'Insufficient' improvements made at inadequate Bradford mental health hospital

The Care Quality Commission (CQC) carried out a focused inspection of Cygnet Woodside, Beacon Road, Wibsey, in March to find whether improvements had been made after a previous unannounced focused inspection in September last year.

Following the September inspection, the hospital was rated inadequate and placed in special measures.

The CQC had also imposed conditions on Cygnet Woodside. It was unable to accept any new people without written agreement and managers had to provide regular reports on the improvements they had made.

Following the latest inspection, the overall rating remains inadequate. The hospital was also rated inadequate for being safe, effective, well led and responsive, and rated requires improvement for being caring. 

Debbie Ivanova, the CQC’s deputy chief inspector for people with a learning disability and autistic people, said:  “During our inspection of Cygnet Woodside, we found that the improvements made since our previous inspection were not enough to ensure people were safe and receiving the best possible care. 

“People were not always supported by staff who could meet and anticipate their caring needs.

"Also, there were not enough staff working at night, especially as the hospital had two floors and staff had to work between these. During our out of hours visit, we saw that two people went for significant periods of time without support. 

“We found that people stayed at the hospital for a long time. This was even though the hospital website described it as an assessment, treatment and fast stream rehabilitation unit where people should only stay for short periods of time. 

“When we saw staff spending time with people, they did receive kind and compassionate care and most relatives spoke highly of the regular, experienced staff and the care their loved one received.

“Following our inspection, the provider recognised the building was not fully fit for purpose and decided to close the hospital. It worked closely with people, their families and staff to find alternative services for people.” 

Inspectors raised concerns that while the hospital said it provided assessment, treatment and fast stream rehabilitation, most people had been at the hospital for long periods of time.

They said people’s needs were not fully met by the physical environment of the hospital.

“For example, the ward was noisy, the upstairs corridor lacked natural light and there was a lack of outside space. This meant that it was not suited or adapted to meet people’s needs, including their sensory needs,” they said.

The report said: “People were not kept fully safe from avoidable harm. One person who was at risk of choking had recently had two episodes of choking.”

Inspectors said that people were not always supported by staff who had the correct training to keep them safe – only 61 per cent of staff had completely mandatory autism training.

They also raised concern that staff did not always recognise incidents and report them appropriately.

“We identified at recent engagement that the service had not told us recently about a notifiable incident involving an injury,” said the report.

“Managers notified us formally after we told them they needed to tell us about this. This was despite managers putting in improved systems to manage and record safety incidents.”

Inspectors said people’s care and treatment “did not focus on their quality of life outcomes and did not meet best practice”.

They added: “People were not always supported by staff who could meet and anticipate their caring needs.

“There were not sufficient staff working at night, especially as the hospital had two floors and staff had to work between the two floors.

“During our out of hours visit, we saw that two people went for significant portions of time without staff support and one had to wait and ask for their needs to be met before they were met.”

People’s spiritual needs were not always met.

“One person had an identified care need to attend religious service or to be offered religious materials,” said the report.

“On the evaluation of the written plan of care, staff had recorded that this had not been achieved stating that there was no evidence that this had been offered to the person. There was no further explanation to understand why this person’s spiritual needs were not met.”

Inspectors said managers “had not taken enough action to manage the risks and develop and improve the service”.

Professor Ted Baker, Chief Inspector of Hospitals, said: "This service was placed in special measures in December 2020.

"Insufficient improvements have been made such that there remains a rating of inadequate for any core service, key question or overall.

"Therefore, we would normally consider acting in line with our enforcement procedures to begin the process of preventing the provider from operating the service.

"However, the provider has notified us that they are no longer operating the service from this location at this time.

"The service will be kept under review and, where necessary, another inspection will be conducted within six months."

In response to the CQC inspection report on Cygnet Woodside, published today, a spokesperson for Cygnet Woodside said: “Although we are disappointed with the overall rating, the CQC report reflects the many improvements that had been made since the last inspection and acknowledges that people received kind and compassionate care from our staff who protected their privacy and dignity.

“As the report highlights, people were safe from abuse, and relatives of service users also spoke highly of our regular, experienced staff who they felt were keeping people safe and knew their needs well.

"Although concerns could be raised easily, the report confirms there had not been any recent complaints.

“As is Cygnet’s priority, people and those important to them were supported to make day to day decisions around their care and treatment and our staff and specialists had received additional relevant training to meet people’s needs.

“Our care focused on helping patients return to the community and to live as independently as possible, and the report highlights that staff planned and managed discharges well and liaised with hospitals that would provide aftercare.

“Despite this progress, we also recognised early in the year that work needed to be done to maintain the physical environment of the hospital and, in consultation with the CQC and commissioners, we have temporarily closed the hospital for maintenance work.

“This was done sensitively and over a longer period so that our staff could work with services that provide aftercare to ensure people received the right care and support in their new placements, and this is also noted in the CQC report.

“We continue to work closely and collaboratively with the regulator and other stakeholders and look forward re-opening.”