Cygnet Fountains

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 good. At this assessment the rating has remained the
same. This meant patients were safe and protected from avoidable harm.

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.

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.

The service reported no serious incidents in the last 12 months.

The service was preparing to move to a new incident reporting framework called Patient Safety and Incident Reporting Framework (PSIRF). However, in the interim, the previous serious incident framework remained in place.

There had been no adverse events specific to this service.

Staff clearly understood which incidents to report and how to do so. There was an electronic incident reporting system for staff to access. There was an incident policy for staff to follow.

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.

Staff received feedback from investigation of incidents, both internal and external to the service. Lessons learnt from other hospital sites was shared with the staff team.

Incidents were reviewed by the registered manager or the head of care. These were then discussed with staff during handover meetings and daily morning meetings. This would be an opportunity to discuss the actions and check that the risk assessment and care plan had been updated. Incidents and learning from incidents were also shared in team meetings and via email.

Staff were able to give examples of how changes had been made as a result of learning from incidents. There had been recent learning regarding a case of coercive control within the wider Cygnet group, as well as learning related to harm from aerosols and drugs hidden in crisp packets. An integrated care board had also shared learning with the service regarding the ordering of online household items for the purposes of self-harming. Themes from the electronic incident reporting system were also shared with the team.

Staff confirmed de-briefs took place when required. We saw evidence of patient de-briefs on the care records system.

We work with patients 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 patients 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 access to the providers national assessment team who conducted comprehensive assessments. Potential admissions were discussed by the registered manager and multidisciplinary team (MDT) to decide the suitability of the patient. The MDT were able to decline patients if they felt unable to manage the risks presented.

The service had 16 beds block purchased from the local mental health trust. The local mental health trust conducted their own assessments that were then scrutinised by the MDT. The service had recently renegotiated their contract with the mental health trust, and they were now able to transfer patients to other Cygnet services if clinically appropriate without authority from the trust in some cases. This now prevents patients waiting for a bed within the trust.

There was a referrals policy for staff to follow which included criteria for rejecting a referral. We saw evidence that referrals were reviewed thoroughly before patients were accepted into the service. However, despite this some staff still told us that some of the patients were unable to participate in activities due to their level of acuity.

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. The service had strong links with the local mental health trust and other health facilitators in the area. Patients had access to community GP’s and attended outpatient appointments for health conditions where needed. Patients attended opticians and dentists. The service attempted to work collaboratively with external stakeholders to seek timely discharge and sought to strengthen this process by requesting funding for a dedicated social work post.

We work with patients 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 patient’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 so when appropriate. Safeguarding training compliance was at 99%. Staff were able to describe a safeguarding incident and how they responded to this. The local authority had introduced an online portal for staff to make referrals. There was a safeguarding report listing incidents and outcomes.

There were 28 safeguarding referrals made in the last 12 months. These included patients assaulting other patients (12), and inappropriate contact (4). Staff had taken appropriate action in each case. There was a safeguarding audit in place for staff to check that processes had been followed.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. There was a safeguarding charter to remind staff and patients of expectations and actions.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff had access to a local safeguarding procedure which contained detailed information regarding safeguarding telephone numbers and online forms.

Staff followed safe procedures for children visiting the service. The service had not had a child visitor for over 12 months. There were processes in place to ensure visits from children went ahead safely. Children were to be supervised at all times by staff and were not allowed onto the inpatient areas. There was a suitable visitors room and toilet in the reception area.

Staff were trained in restraint. There were 4 restraint training modules for staff to complete during their induction period, and training compliance was 95%. Staff completed annual refresher training with training compliance at 88%. Staff described using restraint as a last resort and explained how they used de-escalation skills to avoid using restraint. There was a Restraint and Violence Reduction Policy that was also available in easy read format. There was also a Restrictive Physical Interventions Procedure.

Restrictive practices were kept to a minimum. Some doors were locked for safety reasons. Doors that remained open for patients to freely use were the upstairs social lounge, downstairs ADL kitchen, quiet rooms, communal lounge and the courtyard door.

The service had a list of blanket restrictions which included restrictions related to energy drinks and cannabidiol products, supervised gym access, use of observations, storage of e-cigarette liquid, and the banning of disposable vapes. Blanket restrictions were reviewed and updated every 3 months. There was a list of prohibited items including alcohol and weapons.

We work with patients to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We reviewed 4 risk assessments and risk management plans. These were comprehensive and had been updated following incidents. There was an individual risk assessment and management policy for staff to follow. Two risk assessments did not record how risk would be managed should the patient lapse into a mental health crisis. However, staff were able to verbally explain they understood the patient well and how to manage them should they relapse.

Staff used short-term assessment of risk and treatability and the historical and clinical risk 20 risk assessment tools.

There had been 15 incidents of restraint in the last 12 months. None of these were in the prone position. There were 3 incidents that required rapid tranquilisation and there were no episodes of seclusion or long-term segregation in the last 12 months.

Staff involved patients in care planning and risk assessments. This was evident in care plans and participation in multidisciplinary team reviews. Patients said they had a copy of their care plan and that they understood the content.

Staff communicated effectively with patients so that they understood their care and treatment. They found effective ways to communicate with patients with communication difficulties. Care and treatment options were discussed with patients individually and during weekly ward rounds.

Staff enabled patients to give feedback on the service they received. Patients had access to suggestion boxes and community meetings. There was also a patient’s council every 6 weeks. Actions from these meetings were shared with the registered manager who could take action and feedback to the meetings any updates on changes. Recent actions were around food and activities. There had been a recent patient survey.

Staff enabled patients to make advance decisions (to refuse treatment, sometimes called a living will) when appropriate.

Staff ensured that patients could access advocacy. There was an advocate linked to the service who visited regularly and was well known to the patients. There was an advocacy poster. Staff knew to offer advocacy and how to refer patients to the service.

Description: 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 completed regular risk assessments of the care environment. Risks assessment included related to the environment, buildings, fire, health and safety, ligature risk points and blind spots.

The ward layout allowed staff to observe all parts of ward. Where vision was obstructed, this was mitigated by mirrors and observations.

There were very few potential ligature anchor points but one identified was on the ensuite bathroom doors. For patients at identified risk this could be mitigated by the use of collapsible doors.

All staff had individual alarms and patients had easy access to nurse call systems which were located in bedrooms and communal areas. We observed staff responding promptly to the call system throughout the inspection. Managers had begun plans to install a new system that was silent. This was due to feedback from patients who commented that the alarms were loud and distracting.

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

There was a capital expenditure list for 2025 for environmental improvements. The silent nurse call alarms and window replacements were of high priority. We noted the windows being replaced during the inspection. Manager had already begun to collate the capital expenditure request list for 2026 which included a salad bar for the dining room, air conditioning and outdoor gym equipment.

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

The service had a full registered nursing and health care assistant team. The service had over-recruited due to patient numbers being higher during 2024. The current nursing team consisted of 2 senior nurses, 12 registered nurses and 26 support workers.

This meant that 3 registered nurses were working when only 2 were required at times. Extra annual leave entitlement was also being offered to staff. This meant that regular staff could be used to cover enhanced observations rather than agency staff. Agency usage was minimal.

Staff turnover was 23% over the last 12 months. The currently monthly turnover rate during the onsite inspection was 5%.

Sickness was low. There were currently 4 staff on sick leave.

There was a staffing matrix in place to calculate staffing numbers based on patient numbers and acuity.

Staffing levels were appropriate to meet the needs of the patients. Staff told us they had time to complete their tasks. Patients stated there were staff available to them when required.

The service used agency staff to meet baseline numbers if required. Managers told us they used agency staff who were familiar with the patient group wherever possible. In the last 12 months there had been 4 shifts covered by agency nurses and 304 shifts covered by agency support workers. There were 318 shifts not filled for short notice absences.

The registered manager or head of care could increase staffing to meet the needs of patients.

There were processes in place to ensure all staff had completed corporate and local inductions. There were two induction booklets for staff to work through.

There was always a minimum of 2 registered nurses on shift during the day and night.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. In the last 6 months there was only 1 activity (breakfast club) that was cancelled due to short notice staff sickness. There were 5 incidents of staff not having time to fulfil nursing tasks due to staff sickness and high patient acuity.

There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. There was an on- call rota which meant a consultant could be contacted outside of working hours. There was one responsible clinician and one speciality doctor.

Staff had received and were up to date with appropriate mandatory training. Overall training compliance was 91%. There were no modules that fell below the provider’s target. The training was appropriate for the patient group using the service.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any 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, well furnished, and well-maintained.

Cleaning records were up to date, confirming that the ward areas were cleaned regularly. Patients commented that the facilities were always cleaned to a good standard. We observed ongoing cleaning during the inspection.

Staff adhered to infection control principles, including handwashing.

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

Staff followed good practice in medicines management which was in line with national guidance. Medicines were transported to the hospital via a courier service and stored in a locked cupboard in the treatment room. Medicines were dispensed by a registered nurse, and we noted the medicines administration and recording to be well managed. There was a medicines disposal policy for staff to follow and a medicines disposal and return book for staff to record in.

Staff reviewed the effects of medicines on patients’ physical health regularly and in line with National Institute for Health and Care Excellence, ( NICE) guidance, especially when the patient was prescribed a high dose of antipsychotic medicine. There was a medicines management policy for staff to follow.

There was a physical health lead employed to oversee the physical healthcare of patients. There was regular monitoring of side effects from medicines. Staff had access to various tools for side effect monitoring that we saw in use and action taken from the results. There was a physical health folder for each patient. We noted there were ongoing checks such as blood tests, National Early Warning Score 2 and electrocardiograms. These results were regularly reviewed by the GP or responsible clinician.

Patients had regular MDT meetings. It was evident from the meeting minutes that side effects such as over-sedation were discussed and rectified.

A pharmacist visited weekly and undertook an audit of medicine processes. Any errors were fed into governance meetings.