Cygnet Hospital Harrogate

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 safe and protected from avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

All wards were safe, clean, well equipped, well-furnished, maintained and fit for purpose. Staff assessed and managed risks to patients, and to 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.

All staff knew what incidents to report and how to report them. They did so on an online reporting system which was monitored by managers. We looked at incident record systems to corroborate this. The outcomes of these incidents were discussed in team meetings with staff, which was evident from meeting minutes we viewed, and in meetings attended, when the inspection team were on site. Lessons were learnt and cascaded through good communication with staff. This took place in meetings or by email if staff were unable to be present. There were no serious incidents reported in the previous 12 months.

There was an incident where a patient was absent without leave (AWOL) and an after action review was carried out. All clinical staff re-visited the additional guidance for community escorting. Immediate learning was cascaded to all staff after the incident, and it was discussed in team meeting and clinical governance meetings. Supervisions and reflections were carried out with all staff who were involved in escorting the patient. The service implemented the learning from this to contribute to a wider ongoing thematic review of AWOL incidents.

Handover meeting minutes were also reviewed which listed risks for staff to be aware of, including how patients had presented throughout the shift and any other relevant information.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. Staff received feedback from the investigation of incidents, both internal and external to 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.

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 be safely met. The decision to admit a patient was made by a central hub and not the hospital directly.

Staff used safety formulations, moving on from the previously used START (short term assessment of risk and treatability) risk assessments. On admission staff carried out an initial risk assessment, along with referral information and spoke with patients and their families. The most prominent risks were considered, and these were reflected in care plans.

We reviewed 7 patient records. There was evidence of physical health monitoring, occupational therapy (OT) involvement, goals being set, patients’ views documented and appropriate referrals being carried out, where necessary. Care plans were in easy-to-read language.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and after discharge.

Stakeholders commented that Cygnet Hospital Harrogate operated under a safe system of care which is monitored and assured.

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 knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff followed safe procedures for children visiting the service.

The hospital had a dedicated safeguarding lead, and they worked alongside their allocated safeguarding officer for the local authority. There was also a corporate safeguarding lead in place for Cygnet.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff were trained in an introduction to safeguarding, in line with intercollegiate guidance, with a compliance rate of 99%. For higher levels, the safeguarding training compliance was 95%.

Staff knew how to escalate concerns and make a safeguarding referral and who to inform if they were concerned about individuals. Between July 2025 and July 2026, the service completed 284 safeguarding referrals across both wards, reflecting the hospital’s transparent and proactive approach to identifying and reporting safeguarding concerns. Of these, 80 referrals met the threshold for referral to the local authority safeguarding process.

We reviewed the blanket restrictions register for the hospital. On Sanctuary ward the hospital listed 10 blanket restrictions and on Haven ward there were 9. These were items not allowed to be brought in due to the risks that they posed or involved restrictions on movement around the hospital.

The blanket restrictions included limited access to laundry facilities due to ligature risks and other patients’ belongings being taken. Patients could use the facilities once a member of staff opened it and were present. This was reviewed in the monthly community meeting. Other examples were prohibiting use of plastic bags in line with the positive and safe care policy for reducing restrictive interventions. However, patients were provided with material bags if going to the shops when on section 17 leave.

Staff told us that that the environment was constantly reviewed to remove things that posed a risk to patients. Ceramic mugs and metal cutlery had been removed but these were swapped out to plastic for safety reasons. This was on the blanket restriction list and was reviewed daily by the ward team and discussed with the MDT whether it was safe to reinstate them.

The internal courtyard required supervision due to patients being higher risk and not having grounds access in that area. Staff facilitated access as often as requested and liaised between wards to facilitate appropriate use. Regular reviews of these blanket restrictions took place, at a minimum, weekly, with the multi-disciplinary team (MDT) and daily for the ward staff, to ensure they were proportionate and the least restrictive.

Mental Capacity Act

Staff had training in the Mental Capacity Act. The compliance rate was 97%.

Staff had a good understanding of the Mental Capacity Act, and the five statutory principles.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards (DoLS). Staff were aware of the policy and knew how to access it. The provider had a mental health act administrator based on site and staff could utilise this resource if advice was needed.

Staff took all practical steps to enable patients to make their own decisions.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis regarding significant decisions.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The service had arrangements to monitor adherence to the Mental Capacity Act, carrying out audits of the application of it and acted on any learning that resulted from 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.

The hospital focused on the least restrictive practice approach and had a restraint and violence reduction policy in place, outlining the only reasons for which physical intervention should be used. Staff used restraint only after other attempts at de-escalation were unsuccessful.

Records showed that 67 incidents involving restraint were recorded between July 2025 and June 2026 on Haven ward and 186 on Sanctuary ward for the same period. Staff told us these numbers reflected the high acuity of the patient group (the severity and complexity of a patient’s condition requiring a higher level of care, supervision and intensity of treatment). Between July 2025 and June 2026, staff used rapid tranquilisation 48 times. Rapid tranquilisation is the urgent use of medication to calm an acutely agitated or aggressive patient when other de-escalation methods have failed, without causing unconsciousness. Staff incident reported each occasion, ensured it was only used when necessary, and documented its use in patient records.

If prone restraint was ever utilised, this was audited and consideration given to pre-planning and clinical observation review criteria.

The service did not have a designated seclusion room but had a seclusion and long-term segregation policy which referenced the Mental Health Act Code of Practice (2015) and indicated that seclusion must be used as a last resort and as an emergency response where there is an immediate risk of significant harm to others. If an individual required seclusion in an area which was not a designated seclusion area, staff were provided with guidance to follow to end the seclusion as early as possible. When a patient was placed in seclusion, staff kept clear records and followed the provider’s policy. Staff told us there was only around one instance of seclusion per year.

All records we reviewed had risk assessments and risk management plans in place which were holistic, personalised, and patient focused. It was evident that there was a multidisciplinary approach to managing the needs of patients and their risks. Any restrictions that were in place were regularly reviewed.

We reviewed 7 patient records and found that the risk assessments were detailed and comprehensive and the patient’s voice included. There was just one care plan where one element of risk was not documented fully after an observation, but this was immediately rectified by the ward manager.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to connect with patients with communication difficulties. Staff gave the opportunity for patients to give feedback on the service they received, during one-to-one time with their named nurse or through community meetings.

Cygnet Harrogate Hospital used an expert by experience who visited the site. They had lived experience, or had cared for someone who had experience, of inpatient services. They were there to ensure the opinions of patients were heard and that feedback was acted upon to improve services and outcomes for those who use them.

Staff told us that patient’s observation levels were constantly reviewed to be least restrictive but also to maintain safety and tailored to the patterns of their behaviour. For example, enhanced observations were carried out over the evening, if that was the most unsafe time for patients, then 15-minute observations during the day.

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.

Ward areas were clean, well maintained, well-furnished and fit for purpose. The service employed maintenance staff who responded to any repairs required. The service also employed 2 whole time equivalent housekeeping staff who cleaned bedrooms, bathrooms and communal areas throughout the week. We saw cleaning being carried out during the inspection. Patients we spoke with told us the environment was always clean.

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

Due to the layout of the environment, there were blind spots on both Sanctuary and Haven wards. However, the provider told us that there was always a staff member on the ward, a minimum of hourly observations, there were mirrors used and closed-circuit television, in communal areas.

Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Ligature cutters were available to cut ligatures (which are materials used to tie or bind things together) and the service kept these in a sealed bag away from patients. Staff kept records which indicated when these were checked, used and sharpened. The wardrobes in patient bedrooms were anti-ligature.

The wards complied with guidance and there was no mixed sex accommodation. Personal emergency evacuation plans (PEEPs) were completed as part of the admission process for all patients and detailed to their individual needs. There was a lift in operation for those with limited mobility and fire evacuation procedures in place.

The clinic room was safe for the administration of medicines. It was fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The occupational therapy lead had introduced activity PRN (meaning as and when needed) which was a way of distracting and offering a low stimulus environment if a patient had become agitated. This was used to promote supportive practice that avoided the need for physical restraint.

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.

Managers had calculated the number and grade of nurses and healthcare assistants required, according to their core matrix, based on bed occupancy for the number of staff needed to cover the service safely.

At the time of our inspection the service had vacancies for 3 registered mental health nurses (RMN), and 7 health care support workers (HCSW) with recruitment due to be completed in August. Any gaps were covered with overtime for regular staff and the use of bank and agency staff. There were 11 HCSW on the bank and 1 RMN. The staff numbers met the core matrix of staff required, the extra numbers were to facilitate additional staff if observation levels increased. Two patients out of the 11 we spoke with commented that they had had leave cancelled on one occasion each, when there were not enough staff, due to last-minute unplanned events.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the service.

There was a good mix of staff at the time of our inspection including nurses, health care support workers, occupational therapists and an assistant, a psychologist, assistant psychologist, specialist doctor, consultant, social worker, assistant social worker and activity coordinators.

Turnover rates were low; staff reported being happy and had a desire to stay within the company. The hospital reported the staff turnover rates over the last 12 months ranged between 1% and 5%. In the month of our inspection, it was 2%.

The monthly sickness absence over the same period ranged between 1% and 6% and was 2% at the time of the inspection for short term sickness.

Staff had received and were up to date with appropriate mandatory training. The compliance target for the service was 90% and the and the statutory figures showed 97% overall. The training was appropriate for the patient group using the service.

Managers provided new staff with appropriate induction and mandatory training. Staff we spoke with reported that they were provided with the necessary training to undertake their roles. The figures were less than the compliance target of 90% for basic life support (BLS), at 87%, but 2 staff missed a scheduled course in July due to illness, however, they were scheduled to attend the training in August 2026. To mitigate this, the provider included this on the risk register and ensured that shifts had an adequate mix of staff trained in basic life support alongside those trained in immediate life support (ILS).

Staff undertook mandatory training in reporting incidents using datix and managers were trained in reviewing these. Compliance for both was 100%.

The Psychologist had undertaken training in Eye Movement Desensitisation and Reprocessing (EMDR) therapy (a method of psychotherapy which helps individuals process and heal from traumatic and distressing life experiences). This had enhanced their trauma informed work.

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.

On Sanctuary ward, the clinic room check showed comprehensive cleaning records and these were audited in line with local policy. The same system applied to Haven; however, we did find that there were two gaps in the cleaning records for Haven ward but found the ward to be clean.

Staff adhered to infection control principles, and there were handwashing facilities available. Temperatures were checked daily and all records of these checks were up to date. Quarterly audit checks were carried out for infection control within the hospital. The hospital was up to date with these, and the next one was scheduled for October 2026.

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. They involved people in planning, including when changes happened.

On Sanctuary and Haven wards all medicines were stored appropriately and locked away when not in use. Prescribed medicines were all labelled correctly and were in date. There was a system in place to ensure medicines were accounted for and were given to the correct patient.

We looked at 14 prescription charts across both wards. All were completed correctly, signed and dated and it was evident that consent to treatment had been assessed and allergies noted. The only issue found was that there were only 10 spaces for medicines on the cards, and some patients had multiple cards with some medications crossed out, which made them harder to read. This was addressed with the hospital manager.

The service had a controlled drugs policy in place. There was no excess stock kept on the premises and there were records to show that medicines were checked for expiry dates. Medicines were also disposed of, in line with the hospital’s policy.

Staff knew how to investigate discrepancies and to escalate concerns appropriately to the clinical manager and the pharmacy.

We spoke with a pharmacist who confirmed that regular audits were in place and there were no safety concerns at Cygnet Hospital Harrogate. A sample of these records were checked for the previous couple of months, and all showed 100% compliance.