- Independent mental health service
Cygnet Bury Forestwood
Assessment report published 7 August 2025
Contents
Ratings
Our view of the service
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.
People's experience of this service
During the assessment we spoke with 6 carers, 5 patients. We conducted a Short Observation Framework for Inspection 2 (SOFI2) observation in the service, which is a structured observation which captures people's experience of care during the on-site assessment. We saw good levels of engagement between staff and patients, and it was clear that staff knew patients well. Most patients said that staff were generally kind, caring and respectful towards them. One patient said that they wanted more female staff on shift. Another patient said that sometimes staff could be a bit rude but a lot of the staff were nice and did care about them. All patients said that they had regular one-to-one sessions with their named nurse and that they could ask for more if they needed. Patients said that there were activities on the wards and that they could personalise their bedrooms. Some patients had their pets on the ward with them and they enjoyed being able to look after them.
Feedback from the experts by experience, (who were previous patients of the service and now employed by the service,) was that all wards were kept clean and tidy, with noticeable improvements on Buttercup ward and that the level of cleanliness had progressed. This information had been obtained by the experts by experience from the patients. Other feedback highlighted that patients enjoyed the high visibility of senior leaders on the wards and that concerns and complaints were properly investigated and feedback given.
Most carers were happy with the care and treatment provided to their loved one. Carers were able to receive feedback daily by email or phone from ward staff. One carer was unhappy with the service and felt that communication had been poor until she had made complaints. One carer said that the visiting room for Buttercup ward was too small, and it could be difficult to book the family room as it was shared with another ward. There was mixed feedback from both patients and the carers on food and some felt that more work needed to be done in that area.