Cygnet Raglan House

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 people were protected from abuse and avoidable harm.  

At our last assessment we rated this key question good. At this assessment the rating has remained good.

Good: This meant people were safe and protected from avoidable harm.

Good: The unit was safe, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This service scored 75 (out of 100) for this area.

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 evidence showed a good standard. 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.

Staff knew what incidents to report and how to report them. They followed the policy on reporting incidents. We saw evidence in four incident reports that staff had acted in line with provider policy. All records were completed fully and accurately.

Staff also showed an understanding of the Duty of Candour. They were open and transparent and gave patients and families a full explanation if things went wrong. Two carers told us they were always kept updated with progress or any concerns.

Staff received feedback from investigation of incidents, both internal and external to the service. We saw evidence that incidents were discussed in staff meetings and in multidisciplinary meetings and during shift handovers.

Staff gave us examples of recent learning and changes made to the service following investigation and shared lessons learnt. Staff met to discuss feedback through regular supervision sessions and were offered debriefs following incidents. The manager told us that they have 2 staff support meetings per week. The leadership team promoted an open-door policy which aimed to encourage a culture of accountability and openness. Staff felt supported that they were able to speak up. Survey data reflected strong engagement with reporting processes: 96% of staff said they were encouraged to report errors or near misses, and 94% knew how to report malpractice, fraud, or wrongdoing. Additionally, 96% were aware of the freedom to Speak up Guardian.

We saw evidence that changes were made because of feedback. Staff used “You said, We Did” boards to demonstrate how actions were taken in response to feedback. We saw examples where practice had been improved following feedback from external visits and audits.

The evidence showed a good standard. The service worked with people 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 people 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 safely be met. We saw evidence that the provider’s admissions policy covered every step, from pre-admission to the time of admission, and through to the completion of the process.

We found that the provider was proactive and completed all the necessary paperwork, before patients arrived.

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. Staff told us that patients had access to social workers, occupational therapists, dieticians, and specialist doctors. We found that social workers arranged visits for patients to view their future placements, prior to discharge. Staff also said this help was provided to ease and reduce anxiety about the new place and ensure continuity of care. We were also told that eligible patients were supported with Section 117 aftercare packages, after their discharge assessment to facilitate continuity of care in the community.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

Safeguarding was rooted into daily practice, supported by clear escalation routes and a culture that encouraged accountability and awareness. We saw evidence that staff were trained in safeguarding, they knew how to make a safeguarding alert, and did that when appropriate. They had 2 safeguard leads on site to whom staff could raise their concerns for staff and patients. We saw evidence of a safeguarding log for the last 6 months which staff had filled out. We noticed that all the reports were Level 1, which meant they were sent to the local authority for review before escalation. Leaders told us that none of these concerns met the threshold for a Section 42 investigation by the local authority.

94.6% of staff had completed training in Safeguarding Individuals at Risk (Intermediate) virtual classroom session. 98.1% of staff had completed Safeguarding Individuals at Risk Introduction training.

Staff gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or experiencing, abuse or neglect. This included working in partnership with other agencies like the local authority. Staff followed safe procedures for children visiting the service.

Restraint was always used as last resort. All staff had received training around de-escalation and how to manage restraint safely.

Mental Capacity Act

The provider had a policy on the Mental Capacity Act (MCA), including deprivation of liberty safeguards (DoLS). Staff were aware of the policy and had access to it. Staff had a good understanding of the Mental Capacity Act, particularly the five statutory principles. Staff knew where to get advice regarding the MCA, including DoLS. Staff could seek advice and guidance from the Mental Health Act administrator.

There was no deprivation of liberty safeguards applications made in the last 12 months to protect people without capacity to make decisions about their own care.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis regarding significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture, and history.

The evidence showed a good standard. The service worked with people 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 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 looked at eight risk assessment records whilst we were on site. Risk assessments were comprehensive and updated regularly, including after incidents. The provider used the Short-Term Assessment of Risk and Treatability (START) risk assessment tool on admission. This supported them to create risk management plans to oversee current and ongoing risks.

The manager told us that they used a daily risk assessment for every patient. They used a RAG (Red, Amber, Green) rating tool to identify levels of risk. A red rating indicated high risk, amber as moderate while, green meant the patient was stable. The manager told us that this was an effective clinical tool for managing patient safety. We noticed that they had a total of 48 incidents in the last 6 months up to January 2026. There had been 8 incidents of rapid tranquilisation in the same period. There had been no incidents involving prone restraint.

There was no seclusion room on site and there had been no episodes of long-term segregation. Staff involved patients in care planning and risk assessment shown by evidence in care plans, participation in Multi-Disciplinary Team (MDT) reviews, patient meetings access to a copy of their care plans.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. This was evidenced in staff and patient interactions with named nurses and patient meetings on the ward.

They closely monitored the use of lighters due to fire risk, and provider had a list of contraband which was not allowed on the ward.

Staff enabled patients to give feedback on the service they received (for example, via surveys or community meetings).

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

Staff ensured that patients could access advocacy.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened and took action to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We saw that the ward layout made it difficult for staff to see every area from the nurse station. Staff told us they managed this by using convex mirrors and CCTV cameras in the hallways, to see around corners and by checking on patients regularly. We noticed a privacy film which was covering the nurse station windows. We raised this as a concern during our inspection, because it limited staff members’ view of patients and this was removed immediately by management,

We identified several ligature points in the central garden and on the roof near the main door. These environmental risks were documented and mitigated within the provider's risk assessment. Staff told us that the garden was only accessible via a restricted key system managed by the clinical team. We were also told that staff maintained constant observation when patients utilised the outdoor space for smoking to ensure safety.

Staff did not ensure wet floor warning signs were stored safely. Yellow wet floor signs were left under a cupboard in the day area, accessible to patients, instead of being kept in a locked housekeeping room.

We also identified an unrepaired heater with a hole in the top, demonstrating that the provider was not effectively identifying or resolving environmental hazards.

However, when we told staff of these issues, they were responsive and took immediate action to rectify some of them and make improvements.

The unit was an all-female accommodation and staff had easy access to alarms and patients had easy access to nurse call systems. We also checked the clinic room, and everything was in order and fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

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 people’s individual needs.

There was enough staff to provide safe care and treatment. The service was fully staffed with 8 nurses and 22 healthcare assistants. There were two healthcare assistant vacancies being advertised, because some of the existing staff had moved to part-time hours. Staffing was supported by a wider multidisciplinary team.

Managers reviewed the number of nurses and healthcare assistants required using a staffing matrix and adjusted staffing levels every day to match patients' needs.

The number of nurses and healthcare assistants met planned staffing levels on shifts we reviewed. An average of 332.54 hours of bank and agency staff was used each month. Bank and agency staff received an induction.

A qualified nurse was present in communal areas during our visit. Patients had access to one-to-one time with their named nurse, although patients told us staff were often busy.

Staff told us that escorted leave and activities were rarely cancelled due to staffing shortages and would usually be rearranged if needed.

Staff were trained to carry out observations and physical interventions safely.

Staff told us that there was adequate medical cover and that a doctor attended the ward quickly in an emergency.

Staff turnover between February 2025 and January 2026 was 26.1%. Mandatory training was appropriate for patient group and compliance was high, and none below 75%.

The manager told us staff were completed the Oliver McGowan training and had also completed additional specialist training in in restorative justice, documentation, and physical health checks. The Oliver McGowan training provides staff with essential knowledge and skills, to support autistic people and people with a learning disability, improving understanding, communication and quality of care.

To recognise and escalate concerns about patients’ physical health staff had further training in doing physical health audits.

The evidence showed a good standard. Staff demonstrated a good knowledge of Infection Prevention and Control (IPC) and had completed all mandatory training in this area. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Staff completed regular IPC audits, with clear improvement plans and actions in place to address any identified risks.

We saw staff cleaning communal areas; however, we noticed there was smell of urine which came from one of the patient corridors. We raised this with the manager who told us that this had been noted and was being addressed and they were putting in new flooring. We observed hand hygiene signage displayed in communal areas, including toilets and kitchens, with hand sanitiser stations available for staff and patient use throughout the ward. The manager informed us of a clinical hygiene initiative called “Hands on Deck.” This involves all personnel, including management and patients, participating in a weekly environmental cleaning of the entire facility to maintain IPC standards.

Staff did regular risk assessments of the care environment. However, there was mixed feedback among the patients we interviewed around the cleanliness of the environment. Five patients told us that the area was not clean.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involve people in planning, including when changes happen.

Staff followed good practice in medicines management, including the transport, storage, dispensing, administration, medicines reconciliation, recording, disposal and use of covert medication.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patients were prescribed a high dose of antipsychotic medication. The provider employed a physical health nurse who monitored side effects and completed regular physical health checks with the patient group.

Medication was not used to control behaviours. There was no evidence that as required medication was being used outside the NICE guidelines. This is medication which can be requested any time by patients.

We saw that Lithium and Clozapine health checks were checked in line with protocol, reducing risk of Clozapine and Lithium toxicity to patients. All the T2/T3 records matched the prescription chart PRN, and all allergies were noted on the treatment charts.

One patient was on Stage 4 of self-administration of her medication, and we reviewed a comprehensive risk assessment and monitoring plan to support her with this.

We checked medical records; staff told us that people had given consent to treatment in the records reviewed. Staff kept the clinic room locked and secure when it was not in use. Staff used a colour-coded system for medication keys to support easy identification and quick access to the medicines cupboard.

Pharmacy contact details were clearly displayed in the clinic room. Staff checked fridge temperatures regularly. The pharmacist and nurse in charge completed regular audits. However, staff did not record an opening date on one insulin injection.

The manager told also us that paper charts were going to be replaced by a digital system soon.