Cygnet Bury Hudson

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained Requires Improvement. The service was in breach of Regulation 12 Safe Care and Treatment and 15 Premises and Equipment.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We have not awarded this service a score for Safe.

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

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There had been 9 serious patient safety events in the 12 months prior to the inspection. 3 were deaths, 3 were absent without leave (AWOL), 2 were assaults, 1 was patients testing positive for illicit substances.

All staff we spoke with knew what incidents to report and how to report them.

Incidents we reviewed demonstrated staff were aware of and reported incidents in line with the provider’s policy. We saw incidents reported on the electronic incident record and also within patient records and at handovers.

Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation if and when things went wrong. Written apologies were provided and investigations took place.

Staff received feedback from investigation of incidents, both internal and external to the service. Lessons learnt were shared via the provider’s intranet page and included links to resources including choking awareness and prevention. Service level lessons learnt were shared via monthly lessons learnt bulletins. These included raising awareness of items that could be purchased online with opportunities to bring contraband items into the hospital.

Staff met to discuss feedback. ‘Hot topics’ were published for the service at approximately quarterly intervals. These were shared with the teams and a see and sign sheet was completed by staff to confirm receipt of the information and actions.

There was evidence that changes had been made as a result of feedback. Structured Judgement Reviews took place by medical staff of all deaths in the service. Learning was shared and staff gave examples of learning, including the awareness of the GTN(Glyceryl trinitrate) Protocol, an emergency medicine and when staff should administer this.

Staff were debriefed and received support after a serious incident.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. The clinical team including the Responsible Clinician, nurses and members of the multidisciplinary team were involved in visiting the patient and completing an assessment to determine if they could meet their needs and if the current patient mix was conducive to accepting the new referral. However, at the time of this inspection, there was a change being introduced for all wards except Madison and Columbus wards that a central team would be completing the assessment and the clinical team would not be involved in the assessment. Staff were concerned that they would not be able to determine if they could meet the patients’ needs and if they would be compatible with the current patients on the ward. Although staff had challenged this with the provider, the decision following the on site inspection was that this would be introduced.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. We saw patients’ community teams were invited to reviews of care. The local provider collaborative visited the service regularly to review the placements of patients and their progress.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Introduction to safeguarding training had 100% compliance and intermediate safeguarding training had an average of 96% compliance.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. This included referrals to the local authority and supporting investigations that were completed, as well as managing the patient mix and vulnerabilities of patients and moving wards where appropriate.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Records we reviewed evidenced safeguarding referrals were made and liaison with the local authority and police. There was a weekly safeguarding meeting attended by clinical managers, ward manager and social workers. At this meeting they reviewed all open safeguarding incidents and updated actions on the electronic incident record. Safeguarding care plans were in place for patients with this need, this included guidance for staff in how to safeguard the patient.

Staff had a safeguarding handbook and checklist which provided clear guidance of the actions they should take if they suspected or witnessed abuse.

Staff followed safe procedures for children visiting the service. There was a policy in place and a family visiting room in the reception area which was very welcoming with games and toys, comfy seating and access to drinks and toilet facilities. All visitors were authorised by the patient’s clinical care team and contacted via the Social Work Department prior to a visit taking place.

Mental Capacity Act

99% of staff had had training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

The provider had a policy on the Mental Capacity Act. Staff were aware of the policy and had access to it. Staff had access to a compact set of cards as reminders and a resource for guidance, including the Mental Capacity Act.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act.

Staff took all practical steps to enable patients to make their own decisions. We saw communication cards in place for autistic patients to assist with conveying their emotions and making decisions.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. We saw capacity assessments for physical health treatment and access to high calory food.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. We saw best interest decisions in place regarding meeting physical health needs and food and drink consumption.

The service did not have arrangements to monitor adherence to the Mental Capacity Act. It was difficult to locate capacity assessments in care records.

Staff did not audit the application of the Mental Capacity Act.

We do not always work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 1. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 11 risk assessments and risk management plans during the inspection.

There had been 65 incidences of restraint from March 2025 to March 2026, 4 were in the prone position. The rational for these were discussed in the clinical governance meetings. There had been 2 administrations of rapid tranquilisation in the 3 months prior to the inspection.

Staff had regard to Mental Health Unit (Use of Force) Act 2018 and its guidance and complied with requirements. Staff participated in the provider’s restrictive interventions reduction programme, which met best practice standards including the requirements of the Mental Health Unit (Use of Force) Act 2018 and its guidance. This included information for patients about their rights in relation to use of force and the information was also available in easy read format.

Reducing restrictive practice meetings took place monthly for the hospitals in the North, which this service was one of. One of the clinical leads was the lead in reducing restrictive practice at the service. Examples of interventions included the creation of a “quick information guide for responding to ‘not ok’ behaviours” which provided staff with guidance on how respond to patients in difficult situations. Positive and safe care meetings took place with managers in the service.

Each ward had a restrictive practices log and these were proportionate to the level of security within the service.

The Regional Medical Director chaired monthly seclusion and long term segregation review meetings with consultants to review the patients nursed in these settings.

Staff mostly involved patients in care planning and risk assessment (shown by evidence in care plans, participation in multidisciplinary team reviews, access to a copy of their care plan). Of the 11 care records reviewed, one patient refused to be involved in their risk assessment and 1 patients care plans included generic statements rather than individualised to the patient.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients who had communication difficulties. Patients were actively involved in their review meetings and had opportunities to talk with their care team outside of the review meetings.

Staff enabled patients to give feedback on the service they received via community meetings and the people’s council.

Staff ensured that patients could access advocacy.

Risks were not routinely shared to staff during handover. We observed two handovers and reviewed handover documentation and risk of patients was not discussed as part of this, only if there had been an incident. We reviewed the handover documentation and there was a risk score but the RAG rating was green, showing that risk scores did not always reflect what was discussed at the daily risk meeting. The risk scores did not explain to staff what the risks were. There was a patient on one to one observations for physical health reasons and the handover record did not say what the health reasons were. A patient had epilepsy and this was not included in the handover record. There had been a ward shut down for searching due to potential contraband and this was not included in the handover, night staff were not aware of this when asked. This meant staff were not provided with the information to meet the needs of the patients they were supporting and were not fully aware of the risks they needed to mitigate.

We do not always detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Staff did regular risk assessments of the care environment. Ligature risk assessments were in place for each ward and included blind spots too and how staff should mitigate the risks. However, the documents were lengthy at over 70 pages, and included areas that patients did not have access to. There were heat maps for each ward which showed managed risk areas, medium risk areas, high risk areas and the location of the emergency equipment. However these did not include how to mitigate the risk and the symbol used for the ligature cutters was different in the ligature risk assessments and heat maps. This meant it may have been confusing for new staff to understand the risks in the environment and how to mitigate them.

Ward layout mostly allowed staff to observe all parts of ward. However, on Madison ward, there was a blind spot behind doors in a corridor, this was not mitigated by parabolic mirrors, but staff observation levels. Staff were aware of the risk and understood why they were allocated to observations on the corridor.

Staff had easy access to alarms and patients had easy access to nurse call systems.

Seclusion rooms allowed clear observation and two-way communication and had toilet facilities and a clock. However, Madison ward and Columbus ward seclusion rooms did not have a mattress and safe bedding, staff told us that a replacement had been ordered. The rooms were not being used at the time of the inspection.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The environment needed repair and redecoration. On Madison ward, we found damage around the door frame and mould on an ensuite bathroom sealant. There was cracked and missing plaster around a light switch and door frames. Some of which had been filled but not decorated. Also on Madison ward, there was paint peeling off the wall in the bedroom corridor. In Madison ward garden, there was damage to raised beds, with rotten and broken wood.

On Columbus ward, the window from the communal lounge to outside space had a window screen that was cracked. There was a dining room chair on Columbus ward that was cracked and posed an infection control risk.

On East Hampton ward, the window restrictor in the garden was rusty.

On Lower East ward, there was a patient toilet which was stained. A patient sink that was dirty and in poor state of repair. Also on Lower East ward, the outside window restrictor was very rusty. In the patient garden, the fence was in poor repair with paint peeling. The door to the Lower East ward quiet room was not safe to shut, there was no handle to pull the door shut meaning that patients had to put their hand through the door to shut and remove hand at the last minute.

Upper East ward corridor to stairs was dirty and stained. Another corridor had flaking paint. On Upper East ward, a patient’s en suite had staining and mould around shower. Another patient had a scratched sink.

Although the above maintenance issues were not on the maintenance log or outstanding tasks, the Hudson facilities log showed that from May 2025 to May 2026, they had completed 1264 maintenance jobs, this shows oversight of the maintenance, when jobs were reported they were acted upon. This meant the maintenance team were not aware of all of the maintenance issues required for the wards and staff had not reported them for repair. This meant there were unresolved maintenance issues on 5 out of 6 wards.

We saw and stakeholders told us that there was not enough meeting room space within the building, we saw morning meetings and ward rounds taking place in the visitors room which meant visits could not take place at that time and the meetings were cramped in the environment. The internet connection was not working effectively in the building, resulting in a CPA review being delayed by 30 minutes, the patient and external professionals were waiting excessively to join the meeting.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had over recruited by 12.5 nurses across the service and 68 support workers. These additional posts were to accommodate enhanced observations and reduce the number of bank and agency staff used. There were no vacancies within the multidisciplinary team. Sickness absence was an average of 5% for the last 12 months from March 2025 to March 2026. Turnover was an average of 2% for the last 12 months from March 2025 to March 2026.

Managers had calculated the number and grade of nurses and support workers required. The ward managers could adjust staffing levels daily to take account of case mix. This was discussed at the daily brief meeting with all managers, staffing was one of the agenda items.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Bank staff usage was an average of 6% for the 6 months from October 2025 to March 2026. Agency staff usage was an average of 3% for the 6 months from October 2025 to March 2026.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. Records were scanned into the system and were in place for the bank and agency staff we sampled.

Staffing levels allowed patients to have regular one-to-one time with their named nurse.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely (and staff had been trained to do so).

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. There was an on call rota with 2 tiers of medical cover.

Staff had received and were up to date with appropriate mandatory training. Training compliance was above 75%. The only course with less than 75% compliance was Epilepsy awareness and buccal midazolam for Columbus ward with 50% compliance, however staff were booked on a future session. The training was appropriate for the patient group using the service.

We do not always assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

Ward areas were mostly clean. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff mostly adhered to infection control principles, including handwashing. However, we observed that some hand sanitizer dispensers within the building were empty.

On Madison ward, there was mould on an ensuite bathroom sealant. There was a dining room chair on Columbus ward that was cracked and posed an infection control risk. These maintenance issues were not on the maintenance log or outstanding tasks record.

On Lower East ward, there was a patient toilet which was stained and a patient sink that was dirty and in poor state of repair. On Upper East ward corridor to the stairs was dirty and stained. On Upper East ward, a patient’s en suite had staining and mould around shower. Another patient had a scratched sink. These maintenance issues were not on the maintenance log or outstanding tasks. This meant the maintenance team were not aware of all of the maintenance issues required for the wards and staff had not reported them for repair.

Staff were bare below the elbow and complied with the organisational dress code policy.

We do not always make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 1. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Medicines administration records were clearly completed and where needed the appropriate Mental Health Act authorities for prescribing were in place. However, we saw 1 example, where this needed to be updated following a recent medicines change. We brought this to the attention of staff so that it could be promptly addressed.

Staff worked well as a multidisciplinary team and showed a clear understanding of patients’ needs. They had oversight of the rationale for prescribing, medicine changes and decisions reflected patient preferences.

Care plans were mostly detailed and patient-centred, reflecting individual preferences and conditions. However, we saw in 4 out of 6 records that individual named medicine was not included in the care plan. Care plans were not always fully aligned with medicines administration charts and sometimes lacked key details. For example, asthma plans did not consistently include guidance on correct inhaler use.

A review of 13 records and ward round documentation found that medicine reviews and physical health comorbidities were not recorded in enough detail across wards. Although staff showed strong knowledge of patients’ medicines, including why they were prescribed, how to interpret blood results and when to escalate concerns this was not fully supported in the documentation.

High-risk medicines monitoring was not always carried out in line with policy and monitoring was sometimes delayed or inconsistent. Lithium and high-dose antipsychotic monitoring exceeded the recommended three-month interval in 3 out of 4 records reviewed, however the reasons for delays were documented.

Physical health concerns were managed collaboratively, with strong multidisciplinary working, GP involvement and proactive actions such as substance screening when needed. The on-site physical health team was well integrated and supported patient-centred care. However, escalation for blood pressure and diabetes were inconsistent across wards. We saw in 4 out of 8 records where blood pressure monitoring was reviewed that staff did not escalate high blood pressure readings. Escalation thresholds varied and care plans did not consistently provide clear guidance, we saw 3 out of 8 care plans did not include clear guidance for staff regarding escalation for patients. Although staff reviewed service users regularly to mitigate the risk of adverse events.

Medicines were handled safely and storage was well managed, with clear documentation of expiry dates for opened preparations.

There was a structured audit programme with pharmacy oversight of medicines management and supply and actions were shared through an online platform. An appropriate out-of-hours pharmacy service was in place to support medicine supply and clinical queries.