Cygnet Paddocks

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.

This is the first assessment of this newly registered service. This key question has been rated. This meant people were safe and protected from avoidable harm.

All areas of the service were safe, clean, 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.

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 and managers demonstrated a proactive and positive culture of safety. Safety events were investigated and reported thoroughly, and lessons learned were shared with staff. Safeguarding was high on all staff’s agenda with effective identification and reporting systems. Risks were assessed and managed, so patients were supported in the least restrictive way. Infection prevention and control practices reduced the risks of spreading infections.

The service did not have any serious incidents in the 12 months prior to the assessment, and we saw examples of incidents reported through the provider incident reporting system. Staff told us they felt confident in recognising and reporting incidents and could access support from senior staff when necessary. Staff understood the duty of candour, and were open and transparent when something went wrong, and provided a full explanation to patients and families.

The service had a digital reporting system and staff could access the online policy in place that defined what incidents were, how to record and report incidents, and the expectations of an investigation. Staff could describe the process for reporting incidents and could describe the range of incidents that would be reported and investigated. Any learning from incidents would be shared with the staff, staff had regular supervision, and reflective practice sessions with a psychologist to make sure staff were psychologically safe.

Patients were confident that they could raise concerns with staff, and these would be addressed. Patients felt safe and had confidence in staff taking action to promote their safety. We saw staff used equipment and technology to reduce risk where patients had been identified at risk of falling or hurting themselves.

Staff told us the diverse ways a learning culture was promoted. For example, staff meetings and handovers were used to deliver safety messages to staff. Staff were able to give examples of how changes had been made in response to safety concerns.

People’s safety was promoted because staff and leaders fostered an open proactive culture of safety. Incidents were reported and investigated. Lessons learned were shared and embedded into practice. For example, daily staff meetings or safety huddles involving staff from each ward took place. In addition, there was a daily manager safety meeting. Safety concerns and incidents arising over the previous 24 hours were discussed along with what action staff must take to reduce risk. For example, a medicines review was completed following an incident. The provider had produced and circulated safety bulletins / briefings when important messages needed to be relayed to the whole clinical teams. These included learning from the provider’s other locations and from the wider sector.

The evidence showed a good standard. The service worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service had clear admissions criteria, which provided information to commissioners and the public on the needs of the people that the service could meet.

Patients we spoke with told us about the progress they had made and the support they received for discharge planning and transition between services. Patients were moving toward discharge, discharge plans and leave were in place to support patients to visit the local community they were returning or moving to. Patients had set smart goals to support their internal transition into the independent flats on Roan ward and could describe what progress they had and could make toward discharge.

Staff were able to describe action they had taken or were taking to ensure patients received effective safe care and support. For example, following a patient being admitted to hospital following a seizure, staff carried out a full review to ensure all safety concerns were fully addressed and ensured continuity of care on their return to the service. The registered manager described the ongoing discharge planning for 6 patients. This included the service supporting and facilitating patients with unescorted leave and trial period at another service.

Recent quality monitoring visits undertaken by partner agencies reported effective care and support. Progress and improvement for patients working towards being discharged or transitioning to other services was noted.

The provider had processes and systems in place to establish and maintain safe systems of care, in which safety was managed, monitored and assured. Continuity of care was supported through effective communication with other services and with patients and staff.

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.

Effective systems were in place to manage safeguarding risks. The provider had a comprehensive safeguarding policy in place. This policy included incident reporting and actions staff must take in relation to reporting, escalation and documentation. All staff undertook safeguarding training as part of the induction to the service. Staff compliance rates for safeguarding training were 95%.

In the 12 months prior to the inspection, 13 safeguarding notifications were made to the local authority, and all were closed at the point of referral with no further local authority action, because relevant risk assessments were in place and care plans were followed. The service has systems, policies, and processes in place to ensure that staff identified and reported safeguarding concerns appropriately.

Staff we spoke to were confident in identifying where people were at risk of significant harm, knew how to report these concerns and work with partner agencies when required.

As part of each patients’ assessment to admission, relevant safeguarding concerns were captured and detailed risk management plans put in place for each patient.

Staff supported patients in an appropriate way and took action to protect them from risk and harm. The service had a least restrictive practice approach with no blanket restrictions. Individual restrictions were agreed with patients through the multidisciplinary team. For example, when patients were admitted and higher levels of observation were needed, risk assessment and management plans were coproduced with patients and relatives to reduce observation levels as soon as the patient felt safe and secure at the service and did not present a risk to self and or others. Patients were also be supported with to access the community if needed, until patients were familiar with their local surroundings. Other restrictions included, for example Bay ward, where the garden doors are locked due to the height of the fence. Smoking restrictions were in place across the hospital, where vaping was allowed in the garden, but smoking cigarettes was only allowed off site. Ward meetings included discussions around restrictive practice with patient’s feedback recorded, and examples of restrictions being reduced, where the knives in the patient’s kitchens were not locked away.

Patients told us they felt safe and felt staff would listen and act if they raised any concerns. Patients’ relatives said the service was safe.

Staff knew how to recognise abuse and what action to take if they suspected it. They were confident any concerns they raised would be listened to and action taken. They were able to give examples of when safeguarding concerns had been raised and these were appropriate. The registered manager gave us an example of when a full safeguarding review was carried out following a patient admission to another hospital for a physical illness. They told us this had provided assurances to staff and to the patient’s family.

We scored the service as 3. 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.

We reviewed 5 patient records: all risk assessments were completed and were updated regularly. Risk management plans were comprehensive, holistic and staff managed identified risk well. Patients were assessed as part of their admission or transfer from another service to identify physical, psychological and social risks. Risk and risk management plans were in place for each individual. Patients were involved in developing their care plans and risk assessments.

Patients and staff worked together to develop care plans and risk assessments, and clients confirmed they were involved in care planning. The care records were person centred and reflected the patient voice. Staff told us they were knowledgeable about individual client’s risk, and we observed staff discussing how to address risk during multi-disciplinary team (MDT) meetings.

During the inspection we observed that staff followed best practice and were confident in de-escalating and managing challenging behaviour, while ensuring the safety of other patients.

Relatives told us the service felt safe, and they were kept updated to changes in risk to the individual patient or other person(s).

Staff were knowledgeable about patients’ needs and individual risks and knew what to do to minimise risks. For example, staff knew what level of support patients required and when and knew about their goals and aspirations. They were able to describe the progress patients had made and how care and support had reduced, as their confidence and daily living skills increased.

Staff completed risk assessments for each patient on admission using a recognised tool, and reviewed this regularly, including after any incident. Risks were assessed and care plans and risk management plans were developed. Information about each patient, what was important to them, how they preferred to be supported and triggers which may result in distressed behaviour were recorded so staff knew how to keep people safe and reduce risks.

Following any incident of distressed behaviour, support was provided and consideration given to current risk and care planning. This included discussion and input from the patient where possible. Weekly and monthly meetings attended by the multi-disciplinary team took place where risks and risk management were discussed

Physical risks were also assessed and managed. For example, there was clear written and pictorial information about how to reduce risk for patients with swallowing difficulties and when to escalate any concerns to a Speech and Language Therapist.

Patients were able to give feedback on the service via community meetings or suggestion boxes located in communal areas there where patients could submit anonymised feedback. The service applied a ‘You Said, We Did’ report, so patients could see the outcomes of their feedback. Examples of the outcomes for October 2025 you said we did were, providing a new toaster on a ward, additional activity days out, additional board games and planning a visit to the local cenotaph for remembrance Sunday for ex-servicemen living at the service.

We scored the service as 3. 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 were satisfied with the environment. All rooms were single, and ensuite and some patients had personalised their rooms with pictures and photographs. Each ward had access via a secure key or electronic fob.

There was an off-site estates team. The estates team manager had a good understanding of patients’ needs and how the premises and environment should be managed and maintained to promote safety and reduce risks. They attended daily meetings where any safety concerns in the environment were discussed. Staff we spoke with told us the premises and environment met patients’ needs and the estates team were responsive when any maintenance or repairs were required.

There was a plan for ongoing redecorating and repairs across the site, which included all communal areas as well as patient bedroom areas. There was also a more detailed site improvement plan that identified routine checks required, for example, monitoring of the building; flooring; signage and replacement of furniture, where needed. Each task had a priority rating and completion dates were entered as appropriate. This enabled staff to keep a track of progress.

Routine maintenance checks and safety certificates were in date for gas, electric, lift and hoists. A fire risk assessment had been carried out and fire records showed weekly and monthly checks were carried out to ensure fire alarms and fire safety equipment were in full working order.

The provider had a policy for the assessment and control of ligature points (A ligature anchor point is anything that could be used to attach a ligature). A ligature risk assessment had been completed along with ongoing audits. Any rooms with high-risk ligature points were not accessible or were supervised access only. Mirrors were used in communal corridors to support staff observation of patients and reduce risk where staff did not have clear lines of sight.

Medical equipment such as blood glucose monitoring machines were maintained and re calibrated monthly.

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.

The service ensured they had enough qualified, skilled and experienced staff. The team was made up of clinical, therapeutic, administrative and operational roles.

Patients told us they liked the staff and had confidence in them. Staff attended to their needs in a timely way. Relatives told us there were enough staff and they had confidence in their abilities and competence.

The service had medical cover through a consultant psychiatrist on site from Monday to Friday 0900 to 1700. Out of hours psychiatrist cover was provided through an on-call psychiatry rota from other local cygnet hospitals. In addition to this the service had a physical health needs specialty doctor on site from Monday to Friday 0900 1700. In addition, a local GP attended on site and did a ward round on a Tuesday. Outside of this arrangement the service had a private arrangement with the GP federation where a GP could be contacted as required. The service also had a physical health, non-medical prescriber who provided 40 hours of cover per week to support ward-based staff. The service also utilised 111 and emergency services as required.

Staff told us they received the training and support they required. We saw staff spent time with people through the day and responded to calls for support quickly. Staff were knowledgeable about their roles and responsibilities.

Required staffing numbers to meet patients’ needs and keep them safe were calculated using a recognised staffing tool. Staffing rotas showed required numbers were achieved. Agency staff used were usually known to the hospital and booked for blocks of work to improve consistency.

Staffing numbers were monitored and discussed within the daily safety huddles, as were any appointments, meetings, visits and planned activities. This enabled the team to identify what staff and from what discipline were able to facilitate each activity and to take action to address any staffing shortfalls.

Staff told us they had enough time to meet the needs of patients and to keep them safe. There was a low use of agency staff and staff told us how this had a positive impact on patients and staff because care and support was more consistent. The occupancy level at the service was increasing. The registered manager showed us through staffing rosters, therapist sessions and a staff action plan that staffing numbers including therapy staff such as occupational therapy, physiotherapy and speech and language therapy staff could be increased as patient’s needs fluctuated or patient numbers increased.

There was a safe recruitment process for new staff members which included all required checks and references. For staff on professional registers such as the Nursing and Midwifery Council, checks were carried out to ensure ongoing compliance and fitness to practice.

Compliance with mandatory training was at 90 % or above. All new staff undertook induction training to prepare them for their role and awareness of expected safe standards within the sector.

Staff received regular supervision to monitor their performance and discuss their learning and development needs. Compliance rates had consistently achieved over 90% throughout 2025. Clinical and managerial supervision was recorded at 90% or over.

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.

All areas were clean, had good furnishings and were well maintained.

Patients could be responsible for daily cleaning and household tasks with support and checks by housekeeping staff, to make sure infection control standards were maintained. Housekeeping was flexible and could be increased to support clients cleaning their bedrooms and communal areas, as part of their rehabilitation work.

Patients we spoke with said they were satisfied with how clean and tidy the service was.

Staff knew how to reduce the risk of infection because they received training and were knowledgeable about the provider’s policy and best practice guidance. Housekeeping staff had the equipment and resources they required to carry out expected cleaning of the premises and equipment. They told us there were enough housekeeping staff for the numbers of patients and their working hours were flexible to meet the needs of the service.

The premises and environment were visibly clean and fresh. Staff used personal protective equipment appropriately and practiced effective handwashing. The clinic room was visibly clean and hygienic.

The provider had an infection prevention and control policy for staff to follow. Staff received training about infection prevention and control and was over 90% complaint with training.

Cleanliness and hygiene were monitored and audited to make sure policies and procedures were adhered to. Audit results showed hand hygiene compliance was above 90% from January to October 2025. The hand hygiene audit included guidance for staff to complete with training and an action plan for any shortfalls. The head of housekeeping also carried out weekly and monthly quality checks for the cleanliness of the premises and environment.

Catering staff carried out food and storage temperature checks to ensure safe guidance was followed.

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 happened.

We reviewed medicines records for 9 people. We spoke with nurse leads on Sorrel, Bay and Roan, ward staff and the registered manager

Medicines were stored safely and securely in all areas where people were being cared for.

Allergies and medicines were recorded correctly on people’s medicines records. Systems were in place to ensure regular medicines were given safely. When people went away from the service, suitable arrangements were made so that they had the medicines they needed.

Correct processes were followed for people who were having their medicines given covertly, hidden in food or drink.

People were supported to self-administer their medicines, and medicines risk assessments were completed to ensure this was done safely.

People’s medicines care plans were detailed and person-centred.

Physical health checks were completed in line with care plans and results were recorded accurately.

Staff reviewed people’s medicines and monitored for side effects regularly. Staff were trained and assessed as competent to administer medicines.

Medicines audits were completed at regular intervals to identify issues and drive improvement. Medicines incidents were recorded, analysed and learnt from.

Patients told us staff managed their medicines in the right way. They had their prescribed medicines at the right time and in the right way. Patients and relatives were invited to meetings to discuss medicines and any changes. Relatives told us they felt involved in their family member’s care.

Medicines were stored correctly and safely in a clean and temperature-controlled environment. Administration records for prescribed medicines and controlled medicines were up to date and accurate. Oxygen was stored safely and with appropriate signage.

Capacity assessments were carried out to ensure consent for medicines was lawful. Where medicines were administered covertly a best practice protocol was followed and best interest decision recorded.

Emergency drugs and life support equipment were available, and staff knew how to access these.