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. All wards were 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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew what incidents to report and how to report them. Staff reported incidents clearly in line with the providers policy. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed by the ward manager. Staff understood duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong.

The service had up to date incident reporting processes The service understood its responsibility to submit statutory notifications. Governance processes showed leaders had oversight of incidents and took action to manage risks.

Managers investigated incidents thoroughly, incidents were discussed at daily sit-rep meetings, handovers, team meetings and clinical governance meetings. Managers investigated serious incidents using the Patient Safety Incidence Response Framework (PSIRF) including reviewing closed-circuit television (CCTV) recording of incidents, where these were available, to identify areas of improvement and good practice. After serious incidents managers completed an After-Action Review (AAR).

Staff were de-briefed and received support after an incident. Staff met to discuss learning from incidents which was shared in a variety of ways. Staff told us they received regular communication about learning from incidents. If an incident took place on the ward, it would be discussed at handover. Staff received feedback from the investigation of incidents. They met to discuss this feedback, review lessons learned and continually identified and embedded good practice. The safeguarding lead spoke with staff and patients to share learning and check on people’s welfare. The patient safety lead worked with staff to share key learning messages from across the service.

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.

Managers followed a clear admission inclusion and exclusion policy that guided them on the criteria to follow for admission to the service. The service admitted patients who were stepping down from other wards, such as low secure or acute services. Patients were also transferred to the ward from other rehabilitation services. The multi-disciplinary teams met to discuss new referrals to ensure they could meet the needs of the patient and maintain the safety of all patients on the ward. Ward teams liaised with the senior leadership team and were supported by them if a decision was made not to accept a referral.

Staff involved all the necessary health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Other agencies involved with patients’ care were invited to attend ward rounds and could attend virtually if that was preferred. Staff involved commissioners, care co-ordinators, social workers and the community mental health team.

Staff ensured that patients’ discharges from the service were managed safely. Discharge planning began at a patient’s first meeting following admission. Patients were either transferred to another placement closer to home when appropriate or discharged to their own accommodation. Staff liaised with the appropriate services to ensure robust discharge plans were in place. We looked at 5 patient care plans. Patients had a discharge care plan, which was discussed in meetings and was regularly updated.

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 received and kept up to date with safeguarding training appropriate for their role. The provider offered a range of safeguarding training for staff, from introductory training through to advanced training for safeguarding leads. Compliance for all levels of training varied between 83.9% and 100%. Compliance for the introductory safeguarding course was 97.3%.

The provider had a safeguarding lead who monitored safeguarding investigations and supported staff when reporting potential abuse and ensured they reported to the local authority, CQC and the police when appropriate.

Staff knew who to inform if they had a safeguarding concern. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff gave us examples where they had raised safeguarding concerns.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff followed clear procedures to keep children visiting the ward safe. Children were not permitted to visit patients on the wards. Visits from children took place at other areas in the hospital.

There were clear procedures in place to promote patient’s safety. The safeguarding policies provided guidance to ensure staff were aware of how to raise a safeguarding concern. Noticeboards in the ward offices also provided contact details for the local safeguarding authority, as well as who the safeguarding leads were.

Staff could recognise signs when patients experienced emotional distress and knew how to support them to minimise the need to restrict their freedom to keep them safe. Patients were restrained only where evidence demonstrated it was necessary and for the minimum period. Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the person safe. Staff understood the Mental Capacity Act definition of restraint and worked within it.

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.

Staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident. The multidisciplinary team were involved in completing patient risk assessments, so all aspects of care and treatment were considered. Care records for patients had up-to-date risk assessments, and during ward rounds, staff discussed specific risks to each patient.

The service had a ‘Positive and Safe Care Policy: Reducing Restrictive Practice’ which was updated in May 2025 and provided guidance for staff who may use restrictions for the safety of those in their care and any persons round them. Staff told us they used restrictive practice as a last resort and were open to challenge about these restrictions from patients, staff, family members or other stakeholders. Managers conducted quarterly audits on blanket restrictions (those that applied to all patients on the ward) and restrictions that applied to specific patients which were individually risk assessed.

Staff knew about any risks to each patient and acted to prevent or reduce risks. Staff we spoke with knew the patients they supported and were aware of any risks they posed to themselves, others or their environment. Staff were aware of what strategies to use to minimise and manage risks.

Staff identified changing risk levels and amended observation levels and interaction with patients in response. Staff followed provider policy on the use of observation and searching, and staff discussed levels of observation with the multidisciplinary team.

Ramsey Unit recorded 3 incidents of restraint in the last 4 months. Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe. Staff completed training in the use of restrictive interventions. The provider offered a range of training in safety intervention, from foundation to advanced, which was delivered both as e-learning and face to face. Training compliance was between 89.5% and 100% at the time of inspection.

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.

The ward areas were clean and well equipped. Staff regularly reviewed the environment, identified and managed ligature risks, and mitigated risks quickly to keep patients safe. Managers ensured staff on the wards had easy access to information on environmental risks, this included a map of hotspot areas. The service completed ligature point and blind spot audits, these covered all areas of the ward and external areas. Managers also carried out monthly ward environmental checks; findings were then taken to clinical governance meetings to be actioned. Staff we spoke with knew about any potential ligature anchor points and knew where ligature cutters were located. Staff could describe mitigations taken to reduce risks to patient’s safety.

The service complied with NHS guidance on delivering same-sex accommodation. Each person had their own bedroom, which they could personalise. Patients had a secure place to store personal possessions.

The ward had a range of rooms and equipment to support treatment and care. The ward had quiet areas patients could use. The service had a room where visitors could come and meet patients.

The service did not have a seclusion room. If patient’s risks changed, they would be supported with a move to a more appropriate setting.

Staff could not observe patients in all parts of the ward. This risk was identified and recorded within the ligature risk assessment and mitigated using convex mirrors and staff observations.

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

The service had policies to follow fire and safety practices on site. There was a fire escape plan and fire action notices on the ward which showed the assembly point.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

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.

The service was fully staffed with only 1 vacancy for an occupational therapist which was due to be filled imminently. 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 always 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%.

When necessary, managers deployed agency and bank staff to maintain safe staffing levels. When agency and bank staff were used, those staff received an induction and were familiar with the ward.

There were enough staff to carry out physical interventions, for example, observations and restraint safely. 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. Overall compliance with mandatory training was 97.6%. The mandatory training programme was comprehensive and met the needs of patients and staff.

Leaders supported staff through regular constructive and comprehensive supervision of their work. Managers monitored compliance with supervision. At the time of out inspection, supervision rates were 100%. Leaders also supported permanent staff to develop through yearly, constructive, comprehensive appraisals of their work.

Staff were given a comprehensive induction to the service to ensure they were prepared for the role. Managers monitored staff competencies on an annual basis to ensure staff were competent to carry out their duties.

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

The ward areas were clean, tidy and had good furnishing. Housekeeping staff cleaned the wards daily. Staff maintained equipment well and kept it clean. The service followed their infection control policy, including hand washing.

The service conducted monthly hand hygiene audits which included checking that all staff were using the correct hand-washing technique and adhering to ‘bare below the elbow’s’ policy. Managers also completed quarterly infection prevention and control audits and reported on any actions that needed to be taken.

Staff completed Infection, Prevention and Control training. Staff compliance rate for infection prevention control training was 93.4%.

The service had a detailed Infection Prevention Control policy, which was reviewed regularly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The clinic room was clean, orderly and fully equipped. Cleaning records were available and completed. Staff recorded daily room and fridge temperatures to ensure the safe storage of medicines.

Staff accurately recorded administration of medicines. Staff followed good practice in medicines management (which included, transport, storage, dispensing, prescribing, administration, medicines reconciliation, recording and disposal) and in line with national guidance. There were specific systems in place for the management of controlled drugs and medicines that were liable to be misused.

Medicines were stored appropriately. Medicine cupboards were locked when not in use. Medicines prescribed for individual patients were labelled and stored correctly. Staff kept up-to-date information about stock. Staff knew how to dispose of medicines and associated equipment safely. Staff kept accurate records of medicines. Sharps bins were available on the ward and were marked with the date of opening, as needed. Staff kept records of national medicines alerts and recorded what action they needed to take to improve practice.

The service ensured patient’s behaviour was not controlled by excessive and inappropriate use of medicines.

The service reviewed patient’s medicines regularly and provided advice to patients and carers about their medicines. Patient’s medicines were reviewed as part of their overall review of their progress at ward rounds. However, we found 1 patient had been prescribed lorazepam, as needed (PRN) but this had not been used and not been reviewed for the last 5 months.