The Care Quality Commission
  • Mental Health
  • Independent mental health service

Cygnet Hospital Derby

Overall: Good read more about inspection ratings

London Road, Derby, Derbyshire, DE24 8WZ (01332) 365434

Provided and run by:
Cygnet Health Care Limited

All Inspections

During an assessment of Forensic inpatient or secure wards

Date of assessment: 8 to 12 September 2025. We assessed all 33 Quality Statements across the five key questions: safe, effective, caring, responsive, and well-led. The service had last been inspected in May 2022 and had been rated Good. Following this assessment, the rating remained Good.

Staff provided safe, structured, and patient-focused care. Environments were clean, well-maintained, and designed to minimise risks, including ligature points. Staff completed thorough, ongoing risk assessments and updated them to reflect each patient’s changing needs.

Care and treatment had been delivered in line with national guidance and best practice, with multidisciplinary teams working seamlessly to meet patients’ individual needs. Staff had been highly trained, supported through supervision and appraisal, and had demonstrated innovation in care delivery.

Patients reported that they felt safe, respected, and empowered. Staff actively promoted dignity, independence, and choice, involving patients in care planning and decisions wherever possible.

Families and carers had been fully included in planning, fostering a culture of collaboration.

Leadership had been visible, supportive, and focused on continuous improvement. Staff reported that they had felt valued and confident in their roles.

During an assessment of Forensic inpatient or secure wards

Date of assessment: 8 to 12 September 2025. We assessed all 33 Quality Statements across the five key questions: safe, effective, caring, responsive, and well-led. The service had last been inspected in May 2022 and had been rated Good. Following this assessment, the rating remained Good.

Staff provided safe, structured, and patient-focused care. Environments were clean, well-maintained, and designed to minimise risks, including ligature points. Staff completed thorough, ongoing risk assessments and updated them to reflect each patient’s changing needs.

Care and treatment had been delivered in line with national guidance and best practice, with multidisciplinary teams working seamlessly to meet patients’ individual needs. Staff had been highly trained, supported through supervision and appraisal, and had demonstrated innovation in care delivery.

Patients reported that they felt safe, respected, and empowered. Staff actively promoted dignity, independence, and choice, involving patients in care planning and decisions wherever possible.

Families and carers had been fully included in planning, fostering a culture of collaboration.

Leadership had been visible, supportive, and focused on continuous improvement. Staff reported that they had felt valued and confident in their roles.

During an assessment of Long stay or rehabilitation mental health wards for working age adults

Date of assessment: 8 to 12 September 2025

We assessed all 33 quality statements across the five key questions: safe, effective, caring, responsive, and well-led. The service had last been inspected in May 2022 and had been rated Good. Following this assessment, the rating remained Good.

Wyvern Ward provided a safe, therapeutic, and highly personalised environment focused on rehabilitation and community reintegration. The environment was clean, well-maintained, and appropriate for high-support care, with proactive risk assessments and management in place.

Care and treatment had been delivered to a high standard. Staff had demonstrated skill and innovation, delivering a wide range of interventions, including psychological therapies, vocational and educational support, and structured activity programmes. Patients had made significant progress towards their independence and personal goals.

Patients felt empowered, fully involved in decision-making, and supported to develop independence and control over their care. Families had been included sensitively, and staff had facilitated meaningful community connections.

Leadership had been strong, visible, and focused on innovation, continuous improvement, and staff wellbeing. Staff felt enabled, valued, and confident to deliver good care.

During an assessment of Long stay or rehabilitation mental health wards for working age adults

Date of assessment: 8 to 12 September 2025

We assessed all 33 quality statements across the five key questions: safe, effective, caring, responsive, and well-led. The service had last been inspected in May 2022 and had been rated Good. Following this assessment, the rating remained Good.

Wyvern Ward provided a safe, therapeutic, and highly personalised environment focused on rehabilitation and community reintegration. The environment was clean, well-maintained, and appropriate for high-support care, with proactive risk assessments and management in place.

Care and treatment had been delivered to a high standard. Staff had demonstrated skill and innovation, delivering a wide range of interventions, including psychological therapies, vocational and educational support, and structured activity programmes. Patients had made significant progress towards their independence and personal goals.

Patients felt empowered, fully involved in decision-making, and supported to develop independence and control over their care. Families had been included sensitively, and staff had facilitated meaningful community connections.

Leadership had been strong, visible, and focused on innovation, continuous improvement, and staff wellbeing. Staff felt enabled, valued, and confident to deliver good care.

During an assessment of the hospital overall

Cygnet Derby Hospital is a purpose-built facility run by Cygnet Health Care Limited. It registered with the CQC in 2010 and provides the following regulated activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983
  • Treatment of disease, disorder or injury

The service had a Registered Manager. We visited the following wards as part of the assessment:

  • Alvaston Ward – Female Low Secure Personality Disorder – 16 beds
  • Litchurch Ward – Male Low Secure Mental Health & Dual Diagnosis – 15 beds
  • Wyvern Ward – Male High Support Inpatient Rehabilitation (Level 2) – 19 beds

At this assessment we assessed 2 assessment service groups; Forensic inpatient or secure wards where we assessed all quality statements and Long stay or rehabilitation mental health wards for working age adults where we also assessed all quality statements.

We assessed Cygnet Derby Hospital from 8 to 12 September 2025.

We assessed all 33 Quality Statements across the five key questions: safe, effective, caring, responsive, and well-led. The service was last inspected in May 2022 and was rated Good. Following this assessment, the rating remains Good.

The service provided care that was safe and well-organised. The environment was clean, well maintained, and appropriate for its purpose. Environmental risks, including ligature points, were effectively identified, assessed, and mitigated. Staff completed comprehensive risk assessments for patients and reviewed them regularly.

Care and treatment were consistently delivered in line with national guidance and best practice, and staff went beyond this to achieve excellent outcomes for patients. People had access to a wide range of highly specialised support tailored to their individual needs. Staff were well trained and supported through supervision and appraisals, which enabled them to deliver high-quality, innovative care. The multidisciplinary team worked very well together and maintained strong, proactive partnerships with external agencies to ensure continuity of care and the best possible outcomes.

People using the service were treated with kindness, empathy, and respect. Staff actively promoted dignity, independence, and individual choice, ensuring people remained central to all decisions about their care. Patients consistently told us they felt empowered to understand their rights and stay in control of their wellbeing.

There was strong leadership in place. Leaders were visible, supportive, and fostered a positive culture of learning, collaboration, and continuous improvement across the service.

Mental Health Act & Mental Capacity Act Compliance Summary

During our inspection (8–12 September 2025), we evaluated the service’s compliance with both the Mental Health Act (MHA) and the Mental Capacity Act (MCA). Staff demonstrated a strong understanding of the MHA and its Code of Practice, applying it confidently when admitting and managing detained patients to ensure care remained lawful and patients’ rights were respected. Governance and oversight of MHA use were robust, with clear escalation pathways, regular reviews, and effective monitoring arrangements. Patients detained under the MHA were supported to engage in decisions about their treatment, with access to independent advocacy and second opinion appointed doctors where required, providing safeguards for those who lacked capacity or were subject to treatment under legal compulsion. There was no evidence of systemic overuse or misuse of restrictive powers, and leadership emphasised patient-centred decision-making when restrictions were necessary.

Staff consistently assessed patients’ capacity to make specific decisions using the two-stage test and documented these assessments thoroughly. When patients lacked capacity, staff made decisions in their best interests after consulting the multidisciplinary team, families, and advocates. They clearly recorded the rationale, who was consulted, and what options were considered. Reasonable adjustments were made to support patients in understanding and participating in decision-making, including easy-read materials, interpreters, and adapted communication methods. Governance of MCA practices were strong, with regular audits of capacity assessments and best-interest decisions. Staff received ongoing training in MCA, human rights, and equality to ensure decisions upheld patients’ rights and dignity.

Overall, the service demonstrated very good compliance with both the MHA and MCA. Staff applied legal frameworks appropriately, maintained a balance between care, protection, and autonomy, and ensured patients were involved wherever possible. Governance systems supported compliance, and the service showed a clear commitment to respecting patient rights while delivering safe, personalised care.

10-18 May 2022

During a routine inspection

Cygnet Hospital Derby provides one male and one female low secure wards and a locked rehabilitation ward for male patients who no longer require secure care.

Our rating of this service stayed the same. We rated it as good because:

  • The service provided safe care. The ward environments were safe and clean.
  • The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
  • Patients had an opportunity to manage their own medicines as part of their rehabilitation or recovery.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the ward, which included substance misuse workers and social workers.
  • Managers ensured that staff received training, supervision, and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and their families and carers in care decisions. This included carers' days and there was an allocated staff member on each ward to communicate with carers.
  • Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The service was well led, and the governance processes ensured that ward procedures ran smoothly.

However:

  • The wards looked tired and in need of redecoration particularly on Alvaston and Wyvern wards. There was a programme of planned refurbishment and we saw this had started in the corridors leading to the wards.
  • There was a blind spot in the toilets of the seclusion rooms on Litchurch and Alvaston wards. Seclusion on Litchurch ward was not always in line with the Mental Health Act Code of Practice and one of the seclusion records was incomplete. Documentation was messy and handwritten and not always easy to understand.
  • On Alvaston ward, staff had administered prescribed intramuscular injections to a patient but had not always documented what physical health observations had taken place. One patient did not have a T2 attached to their medicine record on Wyvern ward, but staff ensured this was done during our inspection.
  • Although staff mostly managed medicines safely and where appropriate, patients had an opportunity to manage their own medicines as part of their rehabilitation or recovery, there were some gaps in the recording of monitoring the self-administration of medicines on Wyvern and Litchurch wards, so it was not always clear that patients were managing these safely.
  • Staff did not always make reasonable adjustments in multidisciplinary team meetings to ensure patients could fully participate.

5th and 6th April 2018

During a routine inspection

We rated this service as Good because:

  • The hospital provided a good standard of accommodation to patients. The hospital was clean and records demonstrated this. There were adjustments in place for people requiring disabled access, support of patients’ spiritual needs and an extra care facility for patients needing seclusion or long-term segregation.
  • The hospital was staffed safely and all shifts occurring from staff sickness, absence and vacancies were filled. Each ward had a multi-disciplinary team. Employment records demonstrated that staff were qualified and experienced for the positions they held, and all staff received an induction and mandatory training.
  • Information needed to deliver care was stored securely and was available to staff when they needed it. Risk assessments and care plans were present and up to date in patients’ records. Care plans were recovery focussed and demonstrated that staff shared copies with patients. The Recovery Star provided a visual record of a patients’ recovery progress.
  • Patients said that staff were caring, respectful and polite, and we saw evidence of this in interactions. Patients felt involved in their care and had the opportunity to make decisions about how they would like to be treated if they were unable to make that decision in the future. The hospital had initiatives in place to involve patients in making decisions about the service.
  • The hospital had an established recovery college, offering educational and recovery focussed courses that were co-produced and facilitated by staff and patients. Outcome measures demonstrated the effectiveness of the college and patients described the college’s activities as meaningful.
  • The hospital had a strategy and delivery plan for reducing restrictive practice. Following a risk assessment from staff, where safe to do so, patients could have a key to their bedroom and their own mobile phones. Figures demonstrated that occurrences of restrictive practice including restraint, rapid tranquilisation, seclusion and long-term segregation, were low.
  • The hospital used key performance indicators to gauge the performance of ward teams and had effective governance systems to monitor performance. There was an overarching local action plan that brought together all the actions from risk assessments, incidents, the Peoples Council, peer review assessments, and staff, patient, and carer surveys.

However:

  • Staff had not always completed medicine charts to confirm administration of medicine or record a reason why the medicine had been omitted. Staff had not always kept records of high dose antipsychotic monitoring updated with the correct dates and outcomes of physical health checks.
  • Staff did not routinely record return details on leave risk assessment forms. This meant that a record of the outcome of Section 17 leave was not maintained to inform future decision-making.

1 -2 July 2015

During a routine inspection

We rated services as good because;-

  • All patients we spoke with said they felt safe in the environment. Patients had risk assessments and care plans, these were linked to “the recovery star” and “my shared pathway outcomes” tools which enabled patients to visually see the progress they were making.

  • Patients said that staff were respectful, caring and showed an interest in their wellbeing. Patients had access to advocacy to support them in making complaints and during meetings.

  • There were safe staffing levels on all wards. Staff understood the different security procedures for low and rehabilitation wards .Staff and records confirmed that staff knew how to report safeguarding concerns and incidents. Staff gave examples of changes in practice as result of learning from incidents.

  • There was good multi-disciplinary working, the clinical team reviewed patient outcome to assess patients progress.

  • Staff explained the organisation's values. Staff were committed to support patients to recover, so they could be discharged to less secure environments quickly.

  • Local senior managers were visible in the clinical areas. The hospital had clear arrangements to monitor performance through its governance structures. The hospital had an action plan which incorporated actions from the risk register, complaints, audits and incidents. These were discussed in the team business meetings.

However;

  • The Litchurch ward seclusion room had no intercom system. This meant that communication occurred by talking through the door.

  • All wards and Litchurch seclusion room had blind spots which meant that patients could be hidden from view.This was a breach of regulation 15 of the Health and Social Care Act. Staff managed by observation and supervision of patients. Closed circuit television (CCTV) had been installed in communal and corridor areas to support mitigation of risks.

  • Some staff were unaware of the ligature audit results.

  • Records reviewed did not confirm that patients had been given information when medication was first administered or about the effects of high dosage medication.

  • Nursing staff's understanding of the Mental Capacity Act (MCA) was not consistent.

  • Not all patients had copies of their Section 17 leave forms so that they knew their conditions of leave.

  • Records reviewed did not contain advance decisions on how patients wished to be treated.

  • Patients’ unlabelled personal items were found in the storeroom on Alvaston ward. The quiet room could not be used because patient belongings had been stored in it.

  • Alvaston ward had 16 beds. Department of Health guidance states there should be 15 beds for low secure units.

  • There was one visitor’s room available to three wards, which meant that visiting was by appointment.

4 February 2014

During a routine inspection

We visited all three wards as part of this inspection and spoke with eight people. People told us they were generally treated with respect and their dignity maintained. Comments included 'Staff treat me with respect and observe my dignity' and 'Most staff treat us with respect and observe our dignity but sometimes the bank staff can be a little difficult to get on with.' People felt listened to and able to express their views about how the service was run.

People were supported to maintain their independence and community involvement when safe and appropriate to do so. Each person had an individual activity plan, and were encouraged to take part in activities.

People spoken with told us their care plan had been explained to them, and they were aware of their rights. Care plans were detailed and set out the care, support and treatment required to meet people's needs. People told us their general health care needs were met.

There were good links with a wide range of providers and agencies, to ensure that people received safe and co-ordinated care, treatment and support.

People told us they received their medication as required, and their medication had been explained together with the possible side effects.

4 December 2012

During a routine inspection

We visited Litchurch Ward during our visit and spoke with three people. They all told us they had been involved in planning their care, had seen their care plans and signed to indicate that they agreed with them. People also told us they were involved in weekly ward rounds with medical staff.

People told us they chose what activities they took part in. People were interacting with staff during our visit, playing pool or sitting chatting. We saw people were supported to access the community, either with support from staff or independently. Risks associated with involvement in community projects, or access to community facilities, for example the local gym, was clearly documented and planned for.

All of the men we spoke with told us staff treated them with dignity and respect. They told us staff always knock on their room door prior to entering. People told us they all felt safe and comfortable to raise any issues. One person told us that staff were very good at calming down people when they were angry as well as protecting everyone else. We found systems were in place to protect people and staff had a good knowledge of the procedures.

We saw staff had been recruited safely, and were provided with on going training to maintain their skills and knowledge. Staff received regular supervision, to ensure their practice was satisfactory.

We found the service maintained records appropriately and securely, so confidentiality was maintained.

18 November 2011

During a routine inspection

People we spoke with told us they were generally satisfied with the service. They were involved in decisions about their care and treatment. They had access to a range of therapeutic activities including IT, a gym, gardening and arts and crafts. One person told us the food was, 'always fresh and we have plenty of variety but sometimes it's a little exotic.' People had complained to the service about smoking breaks. One person said, 'There is not enough staff to allow cigarettes at night and staff sometimes have to send for someone from another ward to cover.' They thought the management team was working with them to resolve this.