Cygnet Sherwood House and Cygnet Hospital Sherwood

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 patients were protected from abuse and avoidable harm.

At our last assessment we rated this key question as good. At this assessment the rating has changed to requires improvement. 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.

The service was in breach of regulation 12 for safe care and treatment and regulation 15 for premises and equipment.

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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety. Lessons were not always learnt to continually identify and embed good practice.

Staff did not always manage risks effectively or use incidents as opportunities to learn and improve. During our onsite assessment, we found that staff failed to manage risk items on the unit. Team meeting minutes repeatedly highlighted themes of contraband, absconsion, violence, aggression, and injury. Our review of local clinical governance minutes from April 2025 showed that managers were aware most incidents involved illicit substances and noted that security on the unit was “possibly getting worse.”

Staff raised concerns about these incidents with managers, but managers overlooked or ignored the issues. As a result, staff escalated their concerns in May 2025 to the Freedom to Speak Up Guardian (FTSUG), who informed managers that staff morale had never been so low.

However, staff reported 120 incidents at the service between January and April 2025. Of these, 32 involved violence and aggression, 23 involved patients absconding from the unit, and 16 involved injury. Managers reviewed all reported incidents and discussed them in daily handovers, monthly team meetings, and governance meetings.

The service reported no serious incidents in the last 12 months. Staff and patients were encouraged to raise concerns during daily handovers, where incidents from the past 24 hours were discussed. Staff knew what incidents to report and how to report them. All staff had access to the hospital’s incident reporting system and used it when needed.

Managers notified CQC about the illegal substance incidents and explained the actions they took. They introduced measures to reduce the risk of patients bringing illicit substances onto the unit, including increasing staff awareness and facilitating regular drug dog searches. Staff encouraged patients to seek support to understand risks, for example, by requesting enhanced observations to feel safe on the unit.

Staff understood their responsibilities under the duty of candour. They acted openly and transparently and gave patients and families a full explanation when things went wrong.

The service worked with patients 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 patients moved 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 be safely met. Multi-disciplinary Teams (MDT’s) held discussions before any decisions were made to admit patients. Managers were able to refuse admission if the patient’s needs could not be met by the service. When a patient was admitted to the service, they were offered a pre-admission visit if appropriate, and a full assessment and engagement meeting with the MDT within 72 hours. We saw evidence of this during our review of care records.

We found that when a patients needs changed following admission, the service responded appropriately by escalating the matter to the local Integrated Care Board (ICB) to identify a more suitable placement. Staff worked collaboratively with all the relevant health, social care and Ministry of Justice (MoJ) services to ensure continuity of safe care was maintained throughout the patients stay and following discharge.

ICB’s and community teams were invited to ward rounds and discharge planning meetings. The service had a discharge pathway in place with weekly meetings for those approaching discharge. Staff were also offered discharge pathway training from a local ICB.

The service maintained an excellent relationship with the local GP and registered all patients with them. Staff supported patients to access physical healthcare services when appropriate.

However, we were informed that some patients experienced delays in their discharge due to a lack of suitable placements. The longest current admission was 6 years. Management were actively working with relevant commissioning partners to identify appropriate solutions and minimise the impact on individuals.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ 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.

All staff were trained in safeguarding and knew how to make a safeguarding alert. At the time of our inspection, 100% of staff had completed safeguarding training.

Staff had access to onsite safeguarding leads trained to Level 4 and nurses who were trained to Level 3, who could seek support from a regional safeguarding forum. Staff could make direct referrals to the Local Authority (LA), the head of care, and the registered manager.

Staff gave examples of how they protected patients from harassment and discrimination, including those with protected characteristics under the Equality Act. They knew how to identify adults and children at risk of, or suffering, significant harm and worked in partnership with other agencies. Staff followed safe procedures for children visiting the service.

The service reported and monitored incidents of restraint and safeguarding during local and regional clinical governance meetings. These meetings reviewed the number and type of restraints and safeguarding referrals made to the Local Authority. In the 5 months prior to our assessment, staff made 13 safeguarding referrals, with two meeting the threshold for the Local Authority to proceed. Restraint data for the same period showed restraint was used 17 times. This was an increase since our last inspection in 2019, where was used 7 times during a 5-month period.

The service maintained a reducing restrictive practice plan, which the multidisciplinary team (MDT) managed and audited in line with local guidance.

They did not always provide care to meet patients’ needs that was safe, supportive and enabled patients to do the things that mattered to them.

We looked at 8 care records during our inspection to ascertain if staff assessed and managed patient risk appropriately.

Not all of the records included risk management plans, which meant staff lacked clear guidance on how to mitigate identified risks for all patients. Instead, staff relied on a risk stratification tool as part of patients dynamic risk assessments. This approach does not align with NICE (National Institute of Care Excellence) guidance, which recommends comprehensive, individualised safety plans to ensure patient safety and continuity of care.

We saw evidence in care records that staff involved patients in care planning and risk assessment and offered the patient a copy their care plan. However, views from patients were vague and some were repeated from month to month and there was limited evidence of family involvement.

Staff worked with patients to develop individualised risk management plans that balanced safety with recovery goals. For example, one patient told us how the hospital supported them to have regular home leave to visit a sick relative, describing how much this meant to them. Staff recognised that returning to the hospital after home leave could be a trigger for this patient, so they adapted their approach to provide additional support on return. This demonstrated how staff used personalised planning to help patients progress towards recovery while understanding and managing risks effectively.

There were reasonable blanket restrictions within the service which were monitored using a reducing restrictive practice plan by the MDT.

In the last 12 months, there was 1 incident of staff administering rapid tranquilisation within the service. In the last 5 months, there were 17 incidents of staff using physical restraint within the service, none of which were in the prone position (face down). The service did not have provision for seclusion or long-term segregation.

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.

We were not assured that managers carried out regular risk assessments of the care environment in line with policy.

Our review of the ligature risk assessment dated March 2025 found it stated that the patient gym area was ‘under refurbishment’. However, we observed that the gym was open and being used by patients. This meant that ligature risks in this area had not been assessed and included in the current risk assessment.

In the garden, we found fairy lights placed on the back fence by staff. This posed a potential ligature risk and had not been included in the environmental risk assessment. Managers removed the lights immediately after we raised the concern.

We were not assured that the service had an effective system in place to keep patients safe from specific risk items or environmental hazards.

We found the cigarette bin to be overflowing with discarded cigarette ends, creating a potential fire risk.

We were not assured that the service had a robust system in place for storing risk items such as lighters and razors. While we expected some personal items to be kept in patients bedrooms due to the long-term rehabilitation nature of the service, we also expected robust management of high-risk items. We found staff stored patient’s personal risk items in a cleaning cupboard in a disorganised manner, with no system for recording what was present. Staff did not store items respectfully, and some patient property was left on a window ledge.

However, the ward layout allowed staff to observe all areas of the ward. Staff carried out regular observations of each corridor and in the garden.

During the assessment, we reviewed documents and audits for the safe upkeep of the hospital environment. These included the hospital general maintenance file, fire risk assessment, legionella checks, and the environmental risk assessment, which incorporated a ligature risk assessment. All audits and assessments were in date.

We spoke to the maintenance team, who told us they operated effective systems for staff and patients to report maintenance issues. They confirmed they had the right equipment to make necessary repairs promptly.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency medicines. Staff checked these items regularly to ensure they were safe and ready for use.

Managers did not always make sure staff received effective support, supervision and development. Staff did not always work well together to provide safe care that met patients’ individual needs. This was despite their being enough staff to provide safe care and treatment to patients within the service and at the time of our inspection the service reported no staff vacancies.

The multi-disciplinary team (MDT) included a hospital manager, head of care, doctors, psychologists, occupational therapists, support workers and activity co-ordinators. The service also employed a peer support worker.

We reviewed data around sickness and staff turnover. The provider reported sickness levels were below 2% and turnover was at 3.13% which meant that 2 staff left over the past 12 months.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had received and were up to date with mandatory and statutory training. At the time of our inspection, the compliance rate for mandatory and statutory training did not fall below 95%, which met the providers policy requirements. Managers maintained oversight of each staff member’s training requirements, and compliance with mandatory training was consistently monitored.

We reviewed a sample of staff files and found that all contained the required checks, including up-to-date Disclosure and Barring Service (DBS) certificates.

We were informed that managers provided supervision in a group setting rather than individually. Although they made one-to-one sessions available, we were told that staff did not take these up. Managers failed to recognise that staff might avoid individual sessions because they felt singled out. This approach limited opportunities for staff to discuss issues or concerns confidentially. When we raised this with managers, they acknowledged they had not anticipated a negative impact and committed to reviewing the decision.

During our assessment, we observed staff smoking alongside patients in the communal garden, including a staff member who was on observations at the time. No one challenged this practice. Managers confirmed that a designated smoking area for staff existed outside the communal garden, and policies were available. However, we were not assured that staff understood the negative impact of smoking alongside patients.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We reviewed team meeting minutes that highlighted cleanliness issues on the unit following a quarterly Infection Prevention and Control (IPC) audit in April 2025. Staff were reminded to act as role models for patients by keeping communal areas clean and tidy, paying particular attention to toilet areas Despite this, during our walk around the hospital, we found a collection of dirty plates and food waste near a window. We observed that the communal bathroom on the ground floor, which contained a bath and toilet, was dirty. The toilet had significant staining on the seat mechanisms, and a used bath sponge was left on a ledge. Staff had not ensured the bath was fully cleaned since its last use.

We also saw that some areas of the hospital environment were worn and unkempt, which presented an IPC risk.

However, the service had systems in place to manage and reduce infection risks, following national guidance and best practice. Infection prevention and control was discussed during monthly team meetings as a fixed agenda item. We found staff adhering to bare below the elbow practice. Leaders shared refurbishment plans to upgrade many areas of the hospital, and we saw examples of the standard that would be in place upon completion.

The service made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. They involved patients in planning, including when changes happened.

Overall, the service ensured that medicines and treatments were safe and met patients’ needs, capacities, and preferences. Staff involved patients in planning their medicines, including when changes occurred, and provided appropriate support to facilitate self-administration of medication in line with guidance for rehabilitation services.

Staff followed good practice in medicines management, including transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, and the use of covert medication. They carried out these processes in line with national guidance.

We reviewed 10 patient prescription charts, which were mostly completed in line with national guidance. This included appropriate monitoring of high-dose antipsychotic therapy (HDAT) and physical health checks. However, we found one record with inconsistent bowel chart recording, and concerns raised were not highlighted in the patient’s physical health care plan.

On the day of our inspection, the service did not have an adequate supply of Clozapine (an antipsychotic medication). Managers told us the supply was due that day and provided confirmation once it arrived. This did not impact on the care received by patients’.

Nurses/managers ensured clinics were well organised with effective systems in place for the management of medicines. Nursing and pharmacy staff undertook medicines audits and stock control line with national guidance.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance. Fresh water was given to each patient receiving medication. Nursing staff asked patients if they understood their medication and what it was for, which reflected the supportive approach expected in a long-stay rehabilitation ward.

A patient told us they knew why they had to take medication and were able to describe the name, dose, and potential side effects.

The hospital manager acted as the controlled drugs accountable officer and medication safety officer.