Cygnet Bury Hudson

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

Good: This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We make sure people are at the centre of their care and treatment choices and we decide, in partnership with them, how to respond to any relevant changes in their needs.

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

At admission, patients were involved in their assessments, care planning and goal setting. Occupational therapy staff were involved in creating interest checklists with patients with the aim of patients developing skills and activities they were interested in.

Patients were involved in their review meetings, patients told us and we saw that patients were listened to within those meetings and their requests were considered by the multidisciplinary team.

Positive behaviour support plans and one page profiles were in use, to advise staff how best to support patients. We saw accessible communication aids in use, including symbol cards to express feelings and emotions, social stories to explain what to expect in certain situations. Neuro inclusive passports were in the process of being introduced to the service for neurodiverse patients and included what is important to the patient and how best to support them.

In May 2026 Columbus ward had hosted a Columbus Day to bring staff and patients together in a positive and inclusive environment, helping to strengthen relationships and create a strong sense of belonging and safety across the ward. During the day the mutual expectations were reviewed and collaboration activities took place throughout the day. Positive feedback was received from patients and staff involved in the day.

Activities were tailored to patient needs with the aim of developing self care skills and included groups for sleep hygiene, sensory relaxation, vocational skills, life skills and wellness.

Weekly community meetings took place on the wards to enable planning to take place, expectation to be explored and for patients to feed back about the ward environment.

We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.

We scored the service as 4. The evidence showed an exceptional standard. The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff ensured that patients had access to education and work opportunities. Several patients were volunteering in the local community, including in charity shops. Feedback from one of the patients who volunteered in the local community was “Volunteering makes me happy as it gets me off the ward and keeps my mental health stable. The work keeps me busy and the jobs have been easy and it will be good to learn more as I go along. Volunteering will help me get ready to get into work when getting discharged into the community.”

Patients and staff had collectively collected clothes for a charity supporting homeless people, this idea was suggested by a patient and was well received. Feedback from the charity was “A fresh set of clothing after a shower can help our friends face the day ahead, often full of meetings with various support agencies as they try to rebuild their lives on their journey off the streets. Thank you to Cygnet Bury Hudson for helping them on their journey.” The service had also received a letter of recognition from their local MP for the contribution to the charity.

Patients had access to the recovery college which included courses on Gardening, Painting and Decorating, Home Maintenance, Woodwork, Media, Photography, Arts and Crafts, Maths and English. 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. There was a staff vacancy within the recovery college which had recently been recruited to and when they started, this should have a positive impact on the waiting lists.

The gym and social hub was valued by patients, these provided opportunities for patients to keep healthy, pursue hobbies and interest and socialise with peers.

Staff supported patients to maintain contact with their families and carers. There were 2 visitors’ rooms within the service, one was for families use and included games, toys and activities for children. They were both a welcoming space, with a lounge area, drinks machine and toilet off the room. Patients with authorised leave could see visitors in the local community and for patients with family who could not travel to the hospital, staff supported patients to visit families in the home environment.

The service arranged for a Christmas meal for patients and their families on 21 December 2025, following feedback from families that they had not spent time with their relatives at Christmas for a long time. This event was very well received by all involved with positive feedback.

The service were accredited with Triangle of Care at Star 1 level. This acknowledged the work the service had done to involve carers and identified further areas for improvement including improving internet access for carers to join the meetings remotely and nurses to be involved in providing carer feedback.

There was a parent who was a carer ambassador and attended the carer meetings and delivered carer awareness training to staff.

Staff supported patients to access their chosen place of worship within the community. Some patients visited local churches to worship. An imam visited the service twice a week. There was a multi faith room within the service for patients to access too.

We do not always provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs.

We scored the service as 2. The evidence showed some shortfalls. The service did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed. These included statutory notifications to CQC and commissioners.

Information governance systems included confidentiality of patient records. Patient records were electronic. Staff had individual logins to access the care records. Computers were positioned in offices where patients could not see confidential information. Patient ‘at a glance boards’ were located in the ward office in a location that patients could not see.

The service complied with the Accessible Information Standard. Records included how best to support individual communication needs, including the use of symbol cards and social stories.

Staff ensured that patients could obtain information on treatments, local services, patients’ rights and how to complain. The welcome booklet contained this information and there was information displayed on the notice boards in the wards.

Patients had recently been involved in creating a newsletter which included messages from managers, jokes, wellbeing tips, poetry, yoga poses, details on the advocacy service, patient carer race equality framework champions, healthy eating and available activities within the service.

The information provided was in a form accessible to the particular patient group. There was accessible information available, the newsletter included pictures, images and some symbols.

Staff had access to an interpreting and translation service and could request information in different languages.

Staff mostly ensured carers, families and commissioners were regularly updated about the patient’s progress. We spoke with 10 carers. 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.

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. However, 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.

We make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. We involve them in decisions about their care and tell them what’s changed as a result.

We scored the service as 4. The evidence showed an exceptional standard. The service was exceptional at enabling people to share feedback and ideas, or raise complaints about their care, treatment and support. They always involved people in decisions about their care and told them what had changed as a result.

The service had received 183 Stage 1 early resolution complaints in the 12 months prior to the inspection, the majority of these were resolved locally at ward level. There were 18 Stage 2 formal complaints received by the service in last 12 months.

Of the 18 complaints, 2 were upheld, and 10 were partially upheld. None were referred to Ombudsman in last 12 months.

We reviewed the process for managing complaints. There were locked feedback boxes for each ward, staff involved in the management of complaints had the key to the box, ward staff did not have access to the box. The feedback was collected daily from the boxes. The number of complaints and compliments were added to the daily managers meeting template, the feedback was scanned into the system to record feedback, these were shared with ward managers for their investigation. If the complaint could be resolved locally, patients received an outcome letter. If a stage 2 complaint was raised, these were acknowledged by letter and added to the system and linked to the incident reporting system, the allocation for investigation of the complaint was agreed in the morning managers meeting and the investigator would be independent of the ward manager. Records viewed confirmed the efficiency of the process, including feedback to the complainant.

Patients knew how to complain or raise concerns. Information was included in the welcome booklet and on display on the wards.

Staff received feedback on the outcome of investigation of complaints and acted on the findings. These were shared via monthly team meetings and the team brief. There was a standard agenda item for team meetings for complaints and another for compliments. A recent learning from complaints was for staff to prioritise one to one sessions with patients to ensure patients had regular opportunities to discuss their progress and any concerns.

The service had received 316 compliments in the 12 months prior to the inspection. These were mainly in relation to staff and quality of care they received.

Patients were truly involved in the service. A patient was co facilitating guitar lessons with one of the recovery college tutors. A quarterly newsletter was co-produced by patients and recovery college staff to update patients on changes in the service and provide ideas to improve their wellbeing and support their recovery. A patient’s art work was displayed throughout the hospital to provide inspiration to other patients and staff.

Monthly patient forums took place, co chaired by a patient and supported by a staff member. Discussions included changes in the Care Programme Approach standards and wanting to ensure all patients were actively involved in their reviews. Patient forums included a review of the social hub facilities, discussion about regulation and how to improve the service further, staffing and service development.

Patients were involved in a Gym forum to agree the equipment that would be purchased and how the facilities would be decorated. This had been completed at the time of the inspection, with a welcoming gym with a variety of fitness equipment to meet patients individual needs.

A food forum had been established for patients to co produce the new menu. Patients gave views on the menu and what could be improved.

Annual patient surveys took place, the most recent survey showed an average score of 4 out of 5. The lowest score was 2.8 for there are enough activities for me to do in an evening. Wards had increased their social activities on the ward including a pizza making session which patients told us they thoroughly enjoyed.

Weekly community meetings took place on the wards. The agenda followed the enabling environments model of belonging, boundaries, communication, development, involvement, safety, structure, empowerment, leadership, openness and blanket restrictions in 2 wards and the 5 key questions of safe, effective, caring, responsive and well led on 4 wards. Actions were identified at each meeting and updated and reviewed at the following meetings, minutes showed actions were taken following patient feedback.

At the most recent carers event, in March 2026, there was a presentation from the psychology team about schizophrenia and emotionally unstable personality disorder. Refreshments were provided. The Art Therapist provided a presentation and facilitated a creative activity. Carers then had an opportunity to spend time with their relatives. Carers engaged with the presentations and provided positive feedback about the event.

We make sure that everyone can access the care, support and treatment they need when they need it.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

Staff ensured the needs of patients with mobility issues were met. There was a lift to all floors and the building had ground level access.

Staff made reasonable adjustments for patients – we saw one patient with mobility issues who had an adapted room with aids and adaptations to promote their health and wellbeing.

There was adequate medical cover day and night, a doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital. There were 2 tiers of on call for doctors, with speciality doctors able to contact the consultant on call if required.

The service had models of care in place, one for the services for patients with a mental illness which was introducing me (Pre-Admission), understanding me (Admission), building my skills (Assessment), promoting and building my independence (Treatment) and preparing to move on (Transition and Discharge). The models of care for the services for patients with a personality disorder was admission and assessment, stabilisation, treatment, transition and discharge. These were explained to patients and were included in the welcome pack.

Staff planned for patients’ discharge, including good liaison with care managers. Meetings observed and records showed discharge planning taking place and appropriate liaison with the ministry of justice and home teams.

In the 12 months prior to the inspection, there had been 23 discharges. Five patients went to prison, 5 were repatriated to NHS hospitals, 13 patients progressed to services with lower security levels including low secure services, rehabilitation services and supported living services.

We do not always actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We do not always tailor the care, support and treatment in response to this.

We scored the service as 2. The evidence showed some shortfalls. Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views. Patients told us and records evidenced there were a variety of forums and methods for patients to provide feedback.

The provider had not included equality impact assessments as part of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

Staff were trained in equality, diversity, inclusion and human rights with 100% compliance.

Staff promoted and supported people’s diversity, for example referring to patients with their preferred name and pronouns, enabling patients to practice their faith. There was a bible study group within the service.

A LGBTQ+ group had been set up and was in development to determine the best times to achieve optimum attendance. Patients told us there was more that the service could do to meet the needs of the LGBTQ+ community and did not feel that the service had supported and promoted the development of the group.

We support people to plan for important life changes, so they can have enough time to make informed decisions about their future, including at the end of their life.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff support patients to make decisions about their care and treatment and their future – this was discussed as part of the multidisciplinary reviews and on a one to one basis.

Staff created personalised care plans to account for the patient’s needs, wishes and feelings. These included specific health needs for patients, for example epilepsy and diabetes.

Care for people who are nearing the end of their life was managed and communicated in a sensitive and dignified way. We saw planning in place for older patients with health needs to identify an alternative placement to better suit their needs and abilities.

Staff ensured all relevant healthcare professionals and other relevant bodies are involved in planning the care and treatment of people with complex needs. The service had a full range of multidisciplinary colleagues, however for specific requirements for example speech and language therapy and dietician input, there were referrals made for the input of those professionals. There was a service level agreement in place for a GP to visit the service weekly.