Cygnet Hospital Woking

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

At our last inspection, we rated this key question requires improvement. This was because the provider was in breach of legal regulation 12. The service had improved on those areas of concern that we had identified, however, following our December 2024 inspection the rating has remained the same. The service continued to be in breach of regulations for safe care and treatment. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that patients could be harmed.

Patients told us there were not always enough staff to safely care for patients.

We found staff were not fulfilling their duties in terms of enhanced observations due to sleeping while on observation. We found the provider contributed to this problem by deploying staff to observe patients for four hours without a break. We found blind spots in patients’ bedrooms which were not sufficiently mitigated. Staff did not always ensure people’s risk assessments were updated following review or after an incident.

However, staff were now calibrating medical equipment for measuring blood glucose levels. Staff were now taking action to safeguard medicines supplies when the temperature of medicines storage areas fell outside of the recommended limits. Staff now monitored and reviewed the effects of patients’ medication on their physical health, particularly patients prescribed Clozapine.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service managed patient safety incidents well. Staff recognised incidents and near mises and reported them appropriately via an electronic incident reporting system in line with provider’s policy. Managers investigated incidents and shared lessons learned with the whole team and the wider service.

Most staff had completed incident reporting training. Staff we spoke with could describe what incidents were and knew how to report them. Staff reported incidents in line with the policy and leaders monitored the incident data.

Staff were able to tell us examples of changes implemented because of learning from safety incidents.

When things went wrong, staff told us they apologised and gave patients honest information and suitable support.

Staff discussed incidents and lessons learnt in several forums, including supervision, daily huddles, team meetings and reflective practice sessions. This information was shared with bank staff through group supervision. Staff were debriefed after incidents by managers and psychologists, and an employee helpline was available for additional support.

Staff received feedback from investigation of incidents, both internal and external to the service. For example, staff received a corporate bulletin informing them of any lessons learnt or issues to be aware of from various locations across Cygnet.

Staff met to discuss feedback from managers and looked at improvements to patient care. Managers shared local learning identified with staff via email and as a specific agenda item in team meetings. Staff gave positive feedback about the ways they were informed about learning from incidents. The manager of Greenacre ward had a ‘Greenacre principles’ learning document and shared learning at team meetings and at handovers. The manager produced a daily report which included all incidents for Situation Report (SITREP) meetings and escalated any concerns to the clinical lead.

Patients were able to raise concerns, provide and receive feedback on issues that impacted them. Patients attended a weekly community meeting where patients received an update on actions, including “you said, we did” feedback on safety concerns and environmental issues. A patient we spoke with told us they received a debrief with staff after an incident.

Three carers we spoke with said they felt assured that staff took the safety concerns of their relatives seriously and took actions promptly. One carer said staff always answered questions, investigated CCTV or went through what safety precautions and protocols they were putting in place following an incident. There was evidence that changes had been made because of feedback received following an incident.

Staff told us managers debriefed and supported staff after any serious incident.

Incidents were reported promptly and investigated by managers in line with the policy, with learning documented and relevant actions updated in care records. However, some staff felt that incidents could occur due to lack of adequate staff on the wards.

Quality Statement Score: 3

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

The referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met by the service. Managers described how the referral and admissions processes would be managed and in what ways the acuity of the wards would be considered. Staff involved all the necessary health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. The referral was reviewed and completed by the MDT which included nurses, psychologists, responsible clinician, or ward doctor. The service received referrals nationally, but most referrals came from the Southeast region of England.

Despite the service having clear systems in place to support admissions, patients that we spoke to in relation to admissions and discharges shared mixed feedback about where they had been placed for treatment. Four out of 12 patients said that their families lived very far away from the hospital, and it was a challenge to see their family regularly.

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

The managers of both wards informed us the wards had good processes in place for patient discharges. The managers invited community teams to attend ward rounds and to be part of the discharge process. The Greenacre ward team was developing a vocational pathway, which would be used to support patients when they approached their discharge. For example, the service had introduced vocational roles on the ward to support the patients to develop some living skills before they were discharged from the hospital. A care coordinator was allocated to patients who were getting close to their discharge to complete a Care Act assessment with them. The service contacted the community teams to help facilitate patient discharge.

The service worked with people and partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately with the local authority and other agencies.

Patients gave mixed feedback about their experiences of safeguarding and feeling safe on the wards. All patients we spoke to reported that they felt safe on the wards and had not experienced any violence or aggression. However, there were patients who did not feel safe on the wards, although this was due to the behaviours of other patients.

Staff told us they received training on how to recognise and report abuse, appropriate for their role and kept up to date with their safeguarding training. The compliance rate for the safeguarding adults and children mandatory course was 100%.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. One staff member spoke of how they had supported a patient who had fluctuating capacity to make an informed decision.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies, including the local authority safeguarding team, to protect them.

Staff followed clear procedures to keep children visiting the ward safe.

Information was available to staff on the wards about safeguarding and their responsibilities in relation to this. Staff were aware of how to report a safeguarding concern to the local authority. There was evidence in patient records that staff had made safeguarding referrals where necessary.

Safeguarding was discussed at ward level team meetings. Managers discussed safeguarding issues as part of their daily morning meeting across the hospital.

Restrictive practices were monitored and managed appropriately. Areas of the ward environment such as the activities of daily living (ADL) kitchen and the laundry room had restricted access. This was because of the risks posed by some patients. Oaktree ward patients did not have direct access to the ward garden, therefore 2 members of staff escorted patients to access the garden at regular two-hour intervals throughout the day and always ensured that if requested, staff took patients out in addition to these intervals. Two staff told us they felt patients access to the garden was a challenge because it made patients feel restricted. One patient told us that it was difficult to access the garden especially when staff were busy.

A psychologist visited the ward weekly to discuss blanket restrictions with the staff and blanket rules were reviewed by the manager every quarter. Both Greenacre and Oaktree wards had a reducing restrictive practice lead. Managers engaged in monthly restrictive practice meetings and shared the learning with their staff teams to make them aware of why the restrictions were in place. Staff completed restrictive practice training, and the managers sent staff to other services to learn about their restrictive practices and share the knowledge with other team members.

Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when de-escalation failed and when necessary to keep the patient or others safe. Staff involved patients in discussing restrictions. For example, patients said they were aware they were not allowed to use e-cigarettes on the wards. Staff ensured all contraband items such as razers were seized from patients and stored securely in the office to prevent patients from having access to them.

As part of leave conditions for patients, staff said patients who used their section 17 leave and went out unescorted were thoroughly searched by 2 members of staff in the extra care area when patients returned to the ward. Staff told us they ensured patients’ dignity was maintained. Staff completed randomised screening of patients for drugs when patients went away on overnight leave and returned to the wards. Staff collected urine samples form patients and periodically checked patients’ bedrooms for contraband items. Staff on Oaktree ward informed us the ward had not had incidents of patients bringing drugs onto the ward for a long time.

The wards had systems in place where they recorded the frequency of restrictive interventions. Both wards had a reducing restrictive practice register which recorded hospital wide restrictions along with any ward specific restrictions. The wards also had restrictive practice boards to ensure that patients were aware of what restrictive practice was in place. The hospital produced monthly reports which provided data on how often certain restrictive interventions were used on all wards for that month. These reports were reviewed at the monthly clinical governance meetings where themes and actions required could be identified. We reviewed minutes for October and November 2025.

Staff followed National Institute for Health and Care Excellence (NICE) guidance when using rapid tranquilisation. Staff were able to describe the physical health checks they would carry out immediately following rapid tranquilisation, although staff used rapid tranquilisation very rarely and had not used this in recent months on Oaktree ward.

Patients were risk assessed to have keys to access their rooms.

Patients had access to simple phones, and the service was considering whether patients could have access to more complex phones. Patients with leave could access their smartphones. The service had ward tablets that patients could access under supervision.

Patients could make their own hot drinks and snacks when risk assessed as safe to do so. Otherwise, they were supported by staff to access these. At the time of this inspection, patients on Oaktree ward temporarily did not have access to a drinks station, so staff gave drinks to patients from the hatch. Patients who required support told us the accessibility to kitchen facilities was good. There were soft drinks and snacks available for patients in the communal areas. However, patients who were risk assessed not to be able to make their own drinks were supported by staff to make their own drink.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs that was safe, supportive and enabled patients to do the things that mattered to them.

We reviewed 14 risk assessments and care plans. Each patient had a risk assessment that was detailed. Individual risks were well documented within these records and indicated joined up working across the multidisciplinary team with the management of risk. Each risk assessment included The Short-Term Assessment of Risk and Treatability (START) which is a clinical guide used to evaluate a patient’s level of risk for aggression and a structured professional judgement tool used to assess the risk of future violence (HCR-20) which staff updated regularly. Staff identified individual’s risk and put a risk management plan in place, but staff did not always update the risk management plan following review of an incident. For example, staff repeated the same (START) entries in a patient’s risk management plan for a period without changes following a review of their risk after an incident. All patients had Positive Behavioural Support (PBS) support plans in place.

We spoke to 12 patients during this inspection and 3 stated they had been restrained while at the hospital. One female patient told us even though their key worker was a female, they were restrained by two male staff. The patient said she preferred to have the presence of female staff when she was restrained. Another patient said they did not have a debrief with the staff after they were restrained. The third patient noted that, whilst the restraint itself was distressing for them, staff managed it well and they had a debrief with staff afterwards. However, 8 patients reported no concerns about restraint practices. A carer informed us their relative had been restrained in the past, but they did not have any concerns about how staff managed the restraint.

Staff were aware of the procedures and processes in place to manage risks on the ward. Staff we spoke to could describe specific patient risks and how these were being managed. Staff described how they would make attempts to de-escalate patients where necessary and felt confident that, if restrictive interventions were required, these could be managed safely.

At times staff were required to use restrictive interventions on patients when it was deemed the safest way to keep a patient and others safe. The manager on Oaktree ward informed us there had been two restraint incidents in the last 24 hours prior to our inspection visit. We reviewed the patients records and found that the restraints were managed well. Staff had also nursed a patient in long-term segregation on the ward not long before our on-site visit. We reviewed the patient’s care record and found that the patient was receiving appropriate care. For example, the patient was receiving support from the physical health nurse and gym instructor to manage their weight and was also receiving input from the psychology team and external psychiatrist.

Even though we found evidence that staff involved patients in their risk assessments, staff did not always ensure people’s risk assessments were updated following review or after an incident. For example, on Greenacre ward, we found the daily risk assessment for a patient was scored the same (Green) for few days despite staff reporting high risk of recent violent behaviour.

Staff supported patients who had communication difficulties to have access to interpreters so staff could effectively communicate their care to them.

Staff enabled patients to give feedback on the service they received by facilitating weekly community and planning meetings where patients were encouraged to give feedback about the service they received. The community and planning meeting was patient led. Patients were also given the opportunity to give feedback about their care through patient surveys.

Staff ensured patients could access advocacy. For example, we saw evidence that patients had access to an expert by experience who visited the ward and an Independent Mental Health Advocate. The wards had posters on an information board to empower patients to seek the services of an advocate/ IMHA. However, one patient said they knew what an advocate was but was not sure how they could contact one.

The service did not always detect and controlled potential risks in the care environment and did not always ensure the equipment, facilities and technology support the delivery of safe care.

Staff completed and regularly updated risk assessments of the ward environment and removed or reduced risk they identified. A member of staff was allocated daily to conduct security checks.

The layout of both Greenacre and Oaktree wards allowed staff to observe all communal areas, with mitigations in place for the blind spots using CCTV and convex mirrors. Staff knew about potential ligature risks and how to mitigate these to keep patients safe. Both wards had carried out annual ligature assessments, and mitigations put in place when a risk had been identified. Ligature cutters were also seen in accessible locations on the wards. Ligature risks were included as part of staff induction and staff mandatory training. Over 86% of eligible staff on Oaktree ward and 82% of staff on Greenacre ward had completed the mandatory ligature risk reduction training.

Whilst the provider had carried out environmental risk assessments, we found blind spots in patients’ bedrooms which were not sufficiently mitigated. This made it difficult for staff to observe them and check for signs of life. Staff were required to open patients’ bedroom doors instead of observing them through the door window. This was seen as an invasion of patient’s privacy. One patient complained about this situation to us during our inspection visit which was fed back to the management team. Staff we spoke to understood that this was a risk. We fed back of our findings to the hospital manager after the inspection and the manager assured us that they were going to put systems in place to ensure the safety of the patients.

Patients were able to raise concerns about the safety of the ward environment in the weekly community meeting and staff took actions in response.

The service displayed a list of prohibited items and followed a policy which detailed when routine and exceptional searches were to be conducted. The search area was in a designated room.

The provider admitted only male and female patients onto Greenacre and Oaktree wards respectively to comply with guidance on eliminating mixed-sex accommodation.

All patients on Greenacre had keys for their bedrooms. On Oaktree, only some patients had their own bedroom keys. This decision was based on individual risk assessments.

Staff had easy access to alarms and patients had easy access to nurse call systems on the ward and in their bedrooms to use when required. All staff had keys and personal alarms which were in use on the wards. Managers told us that 2 people on each ward were allocated as responders when the alarms signalled.

Greenacre ward had a de-escalation area which had a seclusion room attached to it. The seclusion room did not have any blind spots and allowed clear observation. It had closed circuit television (CCTV), two-way communication, toilet facilities and a visible clock. Patients had access to natural light and patients could be escorted into the garden for fresh air.

Staff completed Personal Emergency Evacuation Plans (PEEP) for patients who required additional support during evacuations.

The provider ensured that all equipment, including medical devices were regularly checked and maintained to ensure they were in good working order, including the medical emergency bag.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff checked the temperature of the clinic rooms and the medicine fridges daily. There was an examination couch in the clinic room on both wards.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support. They did not work together well to provide safe care that met people’s individual needs.

The service did not always have enough nursing and support staff to keep patients safe even though staff rotas we reviewed showed that all shifts were covered. For example, 11 out of the 12 patients we spoke to told us the service did not always have enough staff on duty. Three patients told us they could not have adequate access to the garden due to staffing problems on the wards.

Patients felt staff did not engage with them or meet their needs in a way that they were satisfied with because staff were too busy. We spoke to 12 patients on both Greenacre and Oaktree wards, and 9 patients told us the wards did not have enough nurses on duty at most times. Patients said the nurses were busy most of the time, and it was difficult to talk to them. Most times patients had to wait for a while for the nurses to attend to their needs especially when staff were taking their breaks. One carer told us at times the ward was short staffed which had impacted on their relative attending an appointment. Two members of staff we spoke to said patients’ escorted leave was not usually cancelled but they were sometimes delayed due to low staffing.

The service had low and reducing vacancy rates. There was 1 vacant post for a clinical psychologist on Greenacre ward, and the vacancy had been covered by a locum psychologist for 4-5 months. The ward manager informed us a trainee psychologist had taken over the role once they had completed their mandatory training. The provider had recruited international nurses to fill some of the recent vacancies on both wards. Oaktree ward had recruited 5 international nurses whose learning and development was supported by a practice development nurse.

Managers reviewed the number and grade of nurses; nursing assistants and healthcare assistants needed for each shift. The ward manager could adjust staffing levels according to the needs of the patients.

The managers of both wards told us they limited their use of agency nurses and that they requested staff familiar with the service who had already been inducted to cover vacant shifts.

Managers provided new agency staff with appropriate induction. We saw agency staff completed the hospital induction process prior to working on the ward.

Whilst there were enough staff who had been trained to carry out physical interventions including restraints, observations and seclusions safely we identified staff were carrying out observations for too long. During our inspection we identified staff were placed on continuous enhanced observations for up to 4 hours at a time without a break. This was unsafe practice and put patients at risk of harm. There was a risk that without a break staff would become tired and less attentive.

The service had enough medical cover day and night and a doctor available to go to the ward quickly in an emergency. The ward doctors were available on the wards during the weekday core hours. There was an out of hours on call doctor rota to cover weekends and emergencies.

Staff had received and were up to date with appropriate mandatory training. On both wards 94% of staff had completed their mandatory training. The mandatory training programme was comprehensive and met the needs of patients and staff. It included training on the Mental Health Act (MHA) and Mental Capacity Act (MCA), supporting autistic people, awareness of self-harm and suicide, ligature risks, incident management, observations and engagement, physical health observations and safeguarding.

Staff received regular supervision. There was a policy and guidance documents to support the supervision process and promote individual development, including management opportunities. At the time of our inspection, supervision compliance for Greenacre ward was 97% and Oaktree ward was 100%.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The care environment on both wards was visibly clean, well-maintained and appropriately furnished. Patients we spoke with told us the ward was clean. Patients were able to give feedback on the environment and raise any issues in weekly community meetings. Cleaning records were up to date and demonstrated all areas of the ward were cleaned regularly. Staff maintained equipment and kept them clean. Clinical equipment was cleaned regularly and after each use. Once staff had cleaned a piece of equipment, they added a sticker to show the date it had been cleaned. We observed ‘cleaned’ stickers on several clinical items. Staff adhered to infection control principles, including handwashing. Staff completed mandatory training in infection prevention control and personal protective equipment. The service carried out regular hand hygiene and infection control audits.

We reviewed a cleaning rota which the cleaner filled in when they had cleaned the ward and this was up to date.

The service did not always ensure medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider did not always manage medicines in line with national guidance or legislation. Patients’ own prescribed medicines and stock medicines were not stored separately. This had been highlighted at a previous CQC inspection, but it was unclear what actions had been taken to reduce the risk.

Whilst the service received clinical and auditing support from an external pharmacy, we identified aspects of medicines management that needed further improvement. We saw delays in medicines supply to the wards from the pharmacy supplier. Although staff told us this had improved prior to our inspection, we identified recent instances where patients were affected because of the delays.

We also identified medicines that had not been administered to patients in line with Mental Health Act consent to treatment authorisations. We reviewed 6 medicines administration records and saw one consent to treatment form that was not up to date and had not been identified from the services’ quality improvement processes. This was fed back to the manager. Ten patients we spoke to said staff regularly reviewed their medicines with them and explained the side effect of their medicines to them. However, two patients told us they did not understand the medicines that they were required to take and that staff just gave them medicines without explaining the side effects of the medicines to them therefore patients could not easily identify the side effects of their medicines. However, staff received medicines management training, and their competencies were assessed. People’s physical health was monitored in line with guidance which was overseen by a nurse practitioner. This included when people were prescribed high risk medicines. The service completed regular audits of medicines management. We saw evidence of learning and improvements being made because of the audits.

At this inspection, the provider ensured that care plans and follow up information for the management of physical health conditions contained all necessary details and information.

People were given rapid tranquilisation (RT) medicines intramuscularly to help reduce agitation and aggression. Physical health monitoring after RT was being completed in line with policy. The service reviewed instances of RT daily. People’s behaviour was not inappropriately controlled using medicines. We saw positive behaviour support plans to help staff support people.

Carers we spoke to told us the staff gave them enough information about medicines given to their relatives and explained its side effects to them during ward round. One carer said they had raised concerns about their relatives’ medicines in the past and were happy with how the manager responded and delt with the complaint. One carer said they always received information when the medicines of their relative was changed. Doctors involved patients when changes were made to their medicines.