The Care Quality Commission
  • Mental Health
  • Independent mental health service

Cygnet Bury Hudson

Overall: Good read more about inspection ratings

Bolton Road, Bury, Lancashire, BL8 2BS (0161) 762 7200

Provided and run by:
Cygnet NW Limited

All Inspections

During an assessment of Forensic inpatient or secure wards

We rated the service as good. The service had made significant improvements since the last inspection. Seclusion rooms had been upgraded to ensure patients had ease of access to toilets and showers. Medicines had an expiry date clearly displayed. There was strong oversight of the service with daily ward based safety review meetings and the hospital wide daily brief meetings to ensure senior leaders had oversight of staffing, incidents, maintenance, housekeeping, catering, complaints and compliments.

The service involved patients in the development of the service and had improved the involvement of carers in the service, with a carer ambassador who attended the carer meetings and delivered carer awareness training to staff. Leaders listened to feedback from patients, carers and staff and acted on the feedback.

However, at this inspection, we found 3 breaches of regulations in relation to medicines monitoring, sharing of risk and incidents and cleanliness and maintenance of the environment. The service had the systems, processes and oversight to address these promptly and had started to address these following feedback during the inspection.

Mental Health Act and Mental Capacity Act Compliance Summary

Staff received training in the Mental Health Act and Mental Capacity Act. Compliance for the service was 96% for Mental Capacity Act and 100% for Mental Health Act.

There were policies and procedures in place for both the Mental Health Act and Mental Capacity Act.

Staff we spoke with understood their role in relation to the legislation.

Medicines administration records were clearly completed and where needed the appropriate Mental Health Act authorities for prescribing were in place.

Records evidenced examples of capacity assessments completed for decisions including treatment for physical health conditions and dietary intake.

During an assessment of the hospital overall

We assessed Cygnet Bury Hudson from 28 April to 1 May 2026.

We assessed the service due to the length of time since the last inspection, which was March 2023.

Cygnet Bury Hudson was registered with the CQC in October 2021 to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983, Diagnostic and Screening procedures and Treatment of disease, disorder or injury. The service had a controlled drugs accountable officer and a Registered Manager.

We visited the following wards as part of the assessment:

  • Madison ward, medium secure unit for men with a personality disorder with 13 beds.
  • Columbus ward, medium secure unit for men with a personality disorder with 13 beds.
  • Lower East ward, medium secure unit for men with 13 beds.
  • West Hampton ward, medium secure unit for men with 13 beds.
  • East Hampton ward, low secure unit for men with 13 beds.
  • Upper East ward, low secure unit for men with 13 beds.

We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

The service had met the breach of Regulation 10 Privacy and Dignity from the last inspection. Seclusion rooms had been upgraded to ensure patients had ease of access to toilets and showers.

The service had met the breach of Regulation 12 Safe Care and Treatment from the last inspection in relation to medicines management. Medicines had an expiry date clearly displayed.

The service had met the breach of Regulation 17 Good Governance from the last inspection, there was strong oversight of the service with daily ward based safety review meetings and the hospital wide daily brief meetings to ensure senior leaders had oversight of staffing, incidents, maintenance, housekeeping, catering, complaints and compliments.

At this assessment we identified breaches of Regulations: 12 Safe Care and Treatment and 15 Premises and Equipment.

At this assessment we assessed 1 assessment service group; Forensic inpatient or secure wards, where we assessed 33 quality statements.

We rated the service as Good. We found 3 breaches of regulations in relation to medicines monitoring, sharing of risk and incidents and cleanliness and maintenance of the environment.

We have asked the provider for an action plan in response to the concerns found at this inspection.

7 - 9 March 2023

During a routine inspection

This service has now been removed from special measures.

Our rating of this service improved. We rated it as requires improvement because:

  • The ward environments needed redecoration and refurbishment. Seclusion suites did not have easy access to bathroom facilities and fresh air. Risk assessments were not always updated following incidents.
  • The patient care record system was a mixture of electronic records and paper records. This meant some documents were difficult to locate and paperwork was duplicated.
  • An epilepsy care plan was not detailed enough to ensure staff responded appropriately.
  • There continued to be medicine management concerns. There were medicines on Upper East ward with no expiry dates. This meant that staff could not be assured that these medicines were safe to administer.
  • Patients felt the quality of food was poor.
  • There were gaps in governance processes that failed to identify areas of concern.

However:

  • The wards had enough nurses and doctors. The service had significantly improved its recruitment and retention rates. They minimised the use of restrictive practices and followed good practice with respect to safeguarding and complaints. The safeguarding and complaints processes had been improved and were now working effectively.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • There were now more audits in place and there were processes for considering and feeding back lessons learnt. The service had been successful in implementing a co-production approach to quality improvement.

7-9 June 2022

During a routine inspection

We rated the service as inadequate overall and decided to place it in special measures.

When an independent healthcare service is in special measures it is the provider’s responsibility to improve it. We expect the provider to seek out appropriate support to improve the service from its own resources, and from other relevant organisations or oversight bodies or both.

We will inspect the service again within six months. If insufficient improvements have been made to justify a higher rating than inadequate overall or for any key question or core service, we will consider whether it is appropriate to extend special measures for a further six months, or whether to begin the process of preventing the provider from operating the service.

Special measures will give people who use the service the reassurance that the care they get should improve.

For more information about special measures for independent healthcare, see our Guide to special measures: independent healthcare on the CQC website.

We rated the service as inadequate overall because:

  • Patients we spoke with said they were being bullied and abused by their peers and staff members and they did not feel safe on the wards. Staff were not always discreet, respectful or kind when caring for patients. Patients and one carer told us staff could be patronising, antagonistic, rude and made negative comments about patients. Safeguarding issues were not always recognised and managed effectively by staff and patients’ needs were not always being put first. A security breach had led to a patient’s index offence being disclosed to their peers and they had to be moved to another ward after receiving abuse.
  • Staff did not always meet the communication needs of patients on the wards. A patient with a learning disability told us they were given information in a way they could not understand and information on noticeboards was in English and Welsh only.
  • Staff did not always actively involve or inform families and carers about their loved ones progress.
  • Staff turnover within the service was high. However, managers were taking steps to recruit more permanent staff and used bank and agency staff to cover staff shortages.
  • Medicines were not always well managed, and we found medicines which were out of date. There was no poster in the clinic room on Upper West ward to inform staff who the first aiders were in the service.
  • Staff did not always follow best practice in relation to the use of rapid tranquilisation. On Upper East ward, a doctor was aware that rapid tranquilisation medicine had been administered to a patient, but staff had not recorded this in the patient’s care record.
  • Staff had not informed a doctor that a patient had been placed in seclusion, so no medic review took place for this patient.
  • The ward environments were not always comfortable for patients. A problem with the central heating system was causing the heating to come on even though it was warm which was making the temperature in the hospital uncomfortable for patients and staff.
  • On East Hampton ward, patients’ sleep was being disturbed by slamming doors and lights from a sensor shining into their bedroom.
  • Staff found difficulty finding information we requested to see in care records which meant staff did not always have timely access to important information they needed to deliver appropriate care to patients.
  • Posters about advocacy were not specific in relation to the roles of Independent Mental Health advocates and Independent Mental Capacity advocates and not all of the staff we spoke with knew what the difference was between the two roles.
  • Governance processes within the service did not always ensure that wards ran smoothly, and clinical audits were not always effective. We found issues in relation to safeguarding, complaint handling, responses to feedback, staff not being able to access patient information in a timely manner, medicines management, staff attitudes to patients and carers, blood monitoring machines not being calibrated, and communication needs not being met for a patient.

However:

  • The ward environments were clean. The provider was taking steps to recruit more nursing staff to the service.
  • Staff minimised the use of restrictive practices and used de-escalation techniques to minimise the use of restraint on the wards. Blanket restrictions were in accordance with identified risks on the wards and were reviewed regularly.
  • Staff provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
  • Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.