Cygnet Bury Forestwood

We carried out our inspection on 13 and 14 January 2026. Our last inspection for this service was carried out in April 2025. We carried out this inspection due to concerns about the service.

The service offers Child and Adolescent Mental Health Service inpatient facilities (CAMHS) as follows:

• Wizard ward – a 12 bedded CAMHS acute ward
• Primrose ward – a 12 bedded CAMHS Psychiatric Intensive Care Unit (PICU) ward
• Buttercup ward – an 8 bedded CAMHS PICU ward
• Mulberry ward – a 12 bedded CAMHS intensive support service

• We found 1 breach of regulation in relation to premises and equipment.

Mental Health Act and Mental Capacity Act Compliance Summary

We did not carry out checks into how the service was complying with the Mental Health Act during this assessment.

The service had an up to date Mental Capacity Act policy in place and staff had received and were up to date with Mental Capacity Act training, which was at 98% compliance. Staff understood the requirements of the Mental Capacity Act and completed capacity assessments that related to decision specific concerns. Staff also understood the Gillick competency (a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment) and used this when required.

We rated the service as Good. We found 1 breach of the regulation in relation to premises and equipment.

• Managers thoroughly investigated all incidents and any concerns raised by young people. They identified learning and shared this with the staff team and where appropriate, with other services. Lessons learned were used to carry out improvements to the service.
• Staff had received training in and understood how to safeguard young people. They raised safeguarding referrals where needed.
• There were enough staff, who had relevant skills and had received appropriate training and supervision, to meet the needs of the young people at the service.
• Staff carried out thorough and detailed risk assessments and put risk management plans in place to address risks.
• Staff mostly treated young people as individuals and promoted their independence, choice and control of their care and treatment.
• Staff mostly felt supported by managers, and managers has the skills and knowledge to run the service.

However

• The environment was not well maintained. Areas of the environment were difficult to keep clean, garden areas were sparse and not looked after, and some areas of the environment were not safe.
• Equipment has not always been checked in line with required schedules.
• We found staff were not always responsive to young people.

• Some staff told us they did not always get their breaks and did not always feel supported if they had acquired a work related injury.

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

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

100% of staff had received training in the Mental Health Act and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.

Staff had easy access to administrative support and legal advice on the implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were and routinely contacted them with any Mental Health Act queries.

Staff had easy access to up-to-date local Mental Health Act policies and procedures that reflected the most recent guidance and to the Code of Practice which were all available on the staff intranet.

Patients had easy access to information about independent mental health advocacy. The advocacy service was visible on all the wards and posters and leaflets were seen on display.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it. Staff considered patients' communication needs and provided easy read information to assist with patients' understanding.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted. Section 17 leave was planned in advance to ensure that there were adequate staff to facilitate this.

Staff requested an opinion from a second opinion appointed doctor when necessary.

Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them. These were available on the electronic recording system which all staff had access to.

The service displayed a notice on the patient information board to tell informal patients that they could leave the ward freely.

Care plans referred to identified Section 117 aftercare services to be provided for those who had been subject to section 3 or equivalent Part 3 powers authorising admission to hospital for treatment.

The Mental Health Act staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act and had a working knowledge of the five statutory principles. 97% of staff had received training in the Mental Capacity Act.

The provider had an up-to-date policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Deprivation of Liberty Safeguards are there to protect people without capacity to make decisions about their own care. Staff were aware of the policy and had access to it on the staff intranet. There were no Deprivation of Liberty Safeguards applications made in the last 12 months.

Staff knew where to get advice from within the service regarding the Mental Capacity Act, including Deprivation of Liberty Safeguards. They spoke with qualified staff, team leaders or the Mental Health Act office when they needed guidance.

Staff took all practical steps to enable patients to make their own decisions. They considered patients communication needs and encouraged patients to attend ward rounds and express their wishes and feelings. Easy read information was provided in cases where this was helpful to patients and staff spent time explaining care and treatment options with patients.

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 reviewed patient records and saw that capacity assessments were appropriately conducted and recorded.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person's wishes, feelings, culture and history. When best interests meetings were held, staff spoke with relatives and carers who knew the patient best. An example of a best interest's decision undertaken was regarding the decision making, planning and access to a mobile phone including maintaining safeguarding online.

The service had arrangements to monitor adherence to the Mental Capacity Act. This was completed by the Mental Health Act team who audited the application of the Mental Capacity Act and acted on any learning that resulted from it.

Staff understood how to support children under 16 wishing to make their own decisions under Gillick competency regulations. This is a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment. There had been a previous complaint regarding consent to medical treatment relating to an invasive procedure and an action plan was completed by the service to address this.