Cygnet Aspen Clinic

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 assessment we rated this key question as requires improvement. The service was in breach of legal regulation in relation to regulation 12 (safe care and treatment) and regulation 15 (premises and equipment). The service had made improvements and was no longer in breach of regulations. Managers ensured the ligature risk assessment was kept up to date and risks had been removed or mitigated against; medicines were correctly prescribed; and the environment was suitable for use by patients, including a private space for medicines administration. At this assessment the rating has changed to good.This meant people were safe and protected from avoidable harm.

Staff completed risk assessments of patients and updated these regularly. There were systems and processes to protect patients from abuse and neglect.

The service had enough staff to deliver care for patients. Staff received training to carry out their roles.

The environment was clean, well-maintained and fit for purpose. Environmental risks, including ligature risks, were assessed, monitored and mitigated against. Staff followed infection control procedures.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

All staff knew what incidents to report and how to report them. Staff did a detailed analysis of incidents each month, and these were reviewed in the clinical governance meeting. The number and types of incidents were reviewed and themes identified. These looked at particular times or locations, and in relation to specific patients. They compared this with incidents over previous months or years.

In the 12 months up to April 2025 the number of incidents each month ranged from 67 in January 2025 month to 179 in March 2025. The most common types of incidents were self-harm. The level of incidents were rated on a 4-point scale, with 4 being the most severe. Level 4 incidents were usually more severe types of self-harm, but they were not fatal. In the 6 months up to April 2025 there had been 92 level 4 incidents, ranging from 10 in January 2025 to 19 in February and March 2025. Incidents were discussed and reviewed in the daily multidisciplinary team meetings, and fed into individual patient risk assessments, care plans and actions. Positive actions were taken following incidents. This included taking immediate action, such as urgent healthcare; immediate review of risk; and any future actions such as a 1-1 with a member of staff. The provider has a central team that reviews all incidents, and a complex case panel every week where all incidents rated moderate or above will be reviewed. Information about lessons learned across the wider organisation were in shared in emails or on the intranet.

Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation if and when things went wrong. Managers met with patients and wrote a duty of candour letter following incidents of self-harm that required further hospital assessment or treatment.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

The service’s 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. The service had a clear model of care that identified the service it provided, what patient needs and diagnosis this was suitable for, and the five broad stages the patient would move through. The stages were pre-admission preparation, admission and assessment, stabilisation, active treatment and rehabilitation, and transition and discharge to prepare the patient to move on. Cygnet Healthcare had a centralised nursing assessment team that carried out a pre-admission assessment of each person referred. This team provided a report to the service who then decided whether they could meet that person’s needs. This report included the person’s history, risk assessment, medicines, triggers and expectations. Once accepted, the service provided information and worked with the patient as much as possible, to support them in their move to the service. This may include staff going to see the patient in their current placement, and the patient visiting the service before they were admitted. On admission, staff completed an initial 8-week care plan, during which time the multidisciplinary team carried out a fuller assessment with the patient and developed further care plans.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. All patients were registered with a local GP and dentist. Patients received support from local healthcare services when required, which included district nurses, speech and language therapists, and the acute hospital. Patients were involved in discussions about where they wanted to move onto when they were ready to leave the service. This included supporting patients to visit potential future placements and the local area. When possible, patients were encouraged to visit several services so that they could make an informed decision.

Patients had a 4-weekly multidisciplinary team and care plan review meeting, during which all aspects of their care were discussed, including discharge. Staff from their local area attended remotely or in person, and family members were also encouraged to attend with the consent of the patient.

The service did not have a waiting list at the time of this inspection. There were no patients who whose discharge was delayed when they were clinically ready for discharge.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did this when required. 89% of staff were up to date with their intermediate safeguarding training, and 98% of staff had completed introductory safeguarding training. Staff could describe the safeguarding process, and when this may involve the local authority, the police and other agencies.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. Staff described examples which included self-harm, financial abuse, and patients disclosing historic abuse (before they were in the service). Staff told us that anyone could report a safeguarding concern, but usually they would report it first to the nurse in charge or the manager. Safeguarding concerns were discussed in the daily morning meeting, and decisions made as to any further action required.

In the last 6 months there had been between 4 and 8 safeguarding referrals to the local authority each month. These were often when a patient had self-harmed and required further treatment. The local authority had been satisfied with the services response to these incidents, as it had not deemed it necessary to initiate any further investigations.

Managers led a weekly meeting to discuss safeguarding concerns, and identify if any further action needed to be taken or lessons learned. This meeting was also attended by the advocacy service to give their perspective.

Staff followed safe procedures for children visiting the service. Visits were risk assessed and arranged in advance, and there was a dedicated visitors’ room.

Managers monitored the service for the possibility of a ‘closed culture’ developing. The provider carried out an audit of the service to look for any indications or risk of a closed culture developing. The service scored 100%, which meant it was unlikely to develop one.

Managers limited the use of blanket restrictions. Where this were in place there was a rationale and they were reviewed regularly. The provider-wide blanket restrictions were listed on a noticeboard, and were primarily illegal or items that may be commonly used to self-harm. Individual restrictions were recorded in patients care plans, and were routinely reviewed in the morning meetings and at the patient’s multidisciplinary team meeting. Individual restrictions were usually related to specific intent to self-harm by a particular patient. Managers told us that in the last year there had been one blanket restriction, when no patients had been allowed to have a lighter because of the high risk presented by a particular individual.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. 91% of staff had completed training in the Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLS). The provider had a policy on the Mental Capacity Act, including DoLS. Staff were aware of the policy and had access to it. Staff knew where to get advice from within the provider regarding the Mental Capacity Act and DoLS. There had been no Deprivation of Liberty Safeguards (DoLS) applications made in the last 12 months.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded their capacity to consent appropriately. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. They did this on a decision-specific basis with regard to significant decisions. Staff provided examples of when capacity assessments had been carried out, such as regarding financial decision making, or physical healthcare.

The service monitored adherence to the Mental Capacity Act through its daily multidisciplinary team meetings and local and regional clinical governance processes.

We plan and deliver people's care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

Staff provided a range of care and treatment interventions suitable for the patient group. This included those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence (NICE) and the Royal College of Psychiatrists. The service had a psychology team that provided therapy to patients, which included dialectical behaviour therapy (DBT). Some of the nursing staff were also DBT trained.

`Enabling environments' is a network established by the Royal College of Psychiatrists (RCP) to support services to create positive psycho-social environments, with a focus on co-production with patients. The service was in the initial process of information gathering and auditing, with a view to ultimately meeting all ten standards following the submission of evidence and independent assessment through the network.

Managers and staff were working to reduce restrictive practices as much as possible. The consultant psychiatrist was the reducing restrictive practice champion. Information is displayed for patients to raise awareness of blanket restrictions and restrictive practices.

Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. The service had 2 registered general nurses who led on physical healthcare within the service. There was a dedicated physical health room suite that was large enough to carry out procedures, but did not have an examination couch. All patients have a mental and physical health check on admission, and an annual health check. There is ongoing monitoring of patients and access to physical healthcare dependent on their needs.

The team included or had access to the full range of specialists required to meet the needs of patients in the service. In addition to doctors, nurses and support workers, the team included occupational therapy and psychology.

All patients were registered with a dentist and local GP. Community and specialist healthcare was accessed through their GP or local hospital. For example, patients may access support from the district nursing team, dietitians, tissue viability nurses, and speech and languages therapists.

Staff were experienced and qualified, and had the right skills and knowledge to meet the needs of the patient group. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Managers ensured that staff received the necessary specialist training for their roles. 96% of staff had completed mandatory personality disorder e-learning. This incorporated an online module, and a workbook for staff to go through. 98% of staff had completed training on maintaining therapeutic boundaries with patients.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Staff did regular risk assessments of the care environment. Staff had a good understanding of environmental risks, and how to manage and mitigate these. At our last inspection we identified environmental and ligature risks in patient areas within the service. Managers told us there had been significant investment in improving the building, and this included removal of potential ligature points. There was ongoing work to improve the layout of the service. There was a ligature audit and environmental risk assessment. The ward layout allowed staff to observe most parts of the ward, and was boosted by mirrors, staff observation and CCTV.

The ward complied with guidance on eliminating mixed-sex accommodation. The service was for women only. There were procedures for male staff working with female patients.

Staff had easy access to alarms and patients had easy access to nurse call systems. Managers had introduced a silent emergency alarm system, to reduce the impact of a loud alarm ringing and distressing patients, particularly those with sensory needs.

The service did not have seclusion facilities, and did not use seclusion or long term segregation.

Staff had access to emergency equipment in the event of a medical or other emergency. This included resuscitation equipment, emergency medicines, and ligature cutters. These items were stored safely away from patients, but were accessible to staff. They were routinely checked and replaced when necessary.

Managers ensured the necessary maintenance and certification was carried out to ensure the building was safe. This included assessment of the building in terms of fire, water supply and other utilities, and installed equipment such as boilers, lighting and lifts. The service had a business continuity plan in the event of a serious problem in the building, for example if there was no water or electricity.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

The service had enough clinical staff to meet the needs of patients. The service had a hospital manager, a head of care, 11 qualified nurses (plus 4 bank nurses), 2 team leaders (not qualified nurses) and 38 support workers. The service had a consultant psychiatrist and had recruited a speciality doctor. The psychology team was led by a consultant clinical psychologist with an assistant psychologist and a trainee counselling psychologist. There had been a recent vacancy for an occupational therapist, which had been recruited to, and there was an occupational therapist assistant and a therapy co-ordinator. At the time of our inspection there were no vacancies that had not been recruited to.

The average short term sickness rate over the 12 months to May 2025 was 2.3%, ranging from 0.7% in January 2025 to 4.3% in June 2024. There was currently no long term sickness.

Managers could adjust staffing levels daily to take account of patients’ needs. When necessary, managers deployed bank staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. Patients and staff told us that it could vary if the ward was busy, but there were usually enough staff on duty. A qualified nurse was present in communal areas of the ward at all times. Staffing levels usually allowed patients to have regular one-to-one time with their named nurse. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. There were enough staff to carry out physical interventions such as observations and restraint, safely.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. The hospital had one part time consultant psychiatrist, and was in the process of employing a staff grade doctor. Cross-cover was provided with the doctor of the Cygnet Healthcare service next door. Out of hours medical support was provided by the regional out of hours cover system.

Staff had received and were up to date with appropriate mandatory training. 100% of psychiatrists, psychologists and occupational therapists, and 96% of nurses and health care assistants were up to date with their mandatory training. The training was appropriate for the patient group using the service.

Managers ensured that staff had access to regular team meetings. Meetings took place every 4 to 8 weeks and there were separate meetings for nurses and healthcare assistants.

Managers monitored staff compliance with mandatory training, supervision and appraisal every month. The most recent governance minutes showed that psychiatrists, psychologists and occupational therapists were all 100% up to date with training, supervision and appraisal. 96% of nurses and health care assistants were up to date with training, supervision and appraisal.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

All ward areas were clean, had good furnishings and were well-maintained. Staff maintained equipment well and kept it clean. General and clinical waste bins were available, and sharps bins were stored securely and not overfilled.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. The provider had policies for the prevention and management of infections, that included equipment, cleaning procedures and monitoring. The registered manager was the infection prevention and control lead in the service. Staff carried out cleaning audits in accordance with the NHS Standards of Healthcare Cleanliness cleaning tool. These showed high levels of cleanliness, typically scoring 100%, and where issues were identified these were addressed.

Staff adhered to infection control principles, including handwashing. Staff had access to protective equipment, such as gloves, and handwashing sinks. The was a dedicated sluice room, and colour-coded mops to minimise the risk of cross-infection.

When patients had infections, staff developed care plans to treat and manage this.

We make sure that medicines and treatments are safe and meet people's needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Staff followed good practice in medicines management. Medicines were dispensed from a dedicated clinic room with an outer area for privacy. Medicines were stored securely, and there were appropriate disposal arrangements. Pharmaceutical waste and sharps bins were secure and not overfilled.

Staff were competent at dispensing medicines, and had access to support. 92% of nurses were up to date with their management and administration of medicines training. A pharmacist visited the service every week to review medicines. They produced a report with any issues or gaps they had identified, and these were addressed and signed off by the service and the pharmacist. Managers told us there were some medicine errors, but these were usually of a relatively minor nature. For example, a missing signature. Where more serious errors occurred, these were logged as an incident and followed up with the staff involved, and any lessons learned shared with the team. In the 6 months up to March 2025 there had been 11 reported incidents.

Staff reviewed the effects of medication on patients' physical health regularly and in line with NICE guidance. Patients who were on high doses of antipsychotic medication were monitored in accordance with national guidance. Consent to treatment documentation for patients treated under the Mental Health Act was completed correctly. Prescription charts contained the necessary information.

Some patients self-administered their own medicines. There was a staged process for patients to follow to administer their own medicines, and several patients in the service were on this. This was regularly reviewed and stages were moved forward or back depending on the needs of the patient.