Cygnet Hospital Colchester

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 as good. At this assessment the rating has remained as 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 serious incidents clearly and in line with provider policy. Staff recorded incidents on an electronic incident reporting system. In the 2025 staff survey, 95% of staff agreed they were encouraged to report errors, near misses and incidents.

Managers reviewed and discussed incidents at the daily sit-rep meetings, handovers, team meetings and clinical governance meetings – both local and regional. Managers investigated serious incidents thoroughly using the ‘Patient Safety Incidence Response Framework’ including reviewing closed-circuit television (CCTV) footage, when available, to identify areas of improvement and good practice. After serious incidents, managers completed an ‘After Action Review (AAR)’ and staff and patients were offered a debrief. 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 across the service. We saw an example of an AAR which was completed following the admission of a patient with a pressure ulcer.

Staff received feedback from investigation of incidents, both internal and external to the service. Learning from incidents was discussed in staff meetings, supervisions, handover and business meetings and shared in e-mails.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. The service had a duty of candour policy which gave additional information on Cygnet’s standards and expectations in relation to the duty of candour.

In the 6 months leading up to inspection, the provider reported 3 serious incidents including 1 episode of a patient going absent without leave (AWOL) and 1 incident of medication not being sent to the person’s placement.

Staff told us they received hot and cold debriefs and received support after an incident. Hot and cold debriefs are post-event review processes, with hot debriefs happening immediately after a serious incident for quick support and information sharing while cold debriefs occur days or weeks later for in-depth analysis, data collection, and formal quality improvement.

Managers and psychology staff facilitated reflective practice sessions for staff.

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 the patient was received to determine if the patient’s needs could safely be met. A Cygnet nurse assessor completed an initial assessment, and this was discussed within the multi-disciplinary team at the hospital. Staff from Cygnet Colchester then visited the patient to further assess their suitability and, once a decision was made to admit, a handover was arranged with the staff or family members who were currently supporting the patient.

Staff made sure they shared clear information about patients and any changes in their care, including during handover meetings. Staff held handover meetings at the end of each shift.

Ward teams had effective working relationships with external teams and organisations. Our review of records from Multi-Disciplinary Team (MDT) meetings and care records indicated involvement of family members, key stakeholders, and care teams in discussing patient progress, future care planning, transitions and discharges. We saw clear partnership working documented at ward reviews.

We looked at the compliments log for the hospital and saw positive feedback regarding hospital systems, pathways, patient flow, safety and quality from commissioners and bed managers who placed patients at Cygnet Colchester. For example, one commissioner fed back that that this is the best that he has ever seen his patient since he had known him and that he could see how well everyone has worked with him.

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. We looked at 4 care records and saw all the patients either had a discharge plan or if there was a delayed discharge, the reason was documented and any actions being taken to address this. For example, we saw a case where the integrated care board was working with hospital staff to find suitable supported accommodation for a patient.

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 that when appropriate. 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 hospital had a Safeguarding Lead and information about how to contact them was displayed around the hospital. The safeguarding lead for the hospital worked closely with the local authority and had a system for tracking the progress of safeguarding referrals which was reported into clinical governance meetings. Safeguarding concerns related to a variety of incidents including violence and aggression towards staff, patients self-harming, medication errors and patients going absent without leave (AWOL).

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. For example, we saw an example where a staff member had made a safeguarding referral when it was alleged that a colleague was asleep on duty.

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.

All the patients and carers we spoke with told us they, or their loved one, felt safe at Cygnet Colchester.

We scored the service as 4. The evidence showed an exceptional standard. The service worked with people to understand and manage risks by thinking holistically. Staff proactively assessed, anticipated and managed risks to patients and themselves. Risk management was embedded and recognised as being the responsibility of all staff. 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 knew patients well and were aware of any risks they posed to themselves, to each other or to the environment. Staff knew what strategies to use to minimise and manage risks. For example, where a patient was at risk of choking if he had a lot of food on his plate, staff had agreed with him to divide meals onto 2 plates, which slowed down his eating and reduced the risk.

Staff developed positive behaviour support plans for patients to equip patients and staff with strategies to recognise when a patient was becoming distressed and to know how they could best support patients in these situations.

We looked at 4 care plans during the assessment. For each patient, there was a RAG rating for risk: Red indicated high risk and green indicated settled. Patient risks were discussed every morning at the daily risk assessment meeting. Following an incident, a patient remained on red for seven days; if no further incidents occurred, the rating returned to green.

Staff communicated with patients so that they understood their care and treatment, finding effective ways to communicate with patients using easy read materials, choice boards, pictorial aids and social stories. We saw an easy read ‘Blanket Restrictions’ poster on the wards which explained why there were rules and what patients could do if they thought the rules were unfair - for example speak with a member or staff or advocate or make a complaint to the patient advice and liaison service (PALS) or the Care Quality Commission (CQC).

Staff ensured that patients and carers could access advocacy. The service had independent advocates who visited the hospital 4 times a week. There was an easy read poster displayed on the ward with information and photographs of the advocates who would be attending, along with contact information. Carers had access to a specialist advocacy service which aimed to support carers to access information, feel involved and raise concerns. Managers told us this service was valued and well-used by carers.

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.

Each patient had an individual reducing restrictive practice plan which described what restrictions were in place for that patient, the rationale and what actions were being taken to reduce the restriction. For example, one patient had a restriction on how much he could drink in one day because he was at risk of drinking an excessive amount which could severely affect his health.

In the 3 months prior to the inspection the provider reported 233 incidents involving restraint. Incident numbers were high due to the reporting of all incidents, and most incidents were attributed to 2 newly admitted patients who were initially displaying a high level of distress and were resistive to attempts to use de-escalation techniques. The provider reported 4 episodes of the use of rapid tranquilisation in the 3 months prior to inspection. No incidents involved prone, face down restraints. There were no incidents of seclusion or long-term segregation.

The number of incidents of restraint was reducing. On Oak Court restraints had reduced from 43 in September to 10 in October as staff got to know new patients and the best way to support them. When incidents occurred, staff responded promptly, documented incidents accurately, and updated care plans and risk assessments. Staff we spoke with knew what incidents to report and how to report them.

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. Staff we spoke to were able to tell us about the various de-escalation techniques they would use such as verbal de-escalation and utilising a low stimulus environment or distraction. We saw an example in a care plan where there was a clear de-escalation approach documented following an episode of distress.

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.

During the inspection visit, we toured all the wards. We observed the wards were clean and well decorated and maintained.

The ward complied with guidance on mixed sex accommodation. The hospital only admitted male patients.

Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe.

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

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

The service did not have a seclusion room. The service did not admit patients who were at risk of needing seclusion. If a patient’s risks changed, they could be supported with a move to a more appropriate setting.

In Larch Court and Chestnut Court, patients had their own bedrooms and lounge areas. Patients on Oak Court had individual bedrooms with access to communal lounges. Patients could personalise their rooms - we saw an example where 1 patient had chosen the paint colours for his bedroom, and another patient had chosen a Christmas tree for his lounge area. All bedrooms had ensuite bathroom facilities and staff supported patients with cleaning their rooms and doing laundry.

Patients had a secure place to store personal possessions.

Staff used a full range of rooms and equipment to support treatment and care. The wards had clinic rooms, 1-1 meeting rooms, low-stimulus areas and rooms for group work, occupational therapy and activities. There was also a gym, activities of daily living (ADL) kitchen, and sensory room available for patients to use on the hospital site. There was a social centre available for all patients a short walk from the hospital.

The service displayed the names and photos of all staff on each ward, 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 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%.

There were enough staff to carry out physical interventions and observations safely and staff had been trained to do so. Integrated care boards (ICBs) had commissioned bespoke care packages for each patient, and they all had 2-3 members of staff who knew them well to always support them.

There was adequate medical cover day and night and a doctor could attend quickly in an emergency. The service had a 24 hour on call rota for staff to access support when needed.

Staff had received and were up to date with appropriate mandatory training. The overall training compliance was 95.1%. The mandatory training programme was comprehensive and met the needs of patients and staff. The provider offered over 200 different training courses for staff, and members of the multi-disciplinary team could offer bespoke training for individual members of staff on request.

The training was appropriate for the patient group using the service. The provider offered staff a programme of service specific training, for example, ‘promoting skill development/meaningful activity’, ‘sensory integration’, ‘social stories’ and ‘epilepsy awareness’. Overall, 90.9% of staff had completed Cygnet’s training in learning disabilities and autism Tier 2 and 93.4% of staff had completed the Tier 1 Oliver McGowan mandatory training on Learning Disability and Autism (for a general awareness of the needs of autistic people and people with a learning disability).

Managers monitored mandatory training and alerted staff when they needed to update their training. Managers received a regular report showing compliance with mandatory training. This report included details of training that was soon to expire.

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

Once a year, staff were re-allocated to different wards to give them an opportunity to work and learn from a different patient group. This gave all staff the opportunity for development and helped to prevent a closed culture developing. (A closed culture in healthcare is a poor environment lacking transparency and external scrutiny, where staff and residents/patients are isolated, increasing risks of abuse, harm, and human rights violations). Staff ensured there was minimal disruption to patients’ routines and supported them to get to know new staff.

We scored the service as 2. The evidence showed some shortfalls in the standard of care. 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.

Staff maintained equipment well and kept it clean. All ward areas were mostly clean, had good furnishings and were well-maintained. However, the clinic rooms on Chestnut Court and Oak Court did not have cleaning schedules so staff were unable to demonstrate when these rooms were last cleaned and in Oak Court there was some heavy dust and bins were not being used appropriately. General waste was disposed of in an incorrect bin, which was overflowing and required emptying.

Staff followed infection control policy, including handwashing. Masks and hand gel were available, and staff followed personal protective equipment guidelines. The service displayed posters reminding staff to wash their hands. Overall, 93.4% of staff had completed the providers infection prevention and control training.

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

We scored the service as 2. The evidence showed some shortfalls in the standard of care. The service mostly 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 systems and processes in place to mostly safely administer, and record medicines use. Prescription and administration records were regularly reviewed by the multi-disciplinary team.

Staff administered medicines in line with relevant mental health act ‘consent to treatment’ authorisations where needed. However, patients discharged from the service or going away for a weekend break, were supplied with discharge medicines to take away commonly known as TTAs. The external pharmacy service did not provide a TTA supply service, rather this was being dispensed in-house by nursing staff. We saw a sample of TTA medicines labels and instructions which did not include cautionary labels. This does not meet the dispensing standard expected compared to when TTAs are supplied by a pharmacy.

Medicines were stored safely and securely, including controlled drugs and other medicines liable to misuse.

Staff ensured that people’s behaviour was not controlled with the excessive use of medicines. The service administered medicines in line with 'Stopping Over-medication of People with a learning disability, autism, or both (STOMP)'. We reviewed all prescribing and administration records and found no concerns.

Rapid tranquilisation (RT) - the process of administering a medicine intramuscularly for rapid sedation - was used as a last resort and staff actively worked to use alternative person-centred ways to de-escalate without the need to administer RT. We saw evidence that when people were given RT, they were appropriately monitored. When PRN (when required) medicines were used the reason for their use and what else had been tried first was clearly recorded on the daily electronic care records.

Patients had regular physical health monitoring, especially those prescribed high risk medicines. All patients had access to a GP, who could also be contacted out of hours. Patients were asked to complete a questionnaire to enable them to record and monitor the side effects experienced from their medicines, and staff used the Glasgow anti-psychotic side effect scale to monitor side effects. We saw evidence that staff used different communication mechanisms to engage with people living with learning disabilities and autism to ensure they understood their medicines.

An external clinical pharmacy service was used to provide advice on safe and effective use of medicines. The pharmacist visited the wards once a week and attended fortnightly Medicines Management meetings to discuss any medication related issues. Staff also used a communication portal, which was checked daily to action any queries raised about medicines management.

Staff completed a medicines audit, and medicines related incidents were recorded on tracker with any corresponding staff competencies. Themes and trends were monitored, and a report produced for clinical governance meetings.