Cygnet Hospital Colchester

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• 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 remained good.

This meant people were safe and protected from avoidable harm.

The service was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

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 in which concerns were listened to. Patient safety incidents were reported and investigated thoroughly, and lessons were learned to continually identify and embed good practices.

We spoke with 9 members of staff; all knew what incidents to report and how to report them. In a staff survey, 95% of staff said they were encouraged to report errors, near misses or incidents.

Patient Safety Incident Investigations (PSII) were undertaken to identify opportunities for improvement and learning. An incident occurred where a patient did not receive 2 doses of prescribed medication. This was identified by a staff member, and an appropriate course of action was taken to ensure the patient received all future prescribed medication. A review was carried out to determine whether any further actions were needed to prevent this from happening to any future patients, including undertaking medication audits.

Staff understood the duty of candour. They were open and transparent and gave patients a full explanation if things went wrong.

There had been 5 serious incidents in the last 6 months - 1 medication error and 4 episodes of a patient going absent without leave (AWOL).

There was a designated patient safety nurse who investigated all incidents including reviewing CCTV, and holding debriefs with both patients and staff to identify if there were any opportunities for learning. We saw examples of learning from incidents being shared with staff. For instance, a patient had managed to bring a prohibited item onto the ward. Staff identified this promptly and addressed the situation appropriately. The learning from the incident was communicated to the wider team, with emphasis placed on the importance of conducting thorough searches when patients returned to the ward.

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 had a clear policy that ensured all required information about a patient was obtained during the admission process to ensure the needs of all patients could be met. A clinical commissioning nurse assessor screened referrals for suitability before arranging either an in person or desktop assessment. The unit manager made a final decision on the suitability of the admission in collaboration with the Responsible Clinician and other clinical staff. The policy had an inclusion and exclusion criteria to ensure they were able to meet the needs of patients they admitted.

The service worked with people and partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The service ensured continuity of care, including when people moved between different services.

We sought feedback from commissioners and external partners who placed or worked with patients at Highwoods ward. We obtained their view of the hospital systems, pathways, patient flow, safety and quality. A commissioner spoke extremely highly of the ward, describing it as the best Cygnet ward they had ever worked with. They praised their collaboration, communication and information sharing and noted they were proven to be patient centred, intuitive and supportive.

We looked at 5 care plans and saw they were reviewed regularly at weekly MDT meetings. We saw discharge planning from admission which included input from patient, carers and community teams.

Care plans were comprehensive and person‑centred, and there were examples of patients being appropriately referred to external providers such as GPs. However, managers acknowledged not all information within a patients’ care plan was recorded in a single place, which made them more difficult to review.

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.

The service had a safeguarding policy and clear processes in place for staff to follow. Staff received training on how to recognise and report abuse, appropriate for their role. All staff completed multiple mandatory safeguarding training modules and compliance was between 93.1% and 100%.

The hospital had a safeguarding lead, and staff knew how to raise safeguarding concerns. Between September and December 2025, staff had made 15 safeguarding referrals. Safeguarding concerns related to a variety of incidents including violence and aggression between patients, neglect and financial abuse.

The safeguarding lead ensured the service had a robust system for tracking the progress of safeguarding referrals. Referrals were reviewed and staff liaised with the Local Authority when appropriate. The safeguarding log was up to date and included details about safeguarding incidents.

Staff followed safe procedures for children visiting the service. Children were not allowed to be on the ward; however, arrangements could be made for the safeguarding lead to supervise external visits.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. We saw evidence of comprehensive training provided to staff to increase their understanding of transgender people.

100% of staff had had training in the Mental Capacity Act.

We spoke with 2 carers; both told us they felt their loved one was safe on Highwoods ward.

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 only after attempts at de-escalation had failed. The ward staff participated in the provider’s positive and safe care policy: reducing restrictive practice They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We looked at 5 care plans. In each one staff completed risk assessments for each patient on admission and reviewed this regularly, including after any incident and at weekly ward rounds.

Staff involved patients in care planning and risk assessment. Staff told us that care plans were co-produced with patients and were discussed in ward rounds and reviews.

There had been 17 incidents of restraint on Highwoods ward between September and December 2025. No incidents involved prone, face down restraints. All staff we spoke with were aware of the positive and safe care policy: reducing restrictive practice. This policy required staff to use the least restrictive option reasonably available.

All patients had access to an Independent Mental Health Advocate (IMHA) during their stay at the hospital. Information about how to access the advocate was displayed around the ward and given to patients on admission.

Staff enabled patients to give feedback on the service. There were regular community meetings held for patients, and they were encouraged to complete a review of the service. A staff member gave an example of a patient complaining about a medication brand change, this was addressed appropriately by staff.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People were cared for in safe environments that were designed to meet their needs. Facilities and equipment were well-maintained and supported staff to deliver safe and effective care.

We toured the ward and observed that it was airy and spacious, very clean and well-maintained, well-furnished and fit for purpose.

Staff could not observe patients in all parts of the wards and outside space. However, the service had fitted convex mirrors and CCTV to monitor communal areas and used enhanced observations to support patients with additional risks.

The ward complied with guidance and there was no mixed sex accommodation. The service only admitted male patients.

Staff had easy access to alarms and patients had easy access to nurse call systems.

The clinic room was clean and fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly.

There was a comprehensive ligature risk assessment and appropriate furnishings to mitigate risk.

Each patient had their own bedroom, which they could personalise, although at the time of our visit none of the patients had chosen to do this. Bedrooms were clean and bright with ensuite facilities. We saw a welcome pack that all patients were given when they were admitted, this included shower gel, a flannel and an oral care package.

Staff used a range of rooms and equipment to support treatment and care. The ward had a clinic room, and rooms that could be used for group work, art therapy and activities.

The service displayed the names and photos of all staff so that staff and visitors were aware of the staff working on the wards.

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 receive effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service was fully staffed with only 1 vacancy for an occupational therapist. The use of agency or bank staff was minimal and at 0.6% at the time of inspection. We could see the wards were fully staffed, and people told us there were mostly enough staff on the wards.

At the time of inspection, the short-term sickness rate was 3.6% and no members of staff were on long term sick leave. The overall turnover rate was 13.8%.

Managers had calculated the number and grade of nurses and healthcare assistants required. The number of nurses and healthcare assistants matched this number on all shifts. Additional nursing staff were utilised every week to assist with supporting the ward round.

Staff had completed and kept up to date with their mandatory training. Overall, staff compliance with mandatory training was 97.4%. There was no mandatory training with a compliance rate of less than 75%. The mandatory training programme was comprehensive and met the needs of patients and staff.

Managers gave each new member of staff a full induction to the service before they started work.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean.

All ward areas and clinic areas were clean and well maintained.

Cleaning records were up to date and demonstrated that all areas of the hospital were regularly cleaned.

Staff followed infection control policy, including handwashing. Hand gel was available at the ward entrance and there were visible hand washing reminder stickers around the ward. Compliance levels for mandatory training in infection control was at 100%.

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 by enabling them to be involved in planning, including when changes happened.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal) and did it in line with national guidance.

Patients’ medicines were reviewed as part of an overall review of their progress at ward rounds. Patients were involved in discussions about medication and care planning.

Staff stored and managed all medicines and prescribing documents safely. All medicines were stored in locked cabinets, or in the medicine fridge in the clinic room. A pharmacist visited the ward twice a week and a consultant reviewed medication records regularly.