26th Jun, 2022

Coventry hospital for mental health patients rated 'inadequate' by watchdog - after two patient deaths

Editorial Correspondent 1st Nov, 2019 Updated: 1st Nov, 2019

A PRIVATE hospital in Coventry for mental health patients has been rated inadequate by national watchdogs following the deaths of two patients.

Cygnet Hospital Coventry in Lansdowne Street, Hillfields, has been placed in special measures by the Care Quality Commission.

The service, which provides inpatient mental health care for women across three wards, was previously rated as Good overall.

CQC made an unannounced inspection of the hospital following during July and August this year, after concerns were raised about the patient care and safety, and treatment.

It took action to close one of the hospital’s wards, Dunsmore ward, and placed restrictions on patient admissions to all other wards.

Following information received since CQC’s inspection, restrictions to wards have been lifted but Dunsmore ward remains closed and the service remains in special measures.

The service is now rated as Inadequate overall, as well as for whether the service being provided is safe, caring and well-led.

The hospital is rated as Requires Improvement for whether its services are effective and responsive.

Dr Kevin Cleary, CQC’s deputy chief inspector of hospitals (and lead for mental health), said: “The level of care we found represented a significant deterioration compared with the standards we found when we carried out our inspection in June 2018, when we were able to rate the service as Good overall.

“There were serious issues which stemmed from a lack regular staff who knew the hospital and patients. This put patients at risk and across the hospital patients were not safe.

“Two patients had died on Dunsmore Ward, one in 2018 and one in 2019. In both cases the service’s internal investigations found that these patients had not been observed in line with the care plan or staff had not conducted observations effectively.

“Patients and staff told us observations were not being carried out in line with care plans and our inspectors were able to verify this through evidence gathered during their inspection. This put patients at risk and, as result, we took action to close Dunsmore ward and placed restrictions on all other wards to manage risks to patients more effectively.

“We also found ward environments were dirty, unhygienic and poorly maintained and we particularly found Dunsmore ward be chaotic, noisy and not conducive with a therapeutic atmosphere.

“Patients did not feel that staff always protected their privacy and dignity and a number of them did not feel safe at the hospital.

“The leadership team at Cygnet Hospital Coventry knows that it must take immediate action to address the problems we identified. We will return to inspect 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 enough people on duty to safely staff each ward, that they have the right skills, knowledge and experience, know patients and the wards well enough and take into account the gender of staff, in relation to patients, risks and their needs.

• The provider must ensure there are sufficient staff trained in the insertion and running of nasogastric feed techniques and ensure feeds are administered according to planned care.

• The provider must ensure all staff working at the hospital have the required level of training and experience in conflict resolution and de-escalation.

• The provider must ensure the respect and dignity of patients is promoted and maintained by all staff.

• The provider must ensure that all staff have a suitable handover of patient need and risk at the start of each shift.

• The provider must ensure that incidents are minimised and that, where they occur, these are managed appropriately, recorded and investigated effectively.

• The provider must ensure patient observation and engagement is carried out in line with policy and best practice.

• The provider must ensure the hospital is clean, hygienic and well maintained.

• The provider must ensure that governance processes at the hospital are fit for purpose to safely run the hospital.

• The provider must act on concerns and make necessary improvements highlighted through audit and findings from adverse incidents.

Cygnet Hospital Coventry’s services include a psychiatric intensive care unit (PICU), a highly specialised personality disorder service that also caters for those with dual diagnosis disordered eating, and a high dependency inpatient rehabilitation service. In addition the hospital also includes St Mary’s Court, seven studio apartments that offer the opportunity to safely test out independent living skills prior to service users moving back into the community.

A spokesperson from the hospital said:

“Since the CQC’s inspection in July this year, and ahead of the publication of this report, we undertook significant steps to immediately address the issues raised and have fully implemented a comprehensive action plan agreed with the CQC. The CQC has since returned to the service and praised the action we took and the measures we have put in place. This has resulted in restrictions on three wards being lifted, with major improvements underway in coordination with the CQC to reopen a further ward.

“We have also initiated a number of other strategic initiatives to further enhance our services. These include undertaking a widespread recruitment drive which has resulted in 92% of staff being permanent Cygnet employees providing consistent, familiar care for patients. We have enhanced the governance structure making it more robust with a clear organisational framework so all team members better understand their roles and can operate as effectively as possible. We have also invested in refurbishments across the hospital to ensure it provides a welcoming environment to best suit the needs of patients and their care pathway.

“We continue to work very closely with the CQC and local stakeholders to ensure that our current high standards are maintained and our service users receive the best possible care.”

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