Cygnet Manor

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

Safe - This means we looked for evidence that people were protected from abuse and avoidable harm. At this assessment we rated this key question Good. This meant people were safe and protected from avoidable harm. The service provided care and treatment in a way which made people feel safe, supported, involved and listened to. People felt they were respected and treated with kindness, compassion and dignity. They were treated as individuals and encouraged to be involved in their care and treatment planning. Staffing, processes and equipment were in place to maintain the safety of people and to meet their needs. Staff engaged with people in a kind, compassionate and caring way. The environment and equipment were clean, tidy and well maintained. Information regarding people’s care, treatment and external resources available were displayed throughout the service.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service ensured that learning from incidents was identified, acted on and shared effectively with staff to improve care and the experience of people using the service. When incidents, for example, episodes of agitation or aggression occurred, staff responded promptly, reported them appropriately and updated care and risk plans accurately. Following incidents, people and staff had debrief meetings. The psychology team also facilitated individual or group reflective practice sessions and were also available on an ad hoc basis if required to provide support. Staff demonstrated a strong understanding of the duty of candour. If things went wrong, people and their families were offered clear explanations and given apologies when required. The service had a Freedom To Speak Up (FTSU) ambassador who was also available to offer support. Managers and nursing seniors provided staff with regular feedback following investigations. One staff member told us “Communication after incidents is very effective and happens quickly, any lessons learnt are always shared through numerous meetings, debriefs and electronically for staff who aren’t on duty, or can’t attend.”

Teams discussed learning during daily morning meetings, handovers, regular team meetings and monthly area operational meetings to identify any areas for improvement. Staff used feedback, both positive and negative as learning opportunities to improve practice and service delivery.

People felt supported and reassured during referral, admission, transfer and discharge processes, which helped reduce anxiety during times of change and transition. They were given information about what to expect from their care and treatment in a variety of formats to suit their individual communication needs.

Staff and leaders explained that the service had effective systems in place that ensured safe admissions, transfers of care and discharge planning. They reviewed referral documentation carefully, including clinical history, risk assessments and care plans. Staff understood the importance of robust admission processes, as they ensured people were appropriate for their service and their needs could be safely and effectively met.

Leaders promoted the importance of early planning and communication across teams. Discharge planning involved coordination between services, for example, the Community Forensic Mental Health Team (CFMHT) to ensure safe, supported and effective transitions and ongoing care and support. The service made every effort to avoid unnecessary delays and remained focused on achieving discharges in a timely manner where possible.

The service followed a structured process where staff completed a comprehensive admission process when people were admitted, the process involved the person as much as possible and was reviewed regularly, any follow up information was used to support safe and timely care planning, effective assessment of risk and ongoing treatment.

People using the service felt safe and empowered to express any concerns knowing staff would maintain their safety and support them appropriately, if they felt unsafe or had any concerns about others. The service promoted and supported people to share their views or concerns via staff members across all teams and the people’s council. They were included and their voices heard.

Staff demonstrated a thorough understanding of safeguarding, confidently identifying and responding to concerns to protect people from harm. They took appropriate and prompt action to protect people from abuse, neglect, or discrimination and worked collaboratively with external agencies when required, for example, the local authority safeguarding team. Staff discussed safeguarding incidents in daily morning meetings, safeguarding meetings and multidisciplinary team meetings. Staff were also supported by safeguarding leads based at the service. Staff demonstrated a clear understanding of Deprivation of Liberty Safeguards (DoLS). Staff explained people’s rights to them, including their rights under the Mental Health Act 1983, Mental Capacity Act 2005, and the Equality Act 2010.

Service leaders ensured staff had the knowledge, support and confidence to act promptly and effectively to safeguard the people they cared for and supported. One staff member told us “You should always consider the right way to support people and in a way that they understand. We work closely with the local authority to protect the people we care for.”

The service had effective safeguarding systems, policies and procedures in place that upheld peoples' human rights and promoted a culture of safety. We reviewed the safeguarding incidents log for the period from 14 March 2025 to 10 October 2025; there had been 7 safeguarding incidents at the service. We found that concerns had been thoroughly investigated, escalated to the appropriate agencies in a timely manner and outcomes and learning shared.

Staff knew and understood people’s individual risks, which ensured they intervened and responded quickly to support people to minimise any distress and to reduce risk. We reviewed 11 risk assessments and found they were person-centred with obvious involvement from people and their families and were reviewed in line with organisational policy. One person told us “I feel involved; my family are involved. I’ve got a great Nurse who is there for me and helps me to be involved.” Staff took a proportionate and balanced approach to risk; people’s observations were completed in line with their care plan and based on the person’s individual needs. People’s records we reviewed showed observations were completed as prescribed.

Staff ensured people’s physical and emotional needs were managed effectively, which protected their human rights and maintained their dignity. Staff had a calm and measured approach when supporting people in periods of distress, which promoted safety and mitigated further potential risks and escalation.

Staff involved people and supported their families to formulate risk plans. The care records we reviewed evidenced that people and their families fully engaged in the multidisciplinary team review process. Families who could not attend multidisciplinary team meetings in person were supported to attend virtually, for example via Microsoft Teams. Staff from across all teams within the service supported people to understand their risks and how to manage them positively, for example, the Psychology team. Numerous communication methods were used for people with identified language barriers or other complex needs, for example, easy read print and picture-based emoji formatted information. Restraint was used as a last resort. It was proportionate and documented accurately in line with best practice. Care and treatment plans reflected any restrictions and were based on people’s individual risks to avoid blanket restrictions.

The service promoted a reducing restrictive practice strategy which focused on positive behaviour support. The strategy worked to embed positive culture and how risk was understood and managed with a focus on proactive risk sharing, rather than reactive risk management.

Staff considered the importance of equality and human rights legislation when imposing any restrictions. If rapid tranquilisation was used, it was proportionate, documented appropriately and recorded in line with best practice.

People using the service and staff felt the environment was safe. The service maintained clean and well-equipped environments that promoted the physical and mental wellbeing of people and supported the safe delivery of care. Equipment was audited, well-maintained, stored safely and used appropriately.

Staff completed security and safety audits of the environment prior to the start of each shift. This ensured there were no unidentified hazards or risks and any findings were fed back at the shift handover meeting. The environmental audits were delegated as a duty to a specific staff member ensuring consistency and accountability. One staff member told us “The environment is checked thoroughly, both inside the building and outside. If concerns are identified, they’re shared amongst the teams, reported and addressed. The safety of people using or visiting our service is a priority.”

Staff completed regular risk assessments of the environment throughout the day and night. Environmental audit consistency ensured any potential hazards were identified and any required actions taken to mitigate risks. Ligature risks were assessed, and the appropriate assessments were in place to manage and reduce any potential risk of harm. The service had CCTV and convex mirrors throughout. This supported and safeguarded both people using the service and staff against the potential risk of blind spots.

Staff carried personal alarms and pager location devices to maintain the safety of people and the environment. People had access to nurse call systems in their bedrooms, bathrooms and throughout the service. This ensured they could request assistance or support if required.

The clinic room was fully equipped with accessible resuscitation equipment and emergency medicines; staff checked and audited these regularly to ensure preparedness for any potential emergency situations.

There was a well-maintained outdoor space which was well used by people. The doors to the outdoor space remained unlocked and allowed people to access the area as they wished. The appropriate security measures were in place throughout the outdoor space, which ensured that people were safe when using it, for example, staff members completing zonal observations with a view of the outdoor space.

Equipment and technology were well-maintained and ensured staff delivered safe and effective care. The service had effective processes which monitored the safety and upkeep of the environment, premises and equipment.

Staff knew what was required to provide and maintain environments that kept people safe from physical and psychological harm including attention to sexual safety and sensory needs.

People felt supported, staff were always present and available. One relative told us “I visit my son regularly and there’s always staff around. There really engaging and always welcoming. They do a great job.” People using the service were supported to have regular one-to-one time with their named nurse which was evidenced in the care records we reviewed. This maintained therapeutic relationships, built trust and promoted continuity of care.

Staff were present in communal areas and throughout the environment. The appropriate medical cover was in place throughout the day and night, with doctors and an on-call pharmacists being readily available to respond quickly in cases of emergency.

Leaders regularly reviewed staffing levels and aligned them to the needs of the service and the people it supported. We saw evidence of how staffing levels were increased when people’s needs changed. Staffing rotas confirmed the required numbers, and the appropriate skill mix was met on all shifts.

The service utilised organisational bank staff to complement the existing workforce when required. Bank staff completed an organisational induction, mandatory training and were regular to the service; familiar with the people using the service and the environment. All staff completed observational competencies, this ensured the correct processes were adhered to which enhanced the safety of people being supported by the service.

We reviewed vacancies, staff turnover and sickness absence levels for the 12 months prior to our inspection and found no concerns. The service was fully staffed and also promoted a successful student nurse programme in collaboration with local universities.

Recruitment processes were robust and ensured that all staff, including bank staff, had current Disclosure and Barring Service (DBS) documentation in place, were suitably qualified, experienced and competent. Disciplinary, conduct and capability processes were adhered to, reviewed regularly, proportionate and free from bias related to protected characteristics.

Staff felt supported by service leaders and had monthly clinical and managerial supervision. The service also promoted and facilitated group supervision across all teams. Staff completed annual appraisals and personal development reviews. We reviewed supervision and appraisal documentation and found it met and often exceeded the organisations compliance target and at the time of our visit had a 99% compliance rate.

Staff had completed and were up to date with role specific mandatory training, with a current compliance rate of 90.1%. The training undertaken was appropriate for the people being supported and included service relevant learning disability and autism training. Staff completed nationally recognised Tier 1 learning disability and autism online learning and Tier 2 learning disability and autism face to face training, Tier 2 training was delivered by an accredited trainer and co-delivered by people with a lived experience of both learning disability and autism. Staff demonstrated confidence and competence in care delivery. Opportunities for learning and development were available to staff at all levels. Any poor performance was managed promptly and effectively.

People using the service were confident in the infection prevention and control processes in place and felt assured that staff were taking the necessary precautions to protect them from the risk of infection and potential harm. One person told us “The place is always clean; we have cleaners who are lovely, they’re busy but always have time for a chat. Staff do cleaning too and keep it nice.”

Staff adhered to infection prevention and control procedures, followed handwashing guidance, used personal protective equipment appropriately and cleaned equipment in line with guidance and best practice.

We observed staff adhering to infection, prevention and control principles and guidance between interventions with people, for example, hand hygiene, changing personal protective equipment and correctly disposing of waste items.

All ward areas were clean and well-maintained. Cleaning records were up to date and showed that areas were cleaned and audited regularly. This ensured the environment was clean and safe. Staff demonstrated a good understanding of their roles in maintaining the cleanliness of the environment. Hand sanitising stations were situated throughout the service; this ensured people were protected and the risk of infection and potential harm mitigated.

The service had clear processes in place for assessing and managing infection risks. The providers’ procedures aligned with current national guidance. Cleaning and infection, prevention and control audits were completed regularly, with all concerns addressed without delay. Information about infection risks was shared appropriately with staff, people using the service, visitors and external partners. There were clearly defined roles and responsibilities for infection prevention and control, and staff received ongoing training in line with organisational policy and best practice guidance.

Staff supported people to be involved in decisions about their medicines. For those who had capacity, staff ensured they understood what their medicines were for and involved them in any discussions regarding changes to their care and treatment. Where people lacked capacity and were not able to fully understand or participate, staff adhered to processes in line with the Mental Capacity Act 2005 and the Mental Health Act 1983. All care and treatment plans we reviewed reflected each person's level of understanding and evidenced the level of their involvement in making decisions about their medicines and treatment.

Staff followed safe and effective practices in all areas of medicines management, including storage, dispensing, administration, reconciliation, recording and disposal. The service adhered to national guidance and best practice and evidenced how they involved people and their families in discussions and decisions about their care and treatment where possible. Staff regularly reviewed the effects of medicines on people’s physical health, particularly in those prescribed high doses of antipsychotic medication, in line with the National Institute for Health and Care Excellence (NICE) guidance.

We observed staff administering medicines safely, explaining their use clearly and supporting people with kindness, compassion, dignity and respect. The service stored medicines securely, including controlled drugs. All medicines were managed under the appropriate legal frameworks. Fridge and room temperatures were checked daily, and all medicines were in date. Expired or unused medicines were disposed of safely. Staff ensured that medicines were used appropriately. Where PRN (as-required) medicines were used, we found they had been used appropriately, in line with guidance and not purely to control behaviour. The service administered medicines in line with Stopping Over-medication of People with a learning disability, autism, or both (STOMP). We reviewed all prescribing and administration records and found no concerns.

The service had robust systems in place for the management of medicines, for example, daily and weekly audits by nursing staff and fortnightly medicines management audits by the Pharmacy team. The management of medicines adhered to current best practice and aligned with national guidance. When staff identified medicines errors, they were addressed and the appropriate actions taken to mitigate the risk of harm or reoccurrence.

Continuity of care during transitions was maintained effectively through medicines reconciliation and clear concise documentation. Controlled drugs were managed safely and audited regularly, with any outcomes from audits acted on. This promoted a learning culture through incident reporting and review. Staff had received training and competency assessments to support the safe, effective and appropriate use of medicines.