but a programme with clear timescales was needed for the remaining work.

We found a number of areas where there had been considerable progress but there was more to do:

  • There had been significant progress in bringing together the legacy organisations (companies that joined Cygnet Health Care as a result of acquisitions or mergers). Staff now identified themselves as working for Cygnet Health Care. However, further work was needed to grow the collaborative working between health and social care services within the organisation. Social care staff still felt that at times health care services were prioritised, for example some said the new business information systems were more suitable for health than social care services.

  • Cygnet Health Care had recognised the value of having arrangements for the independent challenge of the executive team. They had appointed four outstanding independent advisory board members. However, the arrangements needed further consideration to ensure they had the capacity to perform their roles. Also, board development using an external facilitator needed to be taken forward now all the independent advisory board members were in post.

  • Cygnet Health Care had put in the systems to ensure their executive team and independent advisory board members had the necessary fit and proper person checks. We reviewed this for five people and the checks were complete. At the time of the well-led assessment employment tribunal findings were published raising potential Fit and Proper Persons Requirement issues and Cygnet were considering these findings.

  • Staff working for Cygnet Health Care needed to feel more confident about speaking up within the organisation and knowing that their concerns would be heard and addressed without fear of retribution. While good progress had been made with the recruitment and introduction of a Freedom to Speak Up Guardian and ambassadors, in 2020 there had been 173 contacts from staff, service users and relatives with the CQC. This reflected a culture where people did not feel able to raise concerns directly with Cygnet, or where they felt those concerns had not been addressed. There were still some pockets of staff who reported that they were being bullied and harassed.

  • There had been significant progress in implementing an outline governance structure but some of these arrangements were very new and more work was needed to refine this further and ensure it worked effectively. There were still services where incidents of concern were taking place that had not been identified through the governance systems. This highlighted the importance of visiting services and making good use of ‘soft’ information, especially feedback from service users, carers and staff. It was also evident that important areas, such as the monitoring of the use of the Mental Health Act and Mental Capacity Act, received very limited oversight and minimal reporting to the associate board. The feedback from Mental Health Act Reviewer visits was not collated to ensure learning from themes. There was no organisation-wide monitoring of the use of the Mental Capacity Act, such as Deprivation of Liberty Safeguards in place across the services. However, staff had a significantly improved understanding of the clinical governance arrangements and how they promoted improved care and treatment across the organisation through the consideration of data and other information.

  • Cygnet Health Care had successfully introduced business information systems across all the services including service user records and incident reporting. These systems supported the automated production of data used for governance. However, further work was needed to analyse this data so it could be used to support the understanding and improvement of the services. The data produced by Cygnet fed into a number of different dashboards – clinical, quality and financial. This data was not yet brought together into an integrated performance report which would enable the advisory board and sub-committees to have all the key information they needed in one place. It was also found that HR records were still held at individual services and could not be accessed centrally which was an area for development.

  • The reporting and management of serious incidents had improved. However, there was scope to further progress the sharing of learning from incidents across services so this reached front line staff and reduced the same types of incidents happening.

  • While Cygnet had displayed their strategic priorities and these were now known by staff, they were not yet fully embedded in the work of the organisation.

  • The previous well-led assessment was positive about how Cygnet Health Care engaged with people who use services. This continued to be the case although there was scope to further strengthen the engagement and co-production with service users and Experts by Experience to promote improvements in the individual services.

  • Since the last well led assessment Cygnet had established an Inclusion and Diversity Committee and BAME (Black, Asian and minority ethnic) network which was a welcome development. However, there was more to do to promote equality and inclusion across the organisation.

  • Since the previous inspection Cygnet Health Care had introduced safeguarding supervision for staff. However, the support for safeguarding leads to perform their role from a specialist safeguarding team was limited and this needed to be reviewed to ensure adequate support was available.

  • Cygnet Health Care worked to promote positive relationships with external stakeholders including commissioners and regulators. However, ongoing effort was needed to ensure communication was of a consistently high standard.

We found a number of areas where the provider was performing well:

  • There had been a strengthening of the operational leadership capacity. The first key appointment was of a second managing director for health, which meant there were now two people in post covering the North and Midlands, and London and the South. This provided more capacity for operational leadership to Cygnet’s healthcare services although during the well led assessment some senior operational leaders in the health care division lacked insight into the challenges and how these might be addressed across the hospitals. A managing director for social care had also been appointed and was widely welcomed across the social care operational teams.

  • Cygnet Health Care now had effective arrangements in place to identify and escalate risks from services to the leadership team, aligned to their governance processes. This was enabling risks to be identified and monitored.

  • Since the last inspection Cygnet Health Care had remained financially sustainable. They recognised the importance of ongoing support from Universal Health Services and identified this as a risk but had arrangements in place to maintain effective working relationships.

  • Cygnet Health Care had largely managed the risks associated with the pandemic well. This had taken considerable time and energy and offered opportunities for organisational learning. At the time of this assessment the risks associated with COVID-19 were still identified as a major risk on the operational risk register, mainly due to the potential adverse impact on staffing levels. Where a few inspections identified shortfalls, such as staff not wearing PPE correctly, this was addressed as a matter of urgency.

  • Cygnet Health Care had worked to develop one set of policies and procedures across the organisation with arrangements in place to keep these under review.

For more information about what the provider must and should do to improve, see the Areas for improvement section.

Professor Ted Baker

Chief Inspector of Hospitals 

2 July 2019 to 2 August 2019

During an inspection looking at part of the service

The Care Quality Commission (CQC) carried out a reactive provider well-led assessment of Cygnet Health Care Limited between the 2 July 2019 and 2 August 2019, with a short notice announced assessment at the provider's offices on 2, 3 and 12 July 2019.

Cygnet Health Care Limited provides mental health and learning disability services from over 113 locations across England, Wales and Scotland.

During our assessment we:

  • interviewed the leadership team and reviewed evidence at the Cygnet Health Care Limited offices at 4 Millbank, London, SW1P 3JQ

  • carried out focus groups with the registered managers from a range of services delivered by Cygnet Health Care

  • carried out a focus group with the quality assurance managers employed by the provider.

The CQC regulates health and social care providers in England so this assessment did not consider evidence from locations in Wales or Scotland.

CQC has not published a rating as part of this provider well led assessment.

Overall Summary of our findings:

  • Governance systems and processes were not effective in maintaining sustainable and high-quality care. The systems and processes in place had not prevented or identified significant issues in locations which have resulted in breaches of regulation and hospitals being placed into special measures due to inadequate ratings.

  • Not all senior leaders could provide a clear explanation of how governance systems and processes were implemented in the organisation. Data provided to the board lacked interpretation or analysis to support the board in highlighting concerns and considering appropriate action.

  • The integration of services acquired by Cygnet Health Care had not been completed. Some policies and procedures had three versions in use - Cygnet Health Care, Cambian Adult Services and Danshell Group, all now branded as Cygnet Health Care.

    Performance and quality reporting from the Danshell Group locations did not include some measures used by Cygnet Health Care to monitor the quality of services. Different information systems were in use across the organisation for human resources, incident reporting and patient records.

  • There was not a clear escalation process for risks identified at location or regional level to the corporate risk register. The corporate risk register did not rate the severity of risks and detailed only location related risks.

  • Care and treatment did not always include best practice. Training for intermediate life support was not provided to all relevant staff across services where physical intervention or rapid tranquilisation was used. There was a high use of physical restraint and seclusion across services compared to similar services in other mental health providers.

  • Not all the required checks had been carried out to ensure that directors and members of the executive board were “fit and proper”.

  • Not all members of the executive team could describe Cygnet Health Care’s current strategy as a provider of health and social care services. There was no quality strategy in place and no framework for continuous quality improvement across the organisation.

  • The external scrutiny of the executive team’s decisions in the absence of non-executive directors was limited.

  • There was limited capacity to deliver safeguarding supervision to all staff involved in safeguarding children or adults. Further training was being provided to increase the number of staff able to provide safeguarding supervision.

  • A freedom to speak up guardian had not been appointed, although a raising concerns policy and external whistleblowing telephone line were in place to support staff to raise concerns.

However:

  • There was a stable senior executive and leadership team in place with a range of skills, who worked together to support the delivery of care.

  • Cygnet Health Care’s vision and values supported a person-centred approach to providing services. There was a strong emphasis on understanding the patient’s experience of the service they received and how it could be improved. Experts by experience worked across services to provide advice and support to improve patient experience.

  • Senior leaders took steps to improve the quality of patient care once concerns were identified.

  • Senior leaders were known by staff at all levels, approachable and had regular contact with staff across the organisation.

  • A culture of openness was encouraged by leaders and embedded within policy. Most staff knew what should be reported and felt able to do so.

  • Most services across health and social care have been inspected by the CQC and rated as good and some rated as outstanding.

21 - 23 January 2015

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

  • Identified risks were being managed appropriately. For example, the fixtures and fittings associated with curtain rails had been changed to reduce any potential self-ligature risk. Most patients felt safe on the wards and told us that staff reacted promptly to any identified concerns.
  • We reviewed the current and previous staff rotas and these showed us that there was enough staff on duty to meet the needs of the patients on both wards. Additional staff had been rostered to meet the need for enhanced staffing due to assessed patient need. Staff reported receiving effective training opportunities.
  • Assessments took place using the short term assessment of risk and treatability. Discharge planning started on admission as patients could be transferred back to their placing NHS trust at short notice.
  • Different professions worked effectively to assess and plan care and treatment programmes for patients. Staff would work collaboratively with the placing NHS trust to plan effective transfers of care.
  • We saw good examples of effective staff and patient interaction and individual support being provided. An emphasis upon least restrictive practice was noted wherever possible. The provider had a clear complaints policy and good procedures for complaint investigation and for complainants to be given a response.
  • The hospital had produced a ‘welcome pack’ for patients who were admitted to help orientate them to the hospital. These wards reported a large number of admissions and discharges over a month. Admissions were triaged by the shift co-ordinator in conjunction with responsible clinician. The length of stay on these wards ranged from less than 24 hours to three months. The wards had a dedicated social worker and they liaised closely with patients’ families and with statutory agencies as applicable.
  • Most staff were aware of the provider’s vision and values. Evidence was seen that regular unannounced visits took place by senior managers. These included night visits. Senior hospital managers had access to governance systems that enabled them to monitor the quality of care provided. This included the provider’s electronic incident reporting system, corporate and unit based audits and electronic staff training record. Senior staff were visible in the service and staff approached them to raise concerns.
  • Both wards were working towards obtaining the accreditation for in-patients mental health service.

However:

  • Four of the ten care and treatment records we reviewed did not make reference to a Care Programme Approach meeting where relevant.
  • The time allocated by the provider across the hospital for handover between staff shifts was insufficient at 15 minutes. This meant that staff worked longer that their allocated shift time in order to ensure a comprehensive handover took place.
  • Individual assessment and treatment records seen did not always demonstrate an involvement in their care and treatment by all patients. The reasons for this were not clearly recorded.

21 - 23 January 2015

During an inspection of Forensic inpatient or secure wards

  • Identified risks were being managed appropriately. For example, the fixtures and fittings associated with curtain rails have been changed across the hospital to reduce any potential self-ligature risk. Most patients felt safe on the wards and told us that staff reacted promptly to any identified concerns.
  • We reviewed the current and previous staff rotas and these showed us that there was enough staff on duty to meet the needs of the patients on both wards. Additional staff had been rostered to meet the need for enhanced staffing due to assessed patient need.
  • Assessments took place using a nationally recognised risk assessment tool; the historical current risks 20 framework. Outcomes were being monitored using the health of the nation outcome scales. Patients were receiving cognitive analytical therapy and dialectical behaviour therapy (DBT).This was being provided in four modules as group therapy. Self-reported and other outcome measures were being documented. The length of stay on these wards ranged from six months to four years.
  • Staff received training via a monthly mandatory training week. Most staff reported receiving effective training opportunities.
  • Different professions worked effectively to assess and plan care and treatment programmes for patients. The wards had a dedicated social worker and they liaised closely with patients’ families and with statutory agencies as applicable.
  • We saw good examples of effective staff and patient interaction and individual support being provided.
  • The provider had a clear complaints policy and procedure systems for them to be investigated and complainants to be given a response.
  • Most staff were aware of the provider’s vision and values. Senior hospital managers had access to governance systems that enabled them to monitor the quality of care provided. This included the provider’s electronic incident reporting system, corporate and unit based audits and electronic staff training record. Senior staff were visible throughout the hospital and staff approached them to raise concerns.

However:

  • We found examples of poor practice in relation to restrictive practices. Staff did not record incidents of seclusion and restraint in a consistent manner. Some seclusion records were inconsistent and difficult to follow. There was inappropriate use of segregation in some cases. Staff sometimes recorded food and fluid intake inconsistently whilst patients were in segregation.
  • A number of care plans had not been consistently reviewed and updated to reflect changes in assessed risk levels. Individual assessment and treatment records seen did not always demonstrate an involvement in their care and treatment by all patients. The reasons for this were not clearly recorded.
  • Training records for agency staff were difficult to review. Often the main agency of choice subcontracted to other agencies to provide staff for the hospital and this meant that the provider could not be assured of the level of training provided to all agency staff.
  • Across all four wards we noted that patients were subjected to blanket restrictions and that not all of these had been subject to a clear risk assessment.
  • The time allocated by the provider across the hospital for handover between staff shifts was insufficient at 15 minutes. This meant that staff worked longer that their allocated shift time in order to ensure a comprehensive handover took place.