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 good. At this assessment the rating has changed to requires improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed. Not all areas of the premises were clean or well maintained, which presented safety and infection control risks. There were blind spots that had not been mitigated on all wards and equipment was not always checked in line with requirements.

However, there were sufficient staff, who had received appropriate training and supervision to meet young people’s needs. Staff completed relevant risk assessments and updated them where required. Managers investigated incidents thoroughly and identified and shared learning with staff.

The service was in breach of regulation 15 which related to premises and equipment.

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 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.

The number of serious incidents had increased since our last inspection, this seemed to relate to the acuity of the ward. There were 19 serious incidents in the last 12 months. These included swallowing and insertion of foreign bodies, a young person going absent without leave and incidents of violence and aggression. All staff knew what incidents to report and how to report them.

Staff understood the duty of candour. They were open and transparent and gave young people and their families a full explanation if and when things went wrong.

Staff received feedback from internal and external investigation of incidents and met to discuss that feedback. There was evidence that changes had been made as a result of feedback. For example, staff received extra training on how to complete searches following an incident where a young person obtained a prohibited item and used this to self-harm.

The provider shared information about safety improvements specific to this service. Staff received ‘hot topic’ bulletins, team briefs and lessons learnt bulletins which contained learning from incidents and key messages for staff.

Staff were debriefed and received support after serious incidents.

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 young people was received to determine if their needs could safely be met. Referrals were sent to a bed hub and bed hub staff reviewed referrals in collaboration with staff at the hospital. Referral forms contained relevant information to support staff to assess young people’s risks and needs.

Staff involved all the necessary healthcare and social care services to ensure young people had continuity of safe care, both within the service and post-discharge.

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 so when appropriate. Training compliance for safeguarding introduction level was 100% and compliance for intermediate level was 96%. The service had an up to date safeguarding policy and staff also had a safeguarding handbook to provide them with relevant guidance, in the event of safeguarding concerns. In the 6 months prior to our inspection, the service had raised 83 safeguarding concerns with the local authority. 67 of these were investigated internally and did not meet the threshold for an external investigation. In addition to this, incidents were reported to young peoples’ social workers and CQC where required.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies, including social services and where required, the police. Staff knew who their safeguarding leads were and how to report and record concerns.

Staff could give examples of how to protect young people from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff followed safe procedures for children visiting the service. The service had visitors rooms which were used when children were visiting the service and there was a protocol in place which provided guidance for managing children’s visits.

Staff followed a least restrictive approach and mostly attempted de-escalation prior to restraint, although this was not always recorded in restraint records. Each ward had a register detailing any blanket restrictions on the ward. Blanket restrictions matched the risks present on the ward and were regularly reviewed.

Mental Capacity Act

98% of staff had received 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, which was in date and contained relevant information for staff. Staff were aware of the policy and had access to it. Staff knew where to get advice from regarding the Mental Capacity Act.

Staff took all practical steps to enable young people to make their own decisions. For those 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.

When young people over the age of 16 lacked capacity, staff, in collaboration with carers made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Where appropriate best interest’s meetings had taken place.

Staff considered Gillick competence (a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment) when required.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them..

We reviewed 8 risk assessments/ risk management plans during the inspection. Risk assessments were holistic, personalised and detailed. Risk assessments were up to date and staff updated them regularly including after an incident.

There were 3369 incidences of restraint in the last 12 months. 27 of these were prone restraint, 20 of which were patient led. Prone restraint is where a person is held face down. The provider had policies in place to reduce all restraints including levels of prone restraint. We reviewed 4 instances of restraint and found that care plans were in place for restraints; restraints were proportionate to the risk posed and debriefs took place with young people and staff members following restraint. We found that acuity on the wards was high and that many young people had a range of complex needs.

There were 125 instances of rapid tranquilisation in the past 6 months. These varied between wards with the highest number being on Wizard ward with 61 instances of rapid tranquilisation and the lowest being on Mulberry with 5 instances of rapid tranquilisation. We reviewed 5 instances of rapid tranquilisation. Evidence of de-escalation was recorded on 4 out of 5 instances of rapid tranquilisation. Staff completed post rapid tranquilisation documentation, including visual assessment documentation assessing whether patients were alert and ambulant following rapid tranquilisation.

There were 172 uses of seclusion in the last 12 months. Seclusion duration was high but reducing with an average seclusion duration of 296 hours in January 2025 which had reduced to an average of 89 hours in December 2025. We reviewed 2 seclusion records. Staff carried out regular observations, whilst young people were in seclusion and seclusion plans were in place. However, seclusion care plans did not contain plans for exiting seclusion. There were 31 episodes of long-term segregation in the last 12 months. The longest of these was 72 days. We reviewed 2 long term segregation records. Regular multi-disciplinary meetings were taking place which included external stakeholders. Activity planners and diet and fluid records were in place in the documentation.

Staff did not always involve young people in risk assessments, although there was evidence of them involving young people in care planning under the ‘my views’ section of the care plans.

Staff communicated with young people so that they understood their care and treatment, including finding effective ways to communicate with young people with communication difficulties. Most young people had communication care plans and speech and language therapy input where required. However, 1 young person, who had an autistic spectrum disorder and an attention deficit hyperactivity disorder diagnosis did not have a speech and language assessment, although records showed that staff had attempted to complete a sensory needs checklist but the young person had declined.

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 always make sure that equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular risk assessments of the care environment. They completed regular environmental checks and quarterly audits of these.

The service had an up to date fire risk assessment and up to date ligature anchor point and blind spot risk assessment in place. However, staff had not identified or mitigated all identified risks adequately. For example, the ward layout did not allow staff to observe all parts of ward. Bedroom corridors on all wards contained blind spots that were not mitigated. Following our inspection, the provider installed mirrors in order to mitigate these risks.

All bedrooms were considered high risk areas. A number of anti-ligature measures were in place including reduced ligature door handles, collapsible curtain rails and reduced ligature ensuite doors and shower heads. Staff carried out regular risk assessments and increased observations where there were concerns about the risk to young people.

Not all areas of the premises were well maintained, for example we found screws were protruding from smashed plastic on one of the cabinets which potentially presented a self harm risk and some of the furniture was ripped and worn and in a poor state of repair. There was evidence that maintenance was being carried out, although not all issues we identified on our inspection were present on the maintenance log.

Ward gardens were mostly sparse, some of the benches were rusty and one was covered in green algae. Clients could not access the therapy garden because it was not safe, and the high dependency garden had no path from the door which meant young people walked out onto muddy grass. Some areas of wards were cold.

The service mostly complied with guidance on eliminating mixed-sex accommodation. All bedrooms were ensuite and there were multiple lounges for young people to use according to need. However, bedroom corridors were mixed gender and this had resulted in incidents where young people had spent time in each other’s bedrooms unobserved.

Staff had easy access to alarms and young people had easy access to nurse call systems. Seclusion rooms allowed clear observation and two-way communication, and had toilet facilities and a clock.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff mostly checked regularly. However, there were gaps in the checking of the resuscitation equipment on Buttercup ward and the glucometer on Buttercup ward and Wizard ward, which was used for monitoring blood sugar levels had not been checked in line with requirements.

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.

Vacancies were low with most wards over their established numbers. For example, there were 1.5 core nursing vacancies and there were 0 core support worker vacancies. However, high levels of observations required extra staff to be available, and this increased vacancy numbers. In the 3 months prior to our inspection, managers used 2,369 agency shifts and 569 bank shifts. The average turnover for the last 12 months was 23.3%. Staff left for a range of reasons, including finding jobs with better pay or benefits and career changes. Sickness absence rates over the last 12 months were 2.8%.

Managers had calculated the number and grade of nurses and healthcare assistants required. The ward manager could adjust staffing levels daily to take account of case mix.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. There tended to be more agency and bank staff used on evenings and weekends, however, there were substantive staff on all shifts. There was a designated member of staff who oversaw staffing numbers on the night shift. This staff member contacted staff and agencies to bring extra staff on shift where needed.

When agency and bank staff were used, those staff received an induction and were familiar with the ward. Bank and agency staff completed an induction which included familiarising staff with the ward and an observation competency check.

Staffing levels allowed young people to have regular one-to-one time with their named nurse and these were documented in young people’s records.

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 for both day and night shifts and a doctor could attend the ward quickly in an emergency. There was a clear system in place to access medical cover and staff told us they could access a doctor in a timely manner, out of hours if needed.

Staff had received and were up to date with appropriate mandatory training. Most training compliance was at 100% and all training courses met the provider’s compliance targets which were between 90% and 95%. Training was appropriate for the patient group using the service. Staff received a range of training including learning disability and autism training; awareness of self harm and suicide; clinical risk management and basic and immediate life support training.

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.

Some ward areas were not clean, and the wards did not always have good furnishings and were not always well-maintained. Some of the flooring was poorly maintained and not clean and there was peeling paint and bare plaster on some of the walls. The serving hatches in the ward kitchens were painted wood, difficult to clean and an infection control risk. The floor was coming away from the wall in some of the en suite bathrooms and we saw mould around one of the showers, presenting an infection control and safety risk.

The extra care area on Wizard ward contained a dirty toilet and was covered in stains and black marks.

Cleaning records were mostly up to date and demonstrated that the ward areas were cleaned regularly. However, some areas of the wards were difficult to clean and stained and some areas were in need of a deep clean or repair. A range of environmental checks were in place, including water temperature checks, paint schedule checks and cleaning audits, however the checks did not identify all the concerns we identified during the inspection.

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

Staff adhered to infection control principles, including handwashing. The service carried out a quarterly infection control audit.

Quality Statement Score:3

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had up to date policies and procedures in place for prescribing and administering medicines. Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance.

We reviewed 11 prescription charts and found that staff were safely prescribing and administering medicines. Records were accurate and up to date and including appropriate treatment forms required under the Mental Health Act. Staff carried out monthly medication audits and completed action plans where there were concerns. Lessons learned from medicines related incidents were shared with staff, for example a document reminding staff of the required standards for completion of the controlled drugs register was displayed in the clinic room.

Staff reviewed the effects of medication on young people’s physical health regularly and in line with NICE guidance. Medication cards were checked every morning and medication reviews were carried out where there were concerns about young people’s medication. For example, staff held a medication review due to a young person’s frequent use of lorazepam and amended their medication accordingly. However, rapid tranquilisation checks were not always recorded in line with young peoples' care plans.