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 is the first assessment for this newly registered service. We looked for evidence that patients were protected from abuse and avoidable harm.

This key question has been rated as 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.

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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders ensured that safety was a top priority that involved everyone, including staff as well as patients using the service. Concerns were dealt with willingly as an opportunity to put things right, learn and improve. Staff told us they learnt from incidents through debriefs involving patients and discussions in daily and monthly team meetings.

Staff reported 7 serious incidents at the service between March 2025 and March 2026. Of these, 4 were reported as self-harm and 3 were reported as clinical intervention. We reviewed minutes from 3 debrief meetings, which demonstrated that staff received appropriate support following serious incidents. Staff were given the opportunity to reflect on events, with clear documentation of lessons learned and actions taken.

Leaders reviewed all reported incidents and shared local and regional learning with staff through a “lesson learned” log which clearly documented recommendations for improvement following incidents. For example, following an incident, staff were made aware that restricted items could be concealed within everyday objects. As a result, learning was shared to strengthen safety and awareness across the service.

The evidence showed significant shortfalls. The service did not manage or monitor patient’s safety consistently. However, they were working with partners to establish and maintain safe systems of care and ensure continuity of care, including when patients moved between different services.

Staff did not always ensure safety was a priority throughout people’s care journey. We were not assured that risk items were managed safely or consistently on the ward. During our site visit, we observed staff retrieving a lighter and cigarettes for a patient from an office locker during 1:1 time. Staff did not use a formal sign‑in/sign‑out system, and no audit trail was in place to demonstrate who accessed or returned restricted items.

The ward did not have clear procedural guidance for managing restricted, prohibited or ‘contraband’ items. This meant staff did not have consistent direction on how to manage these items safely. For example, 1 locker contained a rucksack holding multiple deodorant cans with no accompanying documentation to confirm whether appropriate checks had been completed.

Staff told us they had concerns about inconsistency in practice, particularly during periods of higher acuity and when newer or agency staff were on duty. They reported that not all staff had received sufficient training or clarity on processes for collecting and managing restricted items.

Incident data reinforced these concerns. The service reported 80 incidents involving restricted, prohibited or ‘contraband’ items in the previous 12 months, indicating ongoing risks that were not effectively mitigated through existing systems. During our inspection, we raised concerns with leaders. They acknowledged our concerns and immediately put measures in place to manage the risk, including introducing a sign-in/sign-out board.

However, 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. Multi-disciplinary Teams (MDT’s) held discussions before any decisions were made to admit patients. Managers were able to refuse an admission if the patient’s needs could not be met by the service. We observed staff discussing all patients in morning ward meetings and management daily “sit rep” meetings.

During our observation of a patient’s ward round, we saw that staff planned and organised care and support with people, together with partners and communities in ways that ensured continuity. Staff liaised with community teams to ensure appropriate care and support for patients continued following discharge from the service.

The evidence showed a good standard. 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 patient’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.

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

Staff had access to an onsite safeguarding lead trained at Level 4 who could seek support from a regional safeguarding forum. Managers told us that the service had regular meetings with the local authority to discuss themes, trends and any unclosed safeguarding referrals. Staff could make direct referrals to the local authority and would also report to the hospital’s head of care, and 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. The service ensured safety for any children visiting the service. There were visiting facilities available outside of the ward area and staff risk assessed any planned visits from children.

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

The evidence showed a good standard. The service worked with patients 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.

We reviewed 7 risk assessments and risk management plans. Staff had completed 6 of these records in a holistic, personalised, and detailed way. The service had recently introduced full safety formulation in line with National Institute for Health and Care Excellence (NICE) guidance. Staff updated and reviewed risk assessments regularly, including after incidents. Managers told us they regularly audited care plans; however, we found 1 record that lacked a detailed risk assessment.

The service reported and monitored restraint and safeguarding incidents at local and regional clinical governance meetings. During these meetings, staff reviewed the number and type of restraints and safeguarding referrals made to the Local Authority. Between 2 January 2026 and 30 March 2026, staff made 32 safeguarding referrals, of which 26 met the threshold for a Local Authority (LA) referral. The LA requested that the hospital completed a full investigation into 1 safeguarding incident, which concluded that no further action was required.

Restraint data for the same period showed staff used restraint 63 times, including 2 incidents in the prone position. Prone restraint involves holding a person face down. Our review of restraint records showed staff implemented restraint care plans, used restraint proportionately to the risk posed, and carried out debriefs with patients and staff following each incident.

Between March 2025 and March 2026, staff carried out rapid tranquilisation on 90 occasions. The number varied between wards, with Fern Ward recording the highest use at 65 instances and Bramble the lowest at 8. Our review of records showed staff appropriately documented evidence of de-escalation. Staff also completed post–rapid tranquilisation documentation, including visual assessments to check whether patients were alert and able to walk following the intervention.

There were 74 uses of seclusion and 1 episode of long-term segregation (Bramble Ward) between March 2025 and March 2026. The number varied between wards, with Fern Ward recording the highest use at 67 instances and Bramble the lowest at 2. Our review of seclusion records showed that staff carried out regular observations, whilst patients were in seclusion and seclusion plans were in place.

We reviewed 7 care plans and found that staff communicated effectively with patients to ensure they understood their care and treatment, including using appropriate methods for those with communication difficulties. Staff enabled patients to provide feedback on the service through regular people’s council meetings and weekly ward manager drop-in clinics. Patients also had access to a weekly onsite advocacy service.

The evidence showed a good standard. The service detected and controlled most risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular risk assessments of the care environment, including daily security checks and monthly health and safety audits.

The layout of all wards allowed staff to observe all areas, with mitigations in place for the blind spots including CCTV and mirrors. Staff knew about ligature risks, how to mitigate these and could give examples of improvements made in response to risks identified and lessons learnt from past incidents.

Patients were able to raise concerns about the safety of the ward environment in the peoples council meeting or ward managers drop in clinics and staff took actions in response.

The seclusion room supported safe care and good practice. Staff maintained clear observation and two-way communication, and the room included toilet facilities and a visible clock. The room was clean and well maintained. Following an incident earlier in the month in which a patient damaged the inner observation window, the provider had arranged prompt maintenance to repair the grouting in the air lock area. Staff used CCTV to provide continuous observation in line with seclusion guidance. The suite was open, spacious, and temperature controlled. An adjacent area allowed patients access to fresh air, helping to maintain comfort during periods of seclusion.

The service also provided a separate de-escalation suite, which staff used as part of a least restrictive care pathway. Staff assessed patients in this area on admission if they were unsettled and completed a multidisciplinary review. Wherever possible, staff admitted patients directly to the ward, using seclusion only when necessary and in line with the principles of the Mental Health Act Code of Practice.

The service displayed a list of prohibited items and followed a policy which detailed when routine and exceptional searches were to be conducted.

The service admitted male patients only and there was no mixed sex or shared accommodation. The provider had a policy on sexual safety and supporting safe relationships. The service also supported staff to feel safe working on the wards.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

However, leaders told us the service had previously experienced issues with staff personal alarms being set to night mode, which meant the system did not function as intended. In response, the service reviewed the alarm system and introduced a pilot to move to a bleeper system.

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 patient’s individual needs.

Managers calculated the number and skill mix of nurses and healthcare assistants needed to provide safe care on the ward. Most staff and patients told us there were enough staff on duty to meet patient’s needs and that they were well supported by knowledgeable leaders.

Our review of staffing information showed there were no vacancies for registered nurses, healthcare assistants or allied health professionals (AHP’s) at the time of the inspection. The service had 1 vacancy for a Responsible Clinician (RC), with cover currently being provided by a long-term locum RC, who had been in post for 2 months. Leaders told us that active recruitment was underway, and interim arrangements meant patients continued to receive appropriate therapeutic support. The services Responsible Medical Officer (RMO) was working their notice, but a replacement had been recruited.

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

Staff completed mandatory and statutory training and kept this up to date. At the time of the inspection, overall compliance for mandatory and statutory training exceeded 95%, meeting the provider’s policy requirements. Managers maintained clear oversight of each staff member’s training needs and consistently monitored compliance.

Staff received regular and appropriate support through supervision. Clinical supervision compliance was 93%, and managerial supervision compliance was 94%. Staff also completed annual appraisals, with compliance at 96%, demonstrating a strong commitment to maintaining staff development and safe practice.

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

When necessary, managers deployed bank staff using a regional “pool” of regular staff to maintain safe staffing levels. When bank nursing staff were used, those staff received an induction and were familiar with the ward.

A qualified nurse was always present in communal areas of the ward and staffing levels allowed patients to have regular one-to-one time with their named nurse.

However, some staff told us that they don’t always feel supported during periods of increased patient acuity on the wards and that staff are frequently pulled from Treetops Ward to cover other wards or section 17 leave.

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 kept ward areas, facilities, and equipment clean and well maintained. Cleaning schedules and audits were up to date and showed that staff cleaned all areas regularly. During the inspection, we observed a clean environment throughout, including stain-free carpets, clean floors, and well-maintained furnishings. High-touch areas such as handrails were regularly cleaned in line with good practice.

Staff followed infection control procedures, including good hand hygiene. The service stored cleaning substances safely, with COSHH cupboards locked and appropriately organised.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We were not assured that robust arrangements were in place for the safe management, use, and oversight of controlled drugs. On Fern and Bramble wards, the completion of the controlled drug register was inconsistent and not in line with guidance; although all drugs were accounted for, there were gaps in the records.

Staff also identified that documentation relating to PRN (as required) medication lacked sufficient detail to support safe administration, with 1 nurse informing the inspection team that a near-miss had occurred due to unclear information, however this was not formally reported to leaders at the service.

These concerns were raised with service management, who took immediate action to rectify the issues.

However, most staff followed good practice in medicines management and followed national guidance.

Our review of care records showed that staff regularly monitored the effects of medication on patients’ physical health in line with national guidance, particularly for those prescribed high‑dose antipsychotic medication. We reviewed 4 patient medicines administration charts and found that patients had been given their medicines as prescribed.