Delay in private provider’s safeguarding probe left patients at risk of abuse, CQC finds

Delay in completing 'root cause analysis' of high numbers of safeguarding alerts at Cygnet Health Care service meant patients 'not always protected from forms of abuse', inspectors find.

Delays in a private mental health provider completing a “root cause analysis” of high numbers of safeguarding alerts at one of its services left patients at risk of abuse, a report by the Care Quality Commission has found.

A February inspection of Blackheath hospital’s Cygnet Wing, a psychiatric intensive care unit run by Cygnet Health Care, found that “aspects of care did not fully protect people”. The inspection report published this month concluded that the service, which provided care to NHS patients from 38 areas in 2011/12, failed to meet four of six care standards it was assessed against.

The Cygnet Wing notified CQC of high numbers of safeguarding alerts throughout 2012/13, including allegations by patients of intimidation, bullying and aggression. In September 2012 CQC requested the provider complete a “root cause analysis” of the issue but February’s inspection found that this piece of work had yet to be completed.

“This presented a risk that people who use the service were not protected from the risk of abuse by the provider taking reasonable steps to identify the possibility of abuse and prevent abuse from happening by making all the appropriate organisational changes required by the analysis,” CQC’s report found.

CQC’s report noted that staff at the hospital engaged with patients in a “sensitive and calm manner” but raised a series of concerns over the service. Issues included:

  • Records indicated that national guidelines for resuscitating patients were not always followed. “Resuscitation equipment bags were cluttered, and staff members were not familiar with the equipment,” inspectors found.
  • The physical health needs of patients “were not always prioritised”. Many patients had not been told how to manage the unpleasant side effects they experienced after being prescribed benzodiazepines by staff.
  • Patients were “not always supported” to be independent. Most of the time people were restricted to the ward as they didn’t yet have approved leave. Any garden leave was often “short and infrequent”. 

A Cygnet Health Care spokeswoman said inspectors highlighted the “skills and experience of dedicated staff” at Blackheath. The concerns raised by CQC were “acted on immediately to ensure the service matches the high standards we demand,” the spokeswoman said.

“This service has undergone a further inspection on 22nd August 2013. We are confident that the evidence we provided to the CQC at that recent inspection demonstrates our compliance with the areas highlighted in the February inspection,” the spokeswoman added.

The company also responded to the findings of a second CQC inspection report, published last month, which failed Cygnet Hospital Stevenage against all seven of the care standards it was inspected against.

Inspectors found staffing levels at the medium-secure unit were insufficient, identified issues with record keeping, and concluded that shortfalls in the hospital’s seclusion areas compromised patients’ “privacy and dignity”.

“The provider had not taken steps to address identified risks to people using the service, “ the CQC report concluded.

A Cygnet Health Care spokeswoman said the service had “independently identified” the areas for improvement prior to the CQC’s inspection and had acted on them in recent months.
“We look forward to demonstrating that we are fully compliant in all areas when the next inspection takes place,” the spokeswoman said.

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