Cygnet Lodge Brighouse

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 inspection we rated this key question good. At this inspection the rating has remained good.

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.

Staff told us that they report incidents on an online reporting system which was monitored. We looked at incident record systems to corroborate this. The outcomes of which 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. This was across different disciplines to embed learning and good practice. We reviewed a selection of incidents. There was an example of a near miss involving a patient and staff member. A management plan was put in place to ensure the lift was used to protect the patient from falling and staff from potential injury. Of the incidents reviewed, safeguarding referrals were raised appropriately where necessary and where a medicines error had occurred, a debrief was held to discuss how to mitigate further errors in the future.

During our inspection we reviewed 10 incident records. The incidents were reported appropriately and the reason for the restraint recorded.

Lessons were learnt and cascaded down through good communication with staff, either in meetings and/or by email if they were unable to be present . Staff we spoke with were aware of what duty of candour is and when to apply it.

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 and 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 person was received to determine if the patients’ needs could safely be met. Staff visited potential patients prior to admission and if the service was not deemed appropriate at that time, they worked on a plan which was future goal focused, with a view to reassessing their suitability later.

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

Staff involved all the necessary healthcare and social care services to ensure people had continuity of safe care, both within the service and post-discharge. Some patients in the hospital were out of area; however, stakeholders confirmed that the service collaborated with external partners and teams from the patient’s home area, when we spoke with them.

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, to appropriate levels as a minimum in line with intercollegiate guidance. Both the clinical and non-clinical staff were expected to undergo safeguarding training - Safeguarding Individuals at Risk Introduction, which evidenced 100% compliance. Qualified professionals were required to complete the Safeguarding Individuals at Risk at a higher level. And all clinical staff showed compliance over 86%. Staff we spoke with could identify risks and how to protect people from harm and report those risks.

Staff knew when to escalate concerns and how to make a safeguarding referral. A safeguarding policy was in place at Cygnet Lodge Brighouse. Between January 2025 and December 2025, the hospital had completed 39 safeguarding referrals. There was evidence that the local authority safeguarding team felt that some of the referrals did not meet the threshold for safeguarding. There was evidence that staff and patients were supported to report incidents to the police where appropriate.

We reviewed the blanket restrictions register for the hospital. The hospital listed 11 blanket restrictions. These were items not allowed to be brought in due to the risks that they posed. The blanket restrictions included a list of contraband items, including weapons, drugs and alcohol. There was limited access to the kitchen, which was listed within the risk register, but hot and cold drinks were accessible 24 hours a day. If patients were deemed appropriate to use the kitchen this was risk assessed. The hospital was working towards the new smoke free policy which meant restrictions were in place on site, but patients could smoke off site, whilst vaping in rooms and the garden was permitted. Any individual restrictions were care planned.

The service used a safeguarding tracker which was saved centrally to ensure all staff had visibility of safeguarding concerns and referrals, promoting transparency across the service. The tracker also enabled different members of the multidisciplinary team to update information following communication with safeguarding services. The Provider’s Social Worker led on safeguarding referrals and updated the tracker when incidents had been resolved. Nursing staff were also able to access and close incidents where they had liaised with the local safeguarding team in the absence of the Social Worker.

Mental Capacity Act

Staff received training in Mental Capacity Act and the Deprivation of Liberty Safeguards as part of their mandatory training. The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were aware of the policy and had access to it. The compliance figure for mandatory training was 88%.

Staff we spoke with had a good understanding of consent including in relation to the Mental Capacity Act. People were supported to communicate and make decisions to enable the service to deliver person-centred care and treatment in line with people's best interests.

The service had arrangements to monitor adherence to the Mental Capacity Act.

Staff audited the application of the Mental Capacity Act 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.

Staff used restraint only after attempts at de-escalation had failed. 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.

We reviewed 6 care records and found that the risk assessments were detailed and comprehensive and there was evidence of the patient’s voice featuring prominently. All records we reviewed had up to date risk assessments and risk management plans in place which were holistic, personalised, patient focused and rehabilitation oriented. It was also noted that there were no undue restrictive interventions in place. There was evidence of a multidisciplinary approach in managing patients risks and needs.

The hospital focused on the least restrictive practice approach. Records showed the hospital recorded 10 incidents involving restraint between May 2025 to April 2026.

All restrictive interventions were reviewed by a multi-disciplinary team and analysed monthly through clinical governance and ward rounds. Reducing restrictive practice had been reviewed by the provider in the last 12 months. There were local champions in the nursing team, (including the Head of Care), who were trainers for reducing restrictive practice and positive safe leads (which is a person or role responsible for ensuring that care, support, and decision-making are both safe and positive — balancing protection with respect for autonomy, wellbeing, and dignity). These leads were in the process of providing refresher courses to staff. All new staff had completed the Reducing Restrictive Practice training.

Staff involved people in care planning and risk assessing, this was evidenced in care plans, participation in multidisciplinary team reviews and feedback from family members.

The hospital confirmed they had no instances of rapid tranquilisation in the 12 months prior to our inspection.

Staff reported that the use of PRN medication (medication given as and when needed) was only given when other techniques such as grounding and distraction strategies were exhausted.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service was located over 3 floors where there were en-suite bathrooms in the patient bedrooms. There were 2 additional communal bathrooms for patient use. On the ground floor the hospital had a communal dining room and communal lounge. Patients had access to a garden. The hospital had two kitchens for patients to undertake activities of daily living, an IT room, quiet room and multi faith room. The service had been recently decorated in collaboration with the patients who decided on colour choices. There was use of a free-standing bath in a shared bathroom.

We saw evidence that staff did regular risk assessments of the care environment. Were there were potential ligature anchor points the hospital mitigated the risks adequately. We reviewed the ligature anchor point and blind spot risk assessment. We also observed a map in the staff office, which was kept out of view of patients, indicating high risk areas and indicating the location of emergency equipment and ligature cutters.

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.

At the time of our inspection the hospital was male only and therefore complied with guidance on eliminating mixed-sex accommodation.

Staff had easy access to alarms and people using the hospital had easy access to nurse call systems.

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. However, we did find an issue with calibration of one blood glucose monitoring machine, where there were no records of its calibration and the solution had expired. This was checked by staff straight away, replaced and a folder created for blood monitoring machine calibration records for ongoing weekly monitoring. To ensure this task was consistently completed, the hospital added the action to their board round tracker, which supports oversight and monitoring of a range of compliance-related tasks. The system provided alerts when actions were due, to aid compliance.

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 had a vacancy for a part time activity co-ordinator, and this position was currently on hold as the position was under review, however, OT staff facilitated activities.

There were vacancies for two support workers out of an average of 15. There was a good mix of staff at the time of our inspection including nurses, health care support workers, two occupational therapists and assistant, a psychologist, assistant psychologist, specialist doctor, consultant, social worker, art therapist and a substance misuse practitioner.

Turnover rates were low; staff reported being happy and had a desire to stay within the company.

The hospital reported the average staff turnover rate over the last 12 months was 5%, the nursing staff had zero turnover. A new responsible clinician had been recently employed. The average monthly sickness absence over the same period was 11%.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Autonomy was given to managers to authorise extra staff to cover. When agency and bank nursing staff were used, there was good oversight of bank staff competencies and training. Staff were only allocated shifts when the service was assured that appropriate training had been completed. Where possible, the service used familiar staff. There was one bank nurse and 6 bank support workers on the staffing matrix.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

The overall compliance level for mandatory training for staff was 89%.

Managers told us they calculated the number and grade of nurses and support workers required and the hospital manager could adjust staffing levels to take account of patient numbers and observation levels. Based on occupancy at the time of our onsite inspection there were 2 nurses and 4 support workers on a day shift and 2 nurses and 3 support workers on a night shift. This was in line with the recommended staffing levels for a high dependency rehabilitation service with this level of occupancy. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. Where there were shortages, extra staff were brought in so there was no impact on patients. There were enough staff to carry out physical interventions (for example, observations and restraint) safely and staff had been trained to do so. The use of physical interventions was used very infrequently.

There were examples of internal progression, such as health care support workers engaging in nurse training, other additional training was also offered for most roles.

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.

During inspection all ward areas were clean and now had furnishings in good condition which were well-maintained. The ward areas were undergoing cleaning whilst we were on site. Staff were observed to be bare below the elbow whilst in clinical areas and when having direct contact with patients in adherence to infection control principles.

Infection control audits were scheduled every 3 months, and a mattress and cover audit was scheduled quarterly or when a room was vacated. There was also a regular audit carried out for hand hygiene.

Quality action review paperwork was reviewed, and it was evident that matters relating to infection, prevention and control were raised and monitored by the service on an ongoing basis.

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.

Staff followed good practice in medicines management, including, dispensing, recording and storage. We reviewed 9 prescription charts and found evidence of safe prescription and medication administration in place. All recorded any allergies present. Of those patients who were prescribed antipsychotic medication, monitoring of side effects was evident. Liverpool University Neuroleptic Side Effect Rating scale (LUNSERS) monitoring tool was in use and dated. There was evidence of High Dose Antipsychotic Therapy (HDAT) limitation plans and checks in place.

There were consent to treatment forms in place and capacity assessments were in place for treatment, where required.

There was a medication policy in place at Cygnet Lodge Brighouse and 2 nurses to check the controlled drugs to mitigate for any medication errors. Audits were carried out on medications, and this was discussed at regional governance level.