Cygnet Fountains

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met patient’s needs.
At our last inspection we rated this key question good. At this inspection the rating has remained good. This meant patient’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We make sure patients are at the centre of their care and treatment choices and we decide, in partnership with them, how to respond to any relevant changes in their needs. However, information was absent from care plans.

Patient care was based on individual needs and preferences. Care plans were individualised and included the patient voice, but three out of four of the care plans we reviewed lacked detail about how patients were engaging in a rehabilitation pathway, such as OT input and which skills and activities were appropriate.

Patients were consulted on any changes to the service. Patients were invited to weekly ward rounds where their views and opinions on their care and treatment were sought.

Patients were empowered to make their own decisions about their care and treatment. Patients were encouraged to engage with the advocate to ensure their voices were heard.

We understand the diverse health and care needs of patients and our local communities. However, patient choice was limited to ward based activities.

Patients access to education and work opportunities were limited. Most of the activities were ward based. There were 10 patients who were at the end of the rehabilitation pathway who were not accessing any education or work opportunities in the community. The registered manager stated that due to the current high acuity of patient risk, most activities were required to be ward based. This met the needs of some patients but not for the patients who were further on in their rehabilitation journey, or those who were ready to be discharged.

Staff supported patients to maintain contact with their families and carers. Families and carers were invited to meetings where appropriate such as care programme approach meetings and ward round if necessary. There was now a designated family room for patients to meet families and carers in. This was an improvement since the last inspection. There was a families and carers group meeting that was not well attended. Patients were encouraged to contact their families independently. Families and carers were sent a welcome pack that outlined the nature of the service. One patient went home to his family most days. There was a quarterly carers newsletter detailing upcoming events at the hospital.

Staff supported patients to access their chosen place of worship within the community.

We provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs.

Staff made notifications to external bodies as needed. Safeguarding alerts were sent to the local authority, and commissioners were made aware of any significant incidents. Notifications were sent to the Care Quality Commission as necessary.

Information governance systems included confidentiality of patient records. Patient records were stored securely on an electronic record system or within paper records that were stored in a locked cupboard in a locked room.

Staff ensured that patients could obtain information on treatments, local services, patients’ rights, how to complain and so on. This information was clearly displayed on notice boards within communal areas. There were also leaflets available. Patients were given a welcome guide on admission which included information on activities, advocacy details and the complaints process.

The information provided was in a form accessible to the patient group. The information was provided in English as all current patients were English speaking. Other languages were available on request. Care plans were written in a way that patients could understand.

Staff ensured carers, families and commissioners were regularly updated about the patient’s progress.

We make it easy for patients to share feedback and ideas or raise complaints about their care, treatment and support. We involve them in decisions about their care and tell them what’s changed as a result.

The service had received 10 complaints in the last 12 months. One was upheld, 3 were partially upheld, 1 was not upheld and 4 were withdrawn. None were referred to the ombudsman. There were no themes identified, but 2 complaints were about poor staff communication. The provider had addressed this by ensuring changes to medicine routines were shared at handover meetings and clearly in patient notes and new staff were reminded about being clear in their communication with patients.

Patients we spoke with understood how to make complaints. One patient told us they had made a complaint and that the provider was investigating this. Patients also told us they could raise issues informally with staff or at community meetings.

Managers kept a log of all complaints. We reviewed this and saw that patients received responses in a timely manner. Staff provided patients with updates about the status of their complaint.

Staff knew how to handle complaints appropriately. There was a complaints policy and process which staff had access to and were able to follow. Complaints were discussed in daily morning meetings and the registered manager would review the complaint and investigate. This included meeting with the complainant to gather more information, sending an acknowledgement letter and having 20 days to fully respond. The process also checked whether appropriate safeguards were made.

Staff received feedback on the outcome of investigation of complaints and acted on the findings. Managers audited complaints to check these were dealt with in line with policy.

We make sure that everyone can access the care, support and treatment they need when they need it. However, discharges were delayed.

Staff ensured the needs of patients with mobility issues were met. There were bedrooms at ground level and access to a lift to the upper floor. There was a ramp at the entrance of the building and there was a disability accessible bathroom and bedroom on the ground floor. There were no wheelchair users present during our onsite inspection.

Staff knew how to make reasonable adjustments for patients with mobility issues. There were no patients with mobility issues at the time of our inspection, however, staff knew how to obtain mobility aids if required.

Current occupancy for the service was 81%. However, managers told us the service sometimes reached full occupancy. For example, between December 2024 and March 2025, bed occupancy was 100%. This was due to the service taking extra patients at the request of the local mental health trust.

There was adequate medical cover day and night. A doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital.

Staff ensured patients had access to post-discharge care. This included S117 aftercare, community mental health services and crisis services. The service completed the majority of discharge planning.

There had been 10 delayed discharges in the last 12 months. The reasons provided were due to external factors including funding delays and mental health relapses. The service met weekly with the local NHS trust to discuss ways to progress patients whose discharge was delayed.

We actively seek out and listen to information about patients who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the patients using the service felt empowered to give their views. The service had set up various formats for patients to give their views and feel heard. Staff were able to explain patient suggestions and how these had been acted upon.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable patients or patients with protected characteristics at a disadvantage.

Staff were trained in equality, diversity, inclusion and human rights. Equality and diversity training had been completed by 100% of staff.

We support patients to plan for important life changes, so they can have enough time to make informed decisions about their future, including at the end of their life. However, care plans lacked detail in relation to future goals.

Staff supported patients to make decisions about their care and treatment and their future. Staff created personalised care plans to account for the patient’s needs, wishes and feelings, but these often lacked in detail with regards to specific goals and plans for discharge.

Staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of patients with complex needs. There were external partners involved in patient care where necessary.