- Independent mental health service
Cygnet Hospital Godden Green
Assessment report published 19 June 2025
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
Date of assessment: 30 April 2024
Cygnet Hospital Godden Green is a 33-bedded, Independent Mental Health hospital that provides specialist acute and psychiatric intensive care (PICU) services for women.
- Castle ward is a 12-bedded specialist PICU service for women and accepts emergency and crisis admissions.
- Oakwood ward is a 15-bedded acute service for women who are experiencing an acute episode of mental illness and require an emergency admission.
- Upper Oakwood is a 6-bedded acute service for women who are nearing discharge from the hospital.
We assessed all 33 quality statements across the safe, effective, caring, responsive and well-led key questions. The service had previously been inspected in September 2021 and received an overall rating of Good across all domains except Responsive which was rated as Requires Improvement. At the last assessment, the provider was in breach of Regulation 10 of the Health and Social Care Act, Dignity and respect. At this assessment, the service had made improvements and was no longer in breach of Regulation 10. However, we found the service to be in breach of Safe care and treatment (Regulation 12). We now rate the service as Good overall, with Safe rated as Requires Improvement.
The service did not always provide safe care. Care plans were not always being followed in respect of patients’ medicines and were sometimes out of date. Rapid tranquilisation on the wards did not always follow national recommendations for what medicines to use and where an alternative medicine was used this was not done in line with the provider’s own policy. Physical health checks following the use of rapid tranquilisation were not always being completed appropriately to ensure people were being kept safe.
However, environments were clean, well maintained and fit for purpose. Environmental risks, including ligature risks, were assessed, monitored and mitigated. Staff protected people from abuse and improper treatment. Staff completed risk assessments for patients and updated these regularly. Care plans mostly guided safe practice. People were supported to have choice and control and were involved in planning their care and could give feedback. The wards had enough staff to keep patients safe and meet people’s individual needs. Governance systems and audits were effective in identifying or addressing areas for improvement.
Mental Health Act and Mental Capacity Act Compliance
Mental Health Act
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice. Managers made sure that staff could explain patients’ rights to them.
Staff received and kept up to date with training on the Mental Health Act and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.
Staff knew who their Mental Health Act administrator was and were positive about the support and guidance given by them on both the Mental Health Act, and the Mental Capacity Act. Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.
Staff explained to each patient their rights under the Mental Health Act in a way that they could understand, repeated as necessary and recorded it clearly in the patient’s notes each time.
We saw evidence of information documents on patients’ rights available in communal areas for both informal and detained patients. The service displayed a notice to tell informal patients that they could leave the ward freely and how to do so.
Patients had easy access to information about independent mental health advocacy and the advocate regularly visited the ward to meet with people.
Staff made sure patients could take section 17 leave (permission to leave the hospital) when this was agreed with the Responsible Clinician.
We saw evidence in care plans of staff requesting an opinion from a Second Opinion Appointed Doctor (SOAD) when they needed to. Staff stored copies of patients’ detention papers and associated records correctly and staff could access them when needed.
Mental Capacity Act
Staff supported patients to make decisions on their care for themselves. They understood the service policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity. Staff received and kept up to date with training in the Mental Capacity Act. Staff told us they regularly discussed capacity and consent during meetings about the patients care and treatment. They also said they would speak to the ward manager or another clinician if they had concerns around capacity.
We saw evidence of capacity and consent recorded in care plans, with capacity to consent to treatment obtained at admission and evidence of this being regularly reviewed. We also saw evidence in care plans of staff attempting to support and engage patients in decision processes before deciding that a patient did not have the capacity to do so. When staff assessed patients as not having capacity, they made decisions in the best interest of patients and considered the patient’s wishes, feelings, culture and history. Staff told us that they held a best interest meeting which would involve the patient, the nursing team, the consultant(s) and the patient’s next of kin, where appropriate.
People's experience of this service
We spoke to 11 people across the three wards. People told us they felt supported and safe on the ward and staff treated them with dignity and respect. They said most staff were visible, approachable and helpful. People told us that staff encouraged them to be involved in their care and treatment and discharge planning and they listened to and respected their needs and wishes. People told us they were supported to be as independent as possible. They felt staff listened to them and acted on their feedback. People felt well supported by staff to maintain personal relationships that were important to them.