- Independent mental health service
Cygnet Bury Hudson
Assessment report published 27 July 2026
Contents
Ratings - Forensic inpatient or secure wards
Our view of the service
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.
People's experience of this service
Feedback from patients
We spoke with 30 patients.
Patients mostly said the wards were clean and that they individualised their rooms.
The majority of patients told us they felt safe in the service, however 3 patients said they did not feel safe and they did not think staff responded quickly enough to incidents.
Patients told us generally there was enough staff however there had been times when staffing challenges impacted on leave, being able to access the social hub and the outside spaces. Patients told us staff mainly were respectful and polite and did their best to respond to their needs. Patients told us that they felt listened to, out of 26 patients that told us about their experiences of staff, 22 patients told us that staff were respectful and polite. 4 patients said staff were not very supportive. With one patient saying “Some staff just stay in the office and don't particularly interact with patients”
Patients mostly felt involved in their care and understood the reasons for their treatment. They had been involved in writing their care plans and received copies of them. However, 3 patients did not feel involved and felt that changes in their multidisciplinary (MDT) team resulted in the MDT not being very visible on the ward and not having drop in opportunities with the MDT.
All patients we asked, confirmed they had access to advocacy. Patients told us how they were involved in the development of the service and gave examples of their involvement in interviews, delivering training and patient meetings.
Patients knew how to complain and told us that when they had submitted complaints they had been investigated and they had received a response and outcome.
Activities were described positively by patients, including the social hub, the gym, football, music studio, gardening, cooking, recovery college, bingo and quizzes. Patients valued the opportunity for paid work within the service. However, patients said there was a long waiting list to access courses at the recovery college which they found frustrating.
Food was an area that patients said could be improved, with 3 patients telling us they made their own food, 7 telling us that there lacked choice and the quality was poor. An example was that there were too many chips on the menu.
Feedback from carers
We received feedback from 10 carers following the onsite inspection. Feedback about the service was mostly positive, with carers saying the service was more responsive than other placements that their loved ones had accessed. A parent said “This hospital is the only one that has phoned me about my son and asked my advice about what he likes and does not like.” 7 carers told us that they received information about the service, 3 did not.
Mostly carers felt involved in their loved one’s care, with 8 carers saying they were involved in the goal setting and care planning process, 2 were not involved. 9 carers were involved in ward rounds and review meetings and appreciated the remote option to join as they lived far away from the service.
Carers felt listened to and 6 were asked for feedback about the service, 3 had not been asked. Carers events were well received with 3 carers who attended saying they were helpful and supportive.
Most carers knew how to complain, with 7 understanding the process, 2 were unsure how to complain.
Due to the distance carers lived from the service, 2 carers said they would like the service to consider home visits to enable them to see their loved one.
Carers mainly found it easy to book visits and that they went well, however one carer found the process difficult and told us when they arrived, they were told the visit was not booked. Another carer did not know that they could visit their relative. There had also been communication challenged with a carer regarding what they could bring to the visit.
Areas for improvement from carers was more activities at a weekend. Also making the meetings more accessible with the terminology that some staff used which was difficult to understand. Also involving support staff in the reviews as they are the staff providing the majority of the care.
Feedback from stakeholders
We received feedback from 4 stakeholders. Stakeholders told us that the service was responsive, if they raised any concerns or queries, the service acted on these promptly and provided an update and outcome. Observations made by stakeholders was that the service was person centred, listened to patients and treated patients with dignity and respect. Staff had a least restrictive approach and showed kindness and compassion towards the patients.
Stakeholders shared how patients were involved in the development of the service, had opportunities for paid roles with the service, involvement with the people’s council and interviewing staff. Patients had shared with stakeholders the value of the social hub, the gym and recovery college. Stakeholders highlighted the improvement in the risk assessment and the training provided to staff.
Areas for improvement raised by stakeholders, included making statutory advocacy referrals more promptly, improving consistency of communication regarding patients’ leave, and adhering more reliably to scheduled meeting times. Also ensuring there are enough staff to deliver activities and facilitate leave. An area of frustration shared by patients to stakeholders was property going missing or being damaged and that it can be a lengthy process to resolve.
Communication was an area for improvement identified by stakeholders, including communicating when there were changes in ward managers. Also, staff absence and who to contact during the absence. Space within the service was identified as a challenge, with there not being enough meeting rooms for meetings to take place which can result in meetings being delayed or visitors rooms being used which would impact on availability for visits to take place.
Staff wellbeing and carer involvement was identified by stakeholders as an area for further development. Also, there was an acknowledgement that the environment requires some improvements.