An independent investigation into the care and treatment of Patient A and Patient B: Published November 2017

Cygnet Health Care should ensure that clinical risk assessment and management tools are used consistently and that clinicians have the skills and competency required to use them, to include formal training in their use.

Cygnet Health Care and Avon & Wiltshire Mental Health Partnership NHS Trust should ensure that where the requirement for forensic assessment as part of the overall assessment process is identified, this should be clearly handed over, acted upon and followed up, or the reasons for not doing so are clearly documented in the clinical notes and formulations.

Cygnet Health Care should ensure that care plans are routinely audited for appropriateness of content based on a robust assessment and risk assessment. Care plans wherever possible should be co-produced with service users and carers.

Cygnet Health Care should ensure that any care plans regarding restrictive practice are compliant with the MHA Code of Practice (revised 2015).

Cygnet Health Care should ensure that all patients in their hospitals have the facility to lock their bedrooms and secure their belongings.

SWYPFT should review its procedures for the transfer of patients to other care settings to ensure that any risks associated with transfer to other providers are mitigated and to ensure the full handover of all needs and risks, including any physical health concerns.

Cygnet Health Care should ensure that hospitals comply with the policy on routine monitoring of physical healthcare checks for patients on anti-psychotic medication.

Cygnet Health Care should ensure that where there is evident concern about a patient’s mental capacity, any assessment of capacity should be clearly recorded and a care plan developed.

Cygnet Health Care should identify a suite of safeguarding indicators including the use of supervision that should be reported through their governance system and used by commissioners to monitor quality in safeguarding.

Cygnet Health Care should ensure that all staff involved fully understand what constitutes a safeguarding event, and that all potential safeguarding incidents are reported and investigated and be monitored routinely by commissioners.

Cygnet Health Care should ensure the policy on levels of observations is clear and understood by staff, and routinely audit engagement and observation records to ensure full compliance with their policy. This audit performance should be reported to local and corporate clinical governance meetings, and at quality performance meetings with local and national commissioners.

Cygnet Health Care should review the location and size of their PICU provision and take steps to ensure that it is compliant with national guidance.

Cygnet Health Care should review the levels of senior clinical cover out of hours to provide more robust support in the assessment and acceptance of referrals, and look to reduce the number of night time admissions.

Cygnet Health Care should ensure that the new Quality Dashboard fully supports the application of integrated governance by triangulation of a range of reports and quality performance data, to enable the Board to assure itself that the organisation has a grip of quality performance at from local hospital to corporate body.

NHS England should ensure that arrangements and responsibilities for the monitoring of quality performance with independent sector providers as outlined in the Memorandum of Understanding is clear in terms of expected accountability and is understood by all CCGs, including the need for diligence before placement. In this respect, Commissioners should liaise with CQC to gain an understanding of any issues affecting quality of placements before patients are placed in spot purchased beds.

NHS England should ensure that the local oversight and information on the quality performance on all non-specialised commissioned services in the independent provider is routinely shared with commissioning CCGs and placing Trusts. CCGs should use an assurance mechanism for quality performance with the independent sector providers in their respective CCG area.

NHS England should provide assurance to local Safeguarding Adults Boards that the local arrangements for commissioning services in PICUs and specialist and non-specialist Mental Health services ensure safety and adequately manage safeguarding risk.

There is an urgent need for NHS England to review the commissioning of PICU beds, to fully understand the demand and available capacity, pattern of need and referral, and issues affecting quality of care and patient mix, and to work with commissioners and providers to increase local capacity to reduce out of area placements.

Cygnet Health Care, NHS Bradford Districts CCG and NHS England Specialised Commissioning should ensure that relevant Serious Incident investigation policies adhere to the framework of the Memorandum of Understanding to ensure that in future, in any incident where there is an ongoing police investigation, the health service providers are able investigate the incident in line with the timescales outlined by the revised NHS Serious Incident framework.

Cygnet Health Care should ensure that the organisation policy on managing and investigating serious incidents complies with national guidance, and that all completed investigation reports are checked for the robustness and quality of the investigation to ensure that appropriate actions can be implemented and organisational learning take place so as to reduce the likelihood of future harm.