- Independent mental health service
Cygnet Hospital Woking
Assessment report published 16 February 2026
Contents
Ratings - Forensic inpatient or secure wards
Our view of the service
Our view of the service
We completed an assessment and inspection of Cygnet Hospital Woking on 10 and 11 December 2024 with additional offsite interviews with carers on 6 and 7 January 2025.
Cygnet Hospital Woking is an independent mental health hospital run by Cygnet Surrey Limited. The hospital offers a range of mental health services for men and women across 5 wards.
Cygnet Hospital Woking delivers acute/psychiatric intensive care wards (PICU) and forensic care across 5 wards. 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 and Greenacre ward is an 18 bedded male only forensic inpatient/low secure ward.
We carried out an unannounced assessment of all 5 wards at the service.
The inspection was triggered by an increase in notification of incidents 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. The service had previously been inspected in April 2022, and we rated it as Good overall. We rated the safe domain as requires improvement because staff were not calibrating medical equipment, did not keep the right room temperature for safe storage of medicines and staff did not monitor the effects of clozapine on patients. The service was rated good in effective, caring, responsive and well led.
At the time of our December 2024 inspection, we found that actions from the previous inspection had been addressed. Staff routinely calibrated medical equipment for measuring blood glucose levels, the provider took action to safeguard medicines supplies when the temperature of medicines storage areas fell outside of the recommended limits, and staff monitored and reviewed the effects of patients’ medication on their physical health, particularly patients prescribed Clozapine.
However, this inspection identified some areas for improvement. Overall, we rated the service as requires improvement because we identified breaches of regulatory standards. Staff did not always involve patients in the planning of their care and treatment, the provider required staff to observe patients for 4 hours without a break and managers of the service did not always use governance processes to effectively monitor, manage and take action to address identified issues in a timely manner.
During this assessment, the provider was in breach of regulation 9- Person Centred Care, regulation 12- Safe Care and Treatment and regulation 17- Good Governance.
The provider did not always ensure the care and treatment of patients was appropriate, met their needs and reflected their preferences.
The provider did not always ensure relatives and carers were involved in their loved one’s care where this was appropriate.
The provider did not always record which rapid tranquilisation medicine was first line when multiple medicines were prescribed.
The provider did not always ensure there were enough staff deployed on the wards to carry out the required observations and therefore could not mitigate risk to patients. Staff were rostered to be on observation for more than 4 hours without a break which increased risk of harm to patients. There was a risk that without a break staff would become tired and less attentive.
The provider did not ensure governance processes were always effective in monitoring and mitigating risks and therefore action to address identified issues was not always taken in a timely manner. Senior managers within the hospital did not always use governance processes to effectively monitor, manage and take action to address identified issues in a timely manner.
People's experience of this service
At the time of our recent inspection, patients on the forensic low secure inpatient wards gave mixed feedback about their experiences of the service overall.
Ten patients told us that staff were generally caring and had positive interactions with them. However, two patients reported staff did not always interact with them. Two patients told us staff were not always visible on the wards but recognised that staff were often busy completing other tasks. Patients described mixed levels of involvement in their care and treatment, with some patients feeling appropriately involved whilst others did not feel they were always listened to or given appropriate information.
However, patients told us the food provided by the hospital was of a good standard.