Cygnet Bury Forestwood

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 changed to Good.

This meant people were safe and protected from avoidable harm.

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.

There had been 6 serious incidents between April 2024 and April 2025. An example of this was a patient going absent without leave (AWOL) and managing to travel some considerable distance away from the Manchester area. As a result of lessons learned from this incident, a new protocol was put in place to ensure that an up-to-date photo of each patient was available if required to show to the police assisting with enquiries.

All staff knew what incidents to report and how to report them. Staff documented incidents on an electronic recording system. We carried out a specific review of incidents and saw that staff reported them and notified the Care Quality Commission and other stakeholders as required.

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. We saw from complaints records that staff met with patients and families and apologised when it was appropriate do so.

Staff received feedback from the investigation of incidents, both internal and external to the service. Feedback was discussed at morning meetings, daily handovers, team meetings and during supervision. Lessons learned were also put up in the nursing office and on the back of staff bathroom doors.

Staff improved patient safety as a result of lessons learned from incidents. An example of this was that the service changed the wording of a policy in relation to self-harming .This was changed from head tapping to headbanging as the words head tapping were sometimes perceived as more minimal than headbanging. This could then affect the response and care given by staff after an incident. As a result, the reworded policy reflected that all cases of headbanging should result in staff carrying out neuro observations to ensure patient safety and escalate for further treatment if required.

Staff shared learning with other CAMHS services. An example of this included sharing that some arts sets contain metal pins that young people may use to self-harm and that each new art set needs to be individually risk assessed as the contents are variable.

After each serious incident staff met for a debrief and support was given to them by managers for example to contact the police, access medical care or counselling if needed. Staff could also access reflective practice if required. Staff met to discuss feedback after an incident and received the debrief discussion in an email sent by the ward manager. We saw evidence that changes had been made because of feedback.

Managers completed after action reviews containing information about improvements in safety specific to this service.

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.

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. Staff arranged additional visits and meetings if they were unsure of accepting a new referral. They considered the existing ward acuity and patient mix in addition to the needs of a new patient.

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. Care co-ordinators and other professionals were invited to patient meetings and discharge planning meetings along with carers and the advocacy service if the patient had requested and agreed to this.

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.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. Safeguarding training compliance was above the provider’s target of 95% on all four wards and on three wards it was at 100%. The provider had a policy in place whereby staff were not allowed to work on the wards if they had not completed safeguarding training.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Training compliance in equality and diversity was at 100% and all staff had completed the mandatory Oliver McGowan training in learning disability and autism.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. The service had safeguarding leads and staff communicated regularly with the local safeguarding board.

Staff followed safe procedures for children visiting the service. There was a family visiting room on each ward and in some cases family visits took place in patients’ bedrooms.

Staff used restraint as a last resort when all other methods of de-escalation had failed. Patients were given a leaflet entitled service user rights which explained the use of restrictive interventions. Every patient had a passport which was tailored to individual needs and was designed to support practice that avoided the use of restraint. Where restraint might be required, the type of restraint to be used was also individualised to the patient. Each ward conducted a quarterly audit of blanket restrictions. Audits on each ward were in date and identified risks, the impact on patients’ rights and the actions that staff would take in response to this.

We 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.

The service used the Strategic Tool for Assessing Risk (STAR). We reviewed 13 risk assessments whilst we were on site. We found that all 13 were detailed, personalised and updated daily at ward round by the multi-disciplinary team and again after every incident.

Staff used restraint as a last resort and after all other attempts at de-escalation had failed. There were 522 incidences of restraint between February and April 2025 across the four wards. However, this included 113 seated and 181 standing, lower level restraints. The highest number of restraints was on Mulberry ward at 241 and the lowest was on Wizard House at 60. Buttercup ward was at 124 and Primrose ward was at 97. Of the overall restraints, six were prone, four of which were patient led and these occurred on Mulberry ward. Between February and April 2025, there were 39 episodes of seclusion across the four wards. This included 18 on Buttercup ward, 10 on Primrose ward, nine on Mulberry ward and two on Wizard House. Between February and April 2025 there were 6 new episodes of long-term segregation with the highest at 3 being on Buttercup ward.

Staff involved patients in care planning and risk assessment. Named nurses held weekly one to one sessions with the young people. All young people were invited to contribute to their care plans and they were offered a copy; however some declined. All young people were able to attend their ward round and could ask to speak to their doctor outside of those times if required. The advocacy service also supported young people to attend their meetings and raised issues on their behalf if they requested this. This was shown by evidence in care plans, participation in multidisciplinary team reviews and access to a copy of their care plan.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. All patients had a hospital passport to support communication. This was a change in practice which had arisen in response to improving communication with a patient with autism.

Staff enabled patients to give feedback on the service they received. Community meetings were held weekly on each ward. These were minuted and patients were able to raise issues and received feedback on any actions taken or changes made. There was also a patients’ council which met regularly and a patient’s survey.

Staff ensured that patients could access advocacy. There were advocacy posters on the wards and the advocate visited the wards weekly.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Staff carried out regular risk assessments of the care environment. There was an up-to-date ligature risk audit on each ward. This identified all the ligature points along with adequate mitigation. Additionally, there was a heat map on each ward which highlighted all the ligature points. These were displayed in the nursing office on each ward. Fire risk assessments were in place and up to date and there were designated fire wardens within the service. Personal Emergency Evacuation Plans (PEEPS) were carried out for those patients that had mobility issues.

Ward layouts allowed staff to observe all parts of ward. There were blind spots on Buttercup ward which were mitigated by the use of concave mirrors and there were blind spots in the garden on Primrose ward which were also mitigated by the use of concave mirrors. In each case, staff used observation to maintain the safety of patients.

Wards were mixed sex. There were quiet lounges on the wards if young people wanted to be away from the communal areas. All bedrooms had en suite bathroom facilities.

Staff had easy access to alarms and patients had easy access to nurse call systems. There were call bells in each patient bedroom and all staff were given an alarm when their shift commenced.

Seclusion rooms allowed clear observation and two-way communication and had toilet facilities, a clock which was visible to patients and the means to change the temperature and lighting within the seclusion rooms. This was in line with the Mental Health Act Code of Practice. The seclusion room on Mulberry ward was out of use for maintenance. Staff used seclusion suites on other wards as an interim measure.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. We reviewed the clinic rooms on each ward. Staff maintained a log of clinic room checks and this was audited by the ward manager. Staff checked, maintained, and cleaned equipment and clean stickers were in place. There were daily medication audits We assessed all 4 clinic rooms and found out of date bandages and dip sticks. This was escalated to staff who immediately removed them

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.

There were low levels of qualified staff vacancies across the 4 wards. The service had recently recruited a number of support workers and was working to increase the number of female staff available to cover shifts, to meet the preferences of some of the patients. Staff turnover was at 33% and staff sickness had remained stable between April 2024 and April 2025 at between 5 and 8%. The highest level of staff sickness was on Wizard House and the lowest was on Mulberry ward.

Managers had calculated the number and grade of nurses and healthcare assistants required using a safe staffing matrix. Additional staff were requested to cover sickness or annual leave. The number of nurses and healthcare assistants matched this number on all shifts.

The ward manager could adjust staffing levels daily to take account of case mix. When observation requirements increased on the ward, managers were able to request an additional staff member to cover this. Managers considered the acuity and requirements of individual patients and ensured the staff skill mix matched this.

When necessary, managers used agency and bank nursing staff to maintain safe staffing levels. At the time of the inspection the use of bank and agency staff was at 6% and we were told by patients that we spoke with that the use of bank and agency staff had decreased.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. All bank and agency staff also had to undergo orientation and completed observation competency training and assessment. This was documented in an induction booklet.

A qualified nurse was present in communal areas of the ward at all times. Staffing levels allowed patients to have regular one-to-one time with their named nurse. Each patient had a named nurse and one to one time took place at least weekly and more frequently if a patient requested this.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. There was an activities lead allocated for each ward along with occupational therapists. We did not identify any instances where leave or activities were cancelled.

There were enough staff to carry out physical interventions including observations, restraint and seclusion safely and staff had been trained to do so. Safety intervention training compliance was between 96% and 100% at the time of the assessment.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had received and were up to date with appropriate mandatory training. Staff were above the provider’s variable compliance target of 90-95% in all areas and in most cases, were at 100%. The training was appropriate for the patient group using the service. This included the CAMHS support worker certificate, naso gastric tube feeding, eating disorders and awareness of neuro psychiatry.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

Staff adhered to infection control principles, including handwashing. Infection prevention and control training compliance was between 97% and 100% at the time of the inspection. There were handwashing facilities on the wards and handwashing signs in place.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. Managers routinely audited the cleanliness and maintenance of equipment. All ward areas were clean, had good furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. We reviewed the cleaning rotas and records for each ward and saw that daily cleaning, and regular deep cleans of specific areas was taking place.

We 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.

Staff generally followed good practice in medicines management including the transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, and did it in line with national guidance. The Mental Health Act office completed the reconciliation of medicines when patients were admitted to the wards. The service used a local pharmacist who attended the wards fortnightly and conducted medication audits and provided information on any required actions. The pharmacist also provided staff training on pharmacology. Staff completed mandatory training on the management and administration of medication. Compliance was at 100% at the time of the assessment.

Staff reviewed children and young people's medicines regularly and provided specific advice to children, young people and carers about their medicines. Patients and carers were given a medication leaflet, and parents and carers were involved in decision making.

Staff stored and managed medicines and prescribing documents in line with the provider's policy and followed current national practice to check patients had the correct medicines.

The service had systems to ensure staff knew about safety alerts and incidents, so children and young people received their medicines safely.

Decision making processes were in place to ensure people's behaviour was not controlled by excessive and inappropriate use of medicines. Treatment was discussed at the weekly multidisciplinary team meeting and second opinion appointed doctors were routinely requested.

Staff reviewed the effects of each child or young person's medication on their physical health according to the National Institute for Health and Care Excellence (NICE) guidance. For example, doctors and nurses monitored the physical health of patients who were on high levels of medicines, or who were prescribed medicines where additional observations were recommended.