Cygnet Hospital Stevenage

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

We rated Safe as requires improvement

Managers used bank and agency staff to cover training, sickness, and changes in patient acuity levels.

Staff told us they were sometimes discouraged from reporting incidents. However, staff knew how to protect people from abuse and neglect. Staff completed and updated individual risk assessments. There were thorough environmental risk assessments in place, and the use of restrictive interventions were a last resort.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events.

A number of staff we spoke with told us that they were sometimes discouraged from reporting safety incidents and safeguarding concerns. However, following our inspection the provider has taken steps to promote reporting.

However, there were systems in place for the recording and reporting of incidents. The service followed the Patient Safety Incident Response Framework (PSIRF) for investigation of serious incidents. In the 12 months before inspection there had been 5 serious incidents requiring a learning response. Two incidents on the female PICU, and 1 each on the male PICU, female acute and male acute.

Staff received feedback from investigation of incidents and there was evidence that changes had been made because of learning. We saw examples of lessons learnt from 2 incidents at Orchid ward and Pattison ward that had been shared with staff across the hospital. Learning was identified and action had been taken.

We saw that feedback from lessons learnt was a standing agenda item at staff team meetings and incidents were also discussed at twice daily Situation Report Meetings (SitRep). Staff told us lessons were shared at daily site handovers.

Staff were debriefed and received support after incidents. We saw examples of this for Orchid and Pattison wards. Staff received mandatory debrief training.

Staff had access to an electronic reporting incident system. Staff we spoke with knew what incidents to report and how to report them.

Staff received mandatory training on the Patient Safety Incident Response Framework (PSIRF). At the time of inspection, the training compliance rate for all wards was above 95%.

The service worked with people and their partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The service ensured continuity of care, including when people moved between different services.

The service had operational procedures in place to support safe systems, transitions and pathways including an admission policy and exclusion criteria, referrals and discharge policies and procedures. Staff worked within multidisciplinary teams including, nursing staff, support workers, medical staff, occupational therapists, psychologists and social workers and worked well together to look at the patient pathway and deliver the service.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if their needs could safely be met. There was a clear care pathway in place from admission through to discharge.

Staff involved all the necessary external healthcare and social care services to ensure patients had continuity of safe care. Staff worked across the wider provider network and care system partners to ensure patients’ needs were met within pathways.

The service worked with people to understand what being safe meant to them as well as with partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect and they made sure to share concerns quickly and appropriately.

The service’s processes promoted people living free from abuse, neglect, and avoidable harm. We saw evidence that there were systems, policies, and practices in place to make sure people were protected from abuse and neglect. The service had a comprehensive safeguarding policy to protect adults and children. The service had an approval of visitors’ procedure in place.

Staff were trained in safeguarding, knew how to make a safeguarding alert and did so when appropriate. At the time of inspection, the training compliance rate for all safeguarding courses on both Orchid and Tiffany wards was 100%. For Pattison this was above 95% and above 90% compliance for Chamberlain ward.

Staff were kept up to date with both training on the Mental Capacity Act, Mental Health Act and the Oliver McGowan Mandatory Training on Learning Disability and Autism, all wards had a 100% training compliance rate, except Chamberlain which was at 96%.

The service worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that matter to them.

During the assessment we reviewed 3 risk assessments and saw that patients had a risk assessment in place on admission, and these were thorough and regularly updated. There were management plans in place for identified risks and needs of individuals. Risks included the temporary removal of risk items and daily food intake.

The service had a restraint and reduction of violence policy in place, which was also available in easy read format. The policy set out the measures taken by the provider to prevent and reduce the use of force, manage the risk of aggression, violence and crisis behaviours using non-physical and physical interventions appropriately. Staff we spoke with described the de-escalation techniques they used and told us that restraint was used only as a last resort.

There was evidence of appropriate restrictions to manage individual risks that had been care planned. There was no evidence of undue restrictive interventions within patient records.

We reviewed the service incident data for July to September 2025. During this time there had been 254 incidences of restraint, of which 185 had taken place on Chamberlain ward and 51 on Pattison ward. Fifty-nine of these incidences resulted in the use of rapid tranquilisation. We saw from the data that on each occasion, the required post tranquilisation physical health checks took place. Staff clearly documented actions taken pre and post incidences of rapid tranquilisation. There had been 3 episodes of restraint in prone position which had been patient led to administer medication.

During this time there had been 11 episodes of seclusion. The majority, 8, had taken place on Pattison ward. There had been 4 episodes of long-term segregation, with two each on Chamberlain and Pattison wards.

Staff received mandatory training on the Prevention and Management of Violence and Aggression. At the time of the inspection the training compliance rate for all wards was above 95%.

The service conducted a blanket restrictions audit. We reviewed examples of these for each ward. We saw that the reason/risk, the rights of the person and the review were clearly documented. We saw the use of restrictive practices on the ward were regularly discussed at clinical governance meetings and at daily site handover meetings. Within patient records we saw evidence of patient involvement in the formulation of risk assessments and care planning and attempts made by staff to support patients to discuss their needs.

There were clear procedures for safe and supportive observations and security checks, staff we spoke with knew these. Staff received mandatory observation and engagement training and security awareness training, all wards were above 95% compliant for the former and all were 100% compliant for the latter. Staff discussed each patient and documented any presenting risks or concerns on each shift.

Staff enabled patients to give feedback on the service they received. We reviewed examples of community meeting minutes. Actions were identified and allocated for action which were then followed up. The minutes also showed that patients were given opportunities to be involved in care and treatment decisions.

The service did not always control potential risks in the care environment.

Some staff told us they did not feel safe on the wards due to the acuity of the patients and low staffing levels. We were told that at times they had been asked to reduce patients’ observation levels and that alarms were not always responded to in a timely manner.

Staff did regular risk assessments of the environment. They completed and regularly updated ligature risk assessments for all internal and external areas. We saw examples of this. Identified risks were removed or reduced. For example, convex mirrors were installed to mitigate blind spots where staff could not easily observe patients.

Staff we spoke with knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Staff assessed risks to patients and took action to reduce risks where possible.

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

Patients and carers we spoke with told us they felt safe on the wards.

We observed wards to be spacious, clean, tidy, safe, welcoming and well furnished.

The service held weekly fire alarm tests, fire extinguisher service dates we viewed were all within date and trained fire wardens were on the wards.

Managers did not always make sure there were enough qualified people to provide safe care that met people’s individual needs.

Managers were aware that staffing levels were a challenge for the service. They told us that in the 3 months before inspection they had recorded 2 incidents where wards were below the safe staffing matrix. They also had occasions, especially at weekends where there had been at least 1 staff short per ward, however this had not fallen below safe staffing levels. Some staff we spoke with told us they were discouraged from reporting incidences of low staffing.

Staffing levels did not always allow patients to participate in activities on and off the ward. Both staff and patients we spoke with told us that activities were sometimes cancelled due to low staffing numbers and some patients told us the wards were short staffed and needed more staff “to cope with the patients”.

Managers calculated the number and grade of nurses and healthcare assistants required for each shift. The service had a process in place where staff registered for work at reception and managers then reviewed the actual number of staff coming into work against the required number and amended the system. Managers deployed bank and agency staff to maintain safe staffing levels, in particular healthcare assistants on both the PICUs (Chamberlain and Pattison wards).

The bank staff used by the hospital were Cygnet employees and are provided with training in order to meet the same level of skills as the hospital’s permanent staff.

Managers told us staffing levels were particularly challenging at the weekends, especially Sundays. They had taken action to rectify this including reviewing flexi working and recruiting fixed term staff.

Managers worked to ensure that staffing challenges did not impact on patient care such as, reaching out to staff to come in and offering shorter shifts. To maintain safe staffing levels, multidisciplinary team staff supported on the wards when required. Also, when necessary, the hospital manager, clinical managers and ward managers covered shifts to support wards and minimise impact on patient care. At the time of inspection managers told us they were closed to new referrals.

At the time of inspection, there were no vacancies for registered nurses or healthcare assistants.

The service had low turnover rates. In the 6 months prior to inspection all wards had a 0% turnover rate, except Pattison ward at 3.9%.

The service employed staff with responsibility for physical health to meet patients’ physical health needs. There was adequate medical cover day and night and at weekends. A doctor could attend the ward quickly in an emergency.

Staff had received and were up to date with all mandatory training courses. All wards had an overall mandatory training compliance rate above 96%. The training was appropriate for the patient group using the service. Managers provided new staff with appropriate induction.

The service had not always assessed and managed the risk of infection, prevented and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

The service documented clinic room and fridge temperatures daily, on each ward and these were regularly audited. However, we found there were 3 gaps in the clinic room records in the past 3 months for Tiffany ward.

We found out of date Personal Protective Equipment (PPE) on Tiffany ward. We raised this with the manager during inspection who took immediate action.

Staff maintained the ward and equipment well, they kept it clean, and they undertook weekly clinic room equipment audits on each ward.

However, we found the inside of the fridge in the kitchenette area on Orchid ward was not clean.

The service conducted a quarterly infection control audit and a hand wash audit. We saw from these that actions were documented.

The service did not always make sure that medicines and treatments were labelled and stored within guidelines or that medicines were given correctly.

The service conducted monthly medication audits on each ward. We reviewed examples of these and saw that actions were clearly documented. The service recorded any medication error. In the period July to September 2025 there had been 13 medication errors across the 4 wards. This included documentation errors, wrong frequency and wrong dosage given. There was a medications management policy in place and staff completed reflections after the incident to ensure correct administration for the future.

The audits also showed that signatures were not always recorded and that the fridge temperature was not recorded daily which could impact the effectiveness of the medication stored.

During the inspection on Tiffany ward, we found 3 bottles of methadone in the medicine cupboard for 1 patient. One bottle was labelled with an incorrect date and 1 bottle was not labelled at all. We also found insulin pens that ran out of date on the day of inspection on Orchid ward. The service took action to order replacements.

Staff reviewed the effects of medication on patient’s physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance.

Systems and processes were in place to ensure the safe prescription, storage, and administration of medicines. This included secure storage of medicines, particularly controlled drugs, which require additional safeguards due to their potential for misuse.

The service monitored high-risk medicines, including antipsychotic medication through regular audit. This was documented in people’s physical health care plans to ensure staff carried out the necessary monitoring.

We saw people detained under the Mental Health Act (MHA), had been prescribed and administered medicines in line with MHA consent to treatment authorisations.

Nursing staff responsible for the administration of medicines were trained and assessed as competent on an annual basis. 100% of eligible staff in Orchid, Tiffany and Chamberlain wards had received medication management and administration for nurses training. This figure decreased to 86% for Pattison ward.