Cygnet Victoria House

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 requires improvement. At this assessment the rating has remained requires improvement.

We identified a breach of Regulation 12 Safe care and treatment in relation to processes in relation to safe environments and medication optimisation. This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed. Whilst we found that staff were committed to learning and continuous improvement, worked hard to develop safe processes and understood safeguarding, governance systems around medication administration and environmental checks were not always robust enough. We were not assured that risks relating to these areas were always mitigated. We have asked the provider for a plan of action to improve these areas of concern.

However, we found that staff had a good understanding of the Mental Health Act and the Mental Capacity Act. Staff tried to involve people in decision making around their care and risk, wherever possible. Where people lacked capacity, they used Best Interest decision making to support them.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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. Lessons were learnt to continually identify and embed good practice.

The service demonstrated a clear commitment to fostering a learning culture and continuous improvement. Learning was embedded through structured processes. Monthly Clinical Leadership Forums provided a platform for heads of care and clinical managers to share lessons learned, review policy updates, and highlight positive practice. Staff reported that lessons from incidents were communicated through team meetings, handovers, and visual prompts such as lessons-learned posters displayed on wards. The hospital director also issued email alerts to all staff when risks were identified, such as items ordered online that could conceal blades or other harmful properties. Staff described regular supervision sessions, structured debriefs following incidents, and a culture of accountability and openness. They felt supported to speak up, with one staff member stating they would raise concerns and had seen responsive action taken as a result.

Survey data reflected strong engagement with reporting processes: 92% of staff said they were encouraged to report errors or near misses, and 98% knew how to report malpractice, fraud, or wrongdoing. Additionally, 94% agreed that the provider acted on concerns raised by service users. However, confidence in being listened to when raising concerns fell to 78%, a 20% decrease from the previous period, indicating an area for improvement in reinforcing responsiveness and trust. Staff also highlighted practical safety improvements, such as the introduction of handheld radios and additional personal alarms to support enhanced observations for high-risk patients. Overall, the service promoted transparency, reflection, and continuous improvement through clear reporting mechanisms, structured forums, and a culture that encouraged staff to learn from experience and act on feedback.

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 or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had structured pathways and governance systems designed to support safe and effective transitions for patients. Comprehensive mental and physical health assessments were undertaken on admission. We observed structured processes for reviewing admissions during morning multidisciplinary team (MDT) meetings and Responsible Clinician (RC) reviews, which took place shortly after admission. The morning meeting included consultants, specialty doctors, nurses, and occupational therapists, where each patient was discussed in detail, covering admission history, presentation, feedback from nursing and the wider MDT, physical health, medication, risks, and actions. New admissions were prioritised, and RC reviews involved the patient and MDT to confirm orientation, explore their understanding of treatment, assess mental and physical health, and agree initial goals for care. Where parts of assessments could not be completed, the reasons for this were documented and follow-up actions were included in management plans. Staff told us that these meetings were essential for ensuring coordinated care and timely updates following admission.

However, staff told us that a central hub was responsible for assessing admission forms and the service had only one hour to decide if an admission was appropriate for the service. Staff told us they felt low occupancy rates impacted on the pressure for the service to take people who may not be suitable. Staff told us they tried to mitigate these risks through early MDT reviews, GP summary requests, and structured handovers, but acknowledged that improvements were needed to strengthen checks at the point of admission.

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. There was a social worker within the service who liaised with external organisations such as community mental health teams, housing services and local authorities.

Feedback from family members told us they felt their loved ones were safe. One family member told us, “I do feel he’s safe and I know he feels safe.”. Another told us, “Staff understand him, it has been a lot of trial and error.” We reviewed feedback from a recent patient satisfaction that showed all 12 respondents (100%) reported that they have always felt safe during their time at the service.

There had been one incident in the last 12 months which met the criteria for Duty of Candour. We reviewed evidence that the service had complied with their policy when an incident met the criteria.

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.

The service had systems in place to identify and respond to safeguarding concerns. Safeguarding was embedded into daily practice, supported by clear escalation routes and a culture that encouraged accountability and vigilance. Staff were trained in safeguarding and knew how to make a safeguarding alert.

At the time of our inspection, 97% of staff had completed their safeguarding training. In the last 12 months, the service had made 90 safeguarding referrals to the local authority, 77 for Albert Ward and 13 for Victoria Ward. All incidents were discussed within the MDT morning meeting, where a member of the management team was present to explore any clinical or operational impact these incidents may have upon the service and service user. All incidents were reviewed within monthly clinical governance meetings. Investigations into incidents were completed by ward managers and above and could be completed by management colleagues from alternative Cygnet sites where this was required.

Staff told us they received safeguarding training and this was mandatory. Staff demonstrated awareness of how to protect patients who were vulnerable. Staff we spoke with were clear about their responsibilities and described the process for escalating issues and knew how and when to contact safeguarding leads or the police, where necessary. Safeguarding was discussed during morning handovers and multidisciplinary team meetings, ensuring risks were reviewed and actions agreed.

Mental Capacity Act

97.3% of staff had had training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. Staff knew where to get advice from regarding the Mental Capacity Act, including deprivation of liberty safeguards. The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

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 capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

There were no Deprivation of Liberty Safeguards applications made in the last 12 months. A Deprivation of Liberty Safeguards application would be made in order to protect people without capacity to make decisions about their own care. 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.

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 and seclusion 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.

In the last 12 months the service reported 61 incidents of seclusion, 331 incidents of restraint, 9 of which were prone restraints and 133 incidents of rapid tranquilisation.

The service involved individuals and, where appropriate, their families or carers in managing risks. We observed morning multidisciplinary team (MDT) meetings and Responsible Clinician (RC) reviews where patients were asked about their orientation, understanding of their admission, what they felt they struggled with, and what they wanted help with. Staff told us that advocates were available if individuals required support, and carers were invited to ward rounds to share their views.

Positive risk-taking was encouraged, with staff focusing on empowering individuals to make informed choices, weighing potential benefits and harms, and using available resources to minimise risk while supporting personal growth. This approach was underpinned by trusting relationships and clear communication, enabling individuals to learn from experience and participate in decisions about leave, activities, and treatment.

Staff described using structured handovers, daily reviews, and escalation processes to reduce restrictive interventions wherever possible. Overall, the service demonstrated a commitment to involving people in assessing and managing risks, supported by advocacy, family engagement, and a strengths-based approach to decision-making.

Quality Statement Score: 1

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

On our arrival at the service, we were not asked for any proof of identity. Although there were no concerns about people getting onto the ward that shouldn’t be, we were concerned that lack of checks may risk the security of the building. We raised this with the clinical lead and when we returned for subsequent days, we were asked for this by the staff member on reception duty.

The design and layout of the wards meant that there were areas accessible to patients that were out of sight of the nurse station. Staff mitigated this by using convex mirrors positioned in corridors to reduce blind spots and through patient observations levels. Staff told us they knew where ligature points and blind spots were and had easy access to alarms and patients had easy access to nurse call systems and were able to tell us where they were. The provider had a policy in place and staff demonstrated a good awareness of this when we discussed it with them.

The seclusion room contained anti-ligature bedding and clothing, two-way communication, toilet facilities and a clock within the room. Patients using the room had access to music, natural light and water. Although there had been some damage to the seclusion room, this was still able to be used. Staff told us had been reported and was waiting for repair.

The provider had policies and procedures in place in relation to the safety of the environment. However, we reviewed documentation relating to health and safety checks of the hospital premises. The information provided to us did not give assurances that the necessary actions identified were being carried out appropriately or that all health and safety processes were effective. For example, annual checks for Water and Heating, Kitchen Appliances, Gas and in relation to Fire Safety were not up to date. An engineer report dated 06/06/2024 found issues with the emergency lighting at the service and it was unclear whether these had been actioned following the report.

The Fire Extinguisher Register showed the extinguishers were last serviced on 19/07/2024. It also showed the 'water' extinguisher in the dining room was due to be replaced in 2025 but did not specify when. When we checked the date on this extinguisher, we found the door on the housing was difficult to open with the fob key so we asked a member of staff to do this and they also found it difficult to open. We were told that staff carried out visual checks on these but did not check the opening mechanism. We were concerned about staff being able to access this equipment in an emergency due to the level of difficulty in opening it. This was raised with staff at the time and immediate action was taken to mitigate the concerns.

Documentation showed that both the hot water and cold water had exceeded the recommended temperatures. The documentation did not show that any action had been taken in response to this. We requested immediate assurances regarding a scald risk for people and were told all of the water temperatures would be checked straight away. Following this, we received evidence that all the water outlets were retested and all of the hot water were within safe ranges. However, some of the blended readings were higher than expected, therefore, they were retested and the TMV values were manually adjusted in the rooms identified, retested one hour later where they were found to be reporting much lower readings. The service also advised us that they had actioned refresher training and guidance for both of their maintenance staff on the completion of water temperature testing, reporting and appropriate actions and escalation procedures to follow. We reviewed incidents to confirm there had been no incidents of individuals having sustained injury or burns relating to water temperature.

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.

There were enough staff to provide safe care and treatment to patients within the service. Staffing across both wards comprised 3 clinical leads, 15 nurses, 29 support workers, three activity coordinators, and one team leader, supported by a wider multidisciplinary team including medical staff, occupational therapists, social workers, psychologists, and administrative roles. This ensured patients had access to a range of professionals to meet their needs. At the time of review, there were no vacancies within the service.

Managers used a staffing matrix to calculate the number and grade of nurses and healthcare assistants required, adjusting for patient acuity and observation levels. Structured handovers, daily risk reviews, and multidisciplinary ward rounds ensured staff were informed and able to respond to patient needs. These measures demonstrated that the service maintained safe and effective staffing through robust planning, contingency arrangements, and a strong focus on patient-centred care.

Managers used agency and bank staff when necessary to maintain safe staffing levels. In the last 12 months, agency staff covered 1,064.5 shifts and bank staff covered 834.5 shifts, primarily due to patient acuity and enhanced observation requirements. Where possible, familiar agency and bank staff were requested to maintain continuity of care. Permanent and bank staff received a comprehensive induction prior to commencing their employment and workbook to complete over a 6-month period to demonstrate competency. There were no occasions where the service operated below safe staffing numbers, supported by a 24/7 on-call manager system to address any out-of-hours issues. Staff shortages rarely resulted in cancelled activities or escorted leave.

Staff turnover was 22.47% over the past year, with themes including career progression and changes in bank staff availability. All staff held current Disclosure and Barring Service (DBS) checks, and renewals were underway for those nearing expiry. Mandatory training compliance was 88.3% overall and covered the following courses:

• Basic Life Support (BLS)
• Immediate Life Support (ILS)
• Dealing With Concerns at Work (E-Learning)
• Equality and Diversity (E-Learning)
• Food Safety at Cygnet (E-Learning)
• Infection Prevention and Control (E-Learning)
• Information Governance Awareness (E-Learning)
• Protecting Our Health & Safety (E-Learning)
• Responding to Emergencies (E-Learning)
• Safeguarding Individuals at Risk Introduction
• Safety Intervention Advanced / Emergency Programme Induction:
• Safety Intervention Advanced Refresher:
• Safety Intervention Compliance:
• Safety Intervention Foundation Programme Induction:
• Safety Intervention Foundation Refresher

The provider had a target of 95% compliance for all training and had an action plan in place to achieve this. Compliance rates for BLS and ILS were 82.2% and 71.4% respectively. The completion rates were impacted by 8 people who were waiting for spaces on face-to-face training. Training for all 8 had been prioritised and booked in. There were processes in place to ensure the wards always had someone BLS and ILS trained on each shift and the compliance rates were reflected in the action plan we reviewed.

98.9% of staff had complete The Oliver McGowan Mandatory Training on Learning Disability and Autism E‐Learning and 100% had complete training in relation to Personality Disorder and Physical Healthcare.

Patients told us there were always enough staff to support them, and 100% of respondents to the Patient Satisfaction Survey stated staff were caring and supportive. There had been no incidents where Section 17 leave had been cancelled due to staffing issues. Family members spoke positively about the staff. One told us, “Staff are friendly enough; you can always get through to them and they always get answers to questions.” Another told us, “He has had occupational therapy (OT) assessments for shopping and making a meal.”

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

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

All ward areas were clean, had good furnishings and were well-maintained.

Staff used handwashing facilities appropriately.

100% of staff had completed infection, prevention and control (IPC) training.

We scored the service as 1. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

100% of staff required to complete Medication ‐ Management and administration for nurses and Medication Competency for Nursing Services had completed this.

However, our review of medication administration records (MAR) found some issues. For example, the MAR did not contain a photo of the person. The presence of a photograph gives staff administering medication assurances that they are administering them to the right person, which is particularly important where the turnover of patients is high and where bank and agency staff are used. Whilst patients were able to consent to use of photos and were within their rights to decline this, we reviewed records where patients had consented to photos but still did not have one on their MAR. Whilst we found no direct impact on patients, we were not assured that staff who were unfamiliar with the patients could ensure they were administering to the right person.

We also found some discrepancies in relation to the cleaning of clinic rooms and the documentation. Staff advised us that domestic staff cleaned these, however the documentation used had ‘NA’ noted on it meaning those rooms did not apply to their cleaning rota. Whilst the clinical rooms were largely clean and tidy, we did observe some areas of the floors that were unclean on Albert Ward. We raised this with the provider during our assessment and they took immediate action to rectify this. They told us that the forms used by domestic staff had been reconfigured so all rooms were present on the form. Managers had also spoken to domestic staff regarding record keeping and had asked them to add more details when documenting what had been done. An additional cleaning schedule for staff nurses had also been implemented on both wards to compliment the work undertaken by domestic staff.

MAR records in relation to the use of intra-muscular (IM) or as required (PRN) medication were sometimes difficult to read and understand if needed to be used in an emergency, or by a member of staff who was unfamiliar with them. We also found instances where medication had been administered in a way that was not in line with prescribing care plans. We did not find any evidence of this issue impacting on the safety of patients, however, we were concerned about this potential impact, therefore, we raised this with the manager during our assessment. They took immediate action to remedy this by printing out PRN care plans which included more details and instructions to assist staff. Following the onsite inspection, we received feedback from staff that the new arrangements were clearer and they felt they would be able to deliver care safely when needed.

We also reviewed records in relation to medication prescribed for ‘seizures’ but there were no specific instructions about when this should be given. Whilst nursing staff were able to tell us what the arrangements were for administration this was not written down anywhere. The medication for seizures was also kept in a separate cupboard to the main medication which was not clear for anyone unfamiliar staff. We raised this with the provider at the time of the assessment and they took immediate action to mitigate this risk by updating and printing PRN care plans which included specific instructions for administration and these were included with the Kardex. They also ensured the cupboard with the seizure medication in was clearly labelled.

We found some stock of medications that were out of date. Managers told us that once a month, a nurse checked all the medications for those due to expire at the end of the month and wrote it on the whiteboard so that at the end of month these should be removed. We raised this with the provider during our assessment and they advised they would review the process for reviewing expired medication to ensure the arrangements were more robust.

Managers told us there were issues with pharmacy supplies across the whole Cygnet organisation and this had been raised as a concern. Cygnet were in the process of reviewing their arrangements. Staff told us there had been no incidents where medication wasn’t available for the patient as they either asked medics to review prescribing or sourced this from a local pharmacy.