Cygnet Hospital Clifton

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 requires improvement. At this assessment the rating has changed to good. The service had made improvements and is no longer in breach of regulations.

This meant people were safe and protected from avoidable harm. 

Staff now understood and managed risks effectively, safeguarding processes were now well embedded, medicines were now managed safely, and incidents were now reviewed appropriately to support learning and improvement.

However, staff did not always safeguard patients from bullying, discriminatory language and homophobic comments from other patients, Leaders recognised these concerns and were taking action to address them.

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 of care. 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. 

The service promoted a positive culture of safety, learning and continuous improvement. Staff were encouraged and supported by reporting incidents, near misses, safeguarding concerns and medication errors. They told us they felt able to raise concerns openly and were confident that issues would be reviewed appropriately and used as opportunities for learning and improvement. 

Leaders routinely reviewed incidents, complaints, safeguarding concerns and audit findings to identify themes, trends and opportunities to strengthen practice. Learning from these reviews had resulted in improvements to medicines management, physical healthcare monitoring and observation processes. 

The Hospital Manager promoted a reflective approach to incident management and ensured lessons learned were shared across the workforce. Key learning points were incorporated into the monthly supervision, which staff were required to read and acknowledge. Staff described an open and honest culture where concerns, mistakes, and learning could be discussed constructively. This supported a culture where patient safety, recovery and continuous improvement were central to service delivery. 

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.

Patients benefited from coordinated systems of care that supported safety throughout admission, rehabilitation, and discharge. Staff worked effectively with multidisciplinary colleagues, commissioners, local authorities, probation services, multi agency public protection arrangements (MAPPA) and community services to ensure continuity of care and safe transitions between services. 

The rehabilitation pathway provided a clear structure for progression through assessment, treatment, and recovery. Discharge planning commenced early and involved patients, carers and external professionals to support successful community reintegration and minimise delays. 

Information was shared effectively through structured handovers, multi-disciplinary team (MDT) meetings, governance reviews, and care planning processes. Staff demonstrated a good understanding of current risks and responded promptly to changes in patients' presentation or support needs. 

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 in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Patients told us they felt safe and knew how to raise concerns if needed. Staff encouraged people to discuss worries, provide feedback and seek support through ward rounds, one-to-one sessions, community meetings and advocacy services. Where safeguarding concerns were identified, these were recorded within patients’ care plans to ensure risks, safeguarding needs and agreed actions were clearly documented, communicated and reviewed by the multidisciplinary team. Staff demonstrated a good understanding of safeguarding responsibilities and were confident in identifying, reporting, and escalating concerns appropriately. Safeguarding matters were routinely discussed through handovers, multidisciplinary team meetings, and governance processes to ensure any risks were reviewed and managed promptly. 

The hospital's social worker-maintained oversight of all safeguarding activities and was responsible for submitting safeguarding referrals to the relevant authorities. They worked closely with staff and external agencies to ensure concerns were investigated appropriately and that necessary actions were taken to protect patients and reduce future risk.  

The service had robust safeguarding systems, policies and procedures in place that promoted people's safety, wellbeing and human rights. A review of safeguarding activity during the 12 months prior to the assessment demonstrated that concerns had been appropriately reported, thoroughly investigated and escalated to external agencies where required. Learning from safeguarding incidents was shared across the service and used to strengthen practice and improve patient safety. 

Mental Capacity Act 

Mental Capacity Act (MCA) training compliance was 95%, and staff demonstrated a good understanding of the MCA 2005 and its five statutory principles. Staff understood the importance of supporting patients to make their own decisions and worked in accordance with the principles of empowerment, least restriction and person-centred care.

Care and treatment were delivered in a way that promoted patients' involvement, choice and autonomy. Staff took practical steps to help patients understand information, consider options and participate meaningfully in decisions affecting their care, treatment and rehabilitation. Patients were encouraged to express their views, preferences and aspirations, and staff worked collaboratively with them to develop care plans and recovery goals that reflected what was important to them as individuals.

Where patients required additional support to make decisions, staff adapted their communication approaches and provided information in ways that met individual needs. This helped maximise patients' ability to participate in decisions and ensured care remained personalised and responsive to changing circumstances.

For patients whose capacity to make specific decisions was in question, staff completed and documented capacity assessments appropriately. Capacity assessments were decision-specific and undertaken in relation to significant decisions affecting care, treatment and welfare. Where patients lacked capacity, staff followed best-interest decision-making processes and involved relevant professionals, advocates and family members where appropriate.

We saw evidence that staff balanced the need to manage risk with patients' rights to make decisions about their own lives. This supported a rehabilitation-focused approach that promoted independence, choice and recovery while ensuring legal safeguards remained in place.

Leaders maintained oversight of Mental Capacity Act practice through care record reviews, supervision and governance processes. Overall, staff applied the principles of the Mental Capacity Act appropriately and supported patients to remain actively involved in decisions affecting their care, treatment and future goals.

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 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.

Staff worked collaboratively with patients to identify, understand and manage risks in a way that promoted both safety and recovery. Risk assessments were personalised, recovery focused and reflected patients' strengths, needs, preferences and aspirations. Patients were actively involved in discussions about their risks and support needs and, where appropriate, family members and carers contributed to care planning and risk management arrangements. Staff regularly reviewed and updated risk assessments and management plans to ensure they reflected patients' current presentation, progress and any emerging risks.

The service adopted a positive risk-taking approach that balanced safety with rehabilitation and increasing independence. Through individually assessed and managed plans, patients were supported to access community leave, rehabilitation activities, technology, personal possessions and opportunities to develop daily living skills. On Ancaria Ward, staff utilised Daily Safety Assessments (DSA) and Daily Risk Notifications (DRN) to support dynamic risk management, helping staff identify and respond promptly to changes in patients' presentation and levels of risk.

The service had effective systems in place to manage restricted and prohibited items whilst promoting individualised decision-making and avoiding unnecessary blanket restrictions. Decisions relating to restrictions were based on individual risk assessment and were reviewed regularly to ensure they remained proportionate, lawful and supportive of patients' recovery.

Staff reviewed observation levels regularly and adjusted these in line with individual needs, presentation and identified risks. Staff demonstrated a good understanding of patients' triggers, early warning signs and preferred support strategies, enabling proactive interventions and reducing the likelihood of escalation. Risk and support arrangements were regularly reviewed through multidisciplinary team (MDT) meetings to ensure they remained responsive, proportionate and recovery focused.

Restrictive interventions were used infrequently and only as a last resort when other de-escalation strategies had been unsuccessful. During the 12 months prior to the assessment, there had been 1 restraint on Acorn Ward and 23 restraints on Ancaria Ward, with 13 incidents relating to a single patient during a period of significant deterioration in their mental health. Rapid tranquillisation had been used on 2 occasions during the same period, demonstrating a measured and proportionate approach to managing acute incidents. Seclusion was rarely required and had been used on 11 occasions since May 2025, with only 1 episode occurring since January 2026.

Leaders maintained oversight of restrictive interventions through regular governance reviews, audit activity and clinical oversight processes. Restrictive practices were scrutinised to ensure they remained lawful, proportionate and were used for the shortest time necessary. Care plans and risk assessments reflected patients' individual needs and promoted the least restrictive approach possible. As a result, patients were supported to manage risks safely whilst continuing to progress through the rehabilitation pathway, increase their independence and work towards their recovery goals.

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

Patients and staff generally described the environment as safe, secure, and supportive of recovery.

Staff completed routine environmental and safety checks and demonstrated a good understanding of environmental risks, security procedures, and risk management.

The clinic room was fully equipped and contained appropriately maintained resuscitation equipment and emergency medicines. Regular checks and audits were completed to ensure equipment remained ready for use in the event of an emergency. 

Staff carried personal alarms and patients had access to call systems throughout the hospital, including within bedrooms and bathroom areas, enabling them to seek support promptly when required. 

Leaders maintained oversight of environmental safety through Closed Circuit Television (CCTV) audits, environmental inspections, health and safety reviews, and cleaning audits. During the assessment, we identified concerns relating to the condition of some ensuite facilities and aspects of the seclusion environment. Leaders had already identified these issues through established audit processes and implemented action plans to address them, with some improvements completed during the assessment.

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 were sufficient numbers of suitably qualified, skilled and experienced staff to ensure patients received safe, effective and consistent care. At the time of the assessment, the service had no staff vacancies and sickness absence remained low at 1.59%. Leaders maintained effective oversight of staffing levels and workforce performance through regular review processes and demonstrated that staffing arrangements were responsive to patient acuity, risk and changing clinical needs. Staffing rotas showed an appropriate skill mix across both wards, providing assurance that patients received care from staff with the knowledge and experience required to meet their needs.

Where temporary staffing support was required, the service utilised experienced bank staff who were familiar with the environment, patient group and rehabilitation model. The service had not used agency staff since 2023. This promoted continuity of care, supported the development of therapeutic relationships and ensured consistency in patient care and treatment.

Patients were supported to have regular one-to-one sessions with their named nurse and told us staff were visible, approachable and available when support was needed. We observed staff maintaining a consistent presence within ward, communal and therapeutic areas throughout the assessment. Appropriate medical cover was available at all times, with doctors able to respond promptly to clinical concerns, emergencies and changes in patients' presentation.

Staff received the training, supervision and professional support required to deliver safe, effective and recovery-focused care. Mandatory training compliance was 96%, supervision compliance was 95% and appraisal compliance was 95%, demonstrating that staff received regular oversight, support and opportunities to reflect on their practice.

New staff completed a comprehensive induction programme designed to develop the knowledge, skills and competencies required for their role. Staff also had access to a range of specialist development opportunities, including training in safeguarding, trauma-informed care, positive behaviour support, risk management, the Mental Health Act and the Mental Capacity Act. Leaders encouraged career development and progression through apprenticeships, leadership programmes and specialist role opportunities within the service and wider organisation. These arrangements supported staff to maintain competence, develop professionally and deliver high-quality care that promoted recovery, rehabilitation and positive patient outcomes.

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.

Patients and carers generally described the hospital as clean, safe and well maintained. Staff demonstrated a good understanding of infection prevention and control responsibilities and followed procedures designed to minimise the risk of infection and protect patients, visitors and staff. 

The service had effective arrangements in place to monitor cleanliness and infection prevention and control standards. Regular cleaning schedules, environmental audits and quality assurance processes enabled leaders to maintain oversight and identify areas requiring attention. Cleaning records were complete, up to date and demonstrated that routine cleaning and monitoring took place across the hospital. We did not identify any gaps within the cleaning records reviewed, providing assurance that cleaning activities and environmental checks were being undertaken consistently. These arrangements supported the maintenance of a clean environment and helped minimise the risk of infection.

During our observations, staff followed infection prevention and control (IPC) practices appropriately, including hand hygiene procedures, the use of personal protective equipment where required, and the safe disposal of waste. Hand-sanitising stations were available throughout the hospital, and staff had access to the equipment and resources needed to maintain a safe and hygienic environment. 

The service had clear systems for identifying, managing and responding to infection risks in line with current guidance. Staff understood their responsibilities and had received relevant training to support safe practice. 

During the assessment, we identified some wear and tear within a number of ensuite facilities which had the potential to affect cleaning standards over time. Leaders had already identified these issues through environmental and cleaning audits and had developed action plans to address them. Planned refurbishment and maintenance of works were being monitored through established governance processes. 

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 involved people in planning, including when changes happen.

Medicines were managed safely and patients were encouraged to be involved in decisions regarding their medicines and treatment wherever possible. Care records demonstrated that staff supported patients to understand their medication, the purpose of treatment, and any proposed changes to their care. Where patients lacked capacity to make specific decisions, staff followed the requirements of the Mental Capacity Act 2005 and Mental Health Act 1983 to ensure decisions were made lawfully and in their best interests. 

 Staff followed appropriate medicines management procedures, including prescribing, storage, administration, recording, reconciliation and disposal of medicines. Controlled drugs were stored and managed safely, medicine storage areas were monitored appropriately and records demonstrated that regular checks were completed. Staff also monitored the physical health impact of prescribed medicines and completed the necessary physical health monitoring in line with national guidance. 

 The service had established systems to support safe medicines management. Nursing staff and pharmacy teams completed regular medicines audits and findings were reviewed through governance processes. Where errors or concerns were identified, actions were implemented promptly to reduce the risk of recurrence and improve practice. 

 Leaders were open and transparent regarding previous medicines incidents and demonstrated learning from these events. Reviews identified opportunities to strengthen second-check processes and medicines' governance, resulting in the introduction of enhanced competency assessments, additional training, increased management oversight, and more frequent audit activity. 

 Leaders managed a serious medicines incident involving expired diazepam appropriately through safeguarding procedures, incident investigation processes and duty of candour requirements. There was no evidence of serious harm or lasting impact to patients as a result of the incident. Learning from the incident was shared across the service and leaders were able to demonstrate improvements in medicines management arrangements, including strengthened oversight, enhanced monitoring processes and a reduction in medicines-related errors following the actions implemented.