- Independent mental health service
Cygnet Hospital Oldbury
Assessment report published 6 August 2025
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
Cygnet Hospital Oldbury is a 27-bed female PICU and acute service. The service has two wards, Rosa, a 12 bed PICU ward and Emmeline, a 15 bed Acute ward.
This is a new service, registered 31 July 2024.
We carried out an on-site assessment on the 2 to 3 April and 7 April 2025 and asked for, and reviewed data related to the assessment.
We carried out this inspection as it was a newly registered service that had not yet been inspected. We looked at both wards.
We rated the service as good. The hospital was clean and well maintained. Staff completed risk assessments for patients and updated these regularly. Care plans guided safe practice. People were supported to have choice and control and were involved in planning their care. The wards had enough staff to keep patients safe and meet peoples’ individual needs. People were supported to have choice and control and could give feedback on their care.
However,
We found two breaches in the legal regulation of safe care and treatment and good governance. The provider did not always detect and control potential risks in the care environment and did not always make sure the equipment and facilities supported the delivery of safe care. Governance processes did not enable staff to identify risk and quality issues and take timely action that led to improvements.
We have asked the provider for an action plan in response to the concerns found at this assessment.
Mental Health Act and Mental Capacity Act Compliance
Mental Health Act
Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. The provider had relevant policies and procedures that reflected the most recent guidance.
Staff had access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were. Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.
Patients had easy access to information about independent mental health advocacy and an advocate visited the wards regularly.
Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded this clearly in patients’ notes.
We saw evidence of information documents on patients’ rights available in communal areas for both informal and detained patients. The provider[LG1]displayed a notice to tell informal patients that they could leave the ward freely and how to do so.
Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted. We saw that staff clearly documented where this had been granted.
We saw evidence in care plans of staff requesting an opinion from a Second Opinion Appointed Doctor (SOAD) when they needed to. Staff stored copies of patients’ detention papers and associated records correctly and staff could access them when needed.
Mental Capacity Act
The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles
Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.
For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to 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. Care records show that there was a clear understanding around mental capacity and best interest decisions. People were appropriately supported to know their rights and make decisions that were safe and in the best interests of the person.
The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.
People's experience of this service
We spoke with 10 patients in total, 6 patients on Emmeline ward and 4 patients on Rosa. We also reviewed patient satisfaction surveys, feedback response and community meeting minutes.
Verbal feedback we received was mixed across the two wards with patients on Rosa being more positive about their experiences of the care they received. All patients across both wards told us that they did not always feel safe due to potential aggression from other patients but told us that they were supported by staff when this happened. All patients told us that that the communal areas of the wards were very noisy and that it was difficult to relax. Patients told us that following feedback the provider had accessed silent alarms to help with the noise levels, and this had made a difference.
Most patients on Emmeline ward told us staff were not always kind and caring. They told us that they although there was enough staff they were not always visible and spent a lot of time in the nursing office. They all said they were confident in making complaints but felt staff would be unresponsive or slow in taking action.
While on Rosa patients told us staff made a positive impact on their wellbeing and listened and took action when concerns were raised. We saw feedback from the Dialectical Behaviour Therapy (DBT) ) skills group that said this therapy had been positive and helped develop coping skills and strategies.
Most patients told us they were involved in their care but the extent of involvement differed. Patients were enthusiastic about the amount and variety of activities and were complementary about activity staff. At the time of our inspection, we observed positive and caring interaction between staff and patients.