- Independent mental health service
Cygnet Hospital Woking
Assessment report published 16 February 2026
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
Date of assessment: 10 and 11 December 2024.
Cygnet Hospital Woking is an independent mental health hospital that provides specialist acute and psychiatric intensive care (PICU) services for women, across three wards and Forensic wards for males and females across two wards. We carried out an unannounced assessment of all 5 wards at the service.
- Acorn ward is a 10 bedded female only psychiatric intensive care unit.
- Kahlo ward is an 11 bedded acute service for women.
- Picasso ward is a 12 bedded acute service for women.
- Oaktree ward is an 11 bedded female only forensic inpatient / low secure ward.
- Greenacre ward is an 18 bedded male only forensic inpatient / low secure ward.
The inspection was triggered by an increase in notifications of incidents (sent by the provider to CQC) about patients swallowing and ingesting objects We were notified of a serious incident where it was found that staff were not fulfilling their duties in terms of enhanced observations due to staff members sleeping on duty. We were also notified about concerns about the inappropriate use of seclusion and the restraint of a patient using an unapproved restraint technique. This assessment was carried out following CQC’s new approach to assessment; Single Assessment Framework (SAF). We assessed all 33 quality statements across the safe, effective, caring, responsive and well-led key questions.
In January 2023, the service had a focussed inspection of the acute wards for adults of working age and psychiatric intensive care units which changed the overall rating for the service and was rated good overall, with requires improvement in effective and good in safe, caring, responsive and well-led.
Following this inspection, we rated the service as Good overall. We rated safe as requires improvement and effective, caring, responsive and well-led as good. We identified areas of improvement that were required in relation to staff not always involving patients in planning their care and treatment, environmental concerns with the cleanliness and maintenance of the wards as well as environmental risks with unidentified blind spots which could present as a safety risk, medicines were not always managed in line with national guidance or legislation and governance processes were not always effective in monitoring and mitigating risks and therefore action to address identified issues was not always taken in a timely manner. We found the service to be in breach of Regulation 12, Safe Care and Treatment.
However:
Staff knew what incidents to report, and how to report them. All records had risk assessments that were regularly updated and contained all relevant risk information. Staff told us they avoided using restraint by using de-escalation techniques, and we saw this in practice. There were enough staff to ensure people’s safety and meet their needs. Staff completed key mandatory training, monthly supervision and yearly appraisals. Patients could access a range of interventions and activities in line with national guidance. Ward activities helped promote a healthy lifestyle for patients. Patients told us staff were kind and treated them well. They told us staff were available on the ward to support them when needed. Patients were supported to have choice and control and could give feedback on their care. All staff told us they felt respected, supported and valued by their colleagues and managers.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
We spoke to 12 patients from Acorn, Kahlo and Picasso ward. We received mixed feedback from people about their involvement in their care and treatment. They told us staff did not always speak to them about what was in their care plans and some of their wishes and needs were not always recorded to ensure all staff were aware. However, most patients told us they felt supported and safe on the wards and staff treated them with dignity and respect. They said most staff were visible, approachable and helpful. Patients told us they were supported to be as independent as possible. They felt well supported by staff to maintain personal relationships that were important to them. Some patients told us they would like more regular patient surveys to be done.
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 patients.
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.