Cygnet Bury Forestwood

Ratings - Child and adolescent mental health wards

• Overall

  Good

• Safe

  Requires improvement

• Effective

  Good

• Caring

  Good

• Responsive

  Good

• Well-led

  Good

Our view of the service

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.

People's experience of this service

During our inspection we spoke with 8 young people and 5 carers, we also carried out 2 Short Observational Framework for Inspections (SOFIs). This is a structured methodology for observing interactions during an inspection.

Young people told us that some, but not all staff were caring, engaged with them and were respectful. They said agency staff provided them with less support and did not engage with them as well as permanent staff. Some young people told us they did not always feel safe on the wards and some young people told us that staff were sometimes too rough when carrying out restraint. We reviewed restraints whilst on site and found these were monitored and managed appropriately by the provider.

We mostly observed warm and compassionate staff interactions, for example we observed a staff member sat on the floor engaged in a colouring activity with a young person and saw staff compassionately supporting a young person who was distressed. However, we also observed staff talking amongst themselves whilst observing a young person, with minimal interaction taking place with the young person.

Most carers shared positive feedback about the service, they told us staff were kind, friendly and supportive of young people. One carer told us, ‘the parent rep was outstanding’, in relation to a member of staff and said, ‘she couldn’t have done more’. Carers also told us that the psychiatrist was good and that the team used a holistic team approach.