Cygnet Hospital Wolverhampton

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 for this newly registered service. This key question has been rated Good.

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

Good: All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves. However, patients were not always involved in risk planning and relevant historical risks were not always documented in risk assessments. 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 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Staff knew what incidents to report and how to report them. The hospital followed the provider’s policy on incident reporting. We reviewed incident reports that showed staff had taken appropriate actions and records were completed fully and accurately. We looked at themes for incidents and leaders provided data on the frequency and type of incidents they had recorded. Leaders had analysed common themes and addressed these ensuring that clinical practice continued to balance risk management alongside person centred care.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong.

Managers investigated incidents thoroughly and supported staff following incidents through debriefs and reflective practice. Some staff told us that debriefs did not always take place after every incident. Leaders recognised that following one incident, actions such as debriefs and contacting the police had not been completed in a timely manner. They had reviewed this incident and lessons learned had been taken forward and debriefs with all staff involved had now taken place.

Staff received feedback from investigation of incidents, both internal and external to the service. We saw evidence that incidents were discussed in staff meetings, governance meetings and where appropriate community meetings. Staff gave us examples of recent learning and changes were made to the service following investigation and lessons learnt. This included regular external searches of the grounds and restrictions around certain vapes being used on the premises.

Leaders discussed how since opening they had actively sort out feedback from patients, commissioners and internal quality leads. They were able to give examples of how feedback from internal audits and commissioners had led to changes in the way they completed physical health monitoring and clinical documentation.

Managers shared learning with their staff about never events that happened elsewhere. The manager shared learning from other services, ensuring that information was cascaded across the team.

We work with people and our partners to establish and maintain safe systems of care. However, safety is not always managed, monitored and assured. We do not always ensure continuity of care, when people move between different services.

Referrals were managed via an external central hub who were responsible for assessing patients’ needs and eligibility for admission. Some staff shared their concerns that this system did not always allow for full scrutiny of referrals at service level due to the expectation that staff reviewed the information within one hour. Staff told us that some patients had been accepted by the referral team who did not meet criteria for the service as sufficient information had not been effectively shared by the referrer during the referral process. Staff also raised concerns on how risks were assessed prior to admission with one patient being admitted despite the staff feeling unable to manage their risk of aggression. The leadership team shared some learning from these referrals and admission and told us they had the ability to raise concerns if they believed they could not meet the patients’ needs. Most staff we spoke to told us they felt supported and listened to by senior leadership when making these judgements. However, two staff members told us that the leadership team’s response to them raising their concerns was variable.

Staff involved necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. External partners within the patients care team were involved with care planning and invited to multi-disciplinary meetings. Staff told us that due to a high number of out of area patients they found some patients were moved from the service quickly once a bed was found in their local area which made onwards planning of support and care difficult. However, there were also incidents where staff had ensured a patient had remained with them whilst they secured a placement able to meet their ongoing needs. Staff were able to give an example of where they had worked with commissioners to agree that a patient was able to remain in the service in line with the patient’s wishes to provide them with consistent care.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Staff we spoke with had good knowledge about safeguarding and any potential safeguarding concerns were discussed in morning risk meetings, handovers, clinical governance and multidisciplinary meetings.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff kept up to date with their safeguarding training. They were 96.8% compliant in mandatory safeguarding training of all staff.

All staff we spoke to knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns.

Staff followed clear procedures to keep children visiting the ward safe. Staff assessed potential risk and considered any child protection issues. A visiting room was available outside of the ward and staff were available if needed.

Staff explained the safeguarding procedures to patients on admission and patients had access to relevant information.

The hospital monitored the use of restraint and restrictive interventions and worked closely with staff to ensure they were appropriately trained and up to date with relevant practice and policy.

Staff regularly reviewed blanket restrictions discussed them with patients in community meeting and when in place could evidence why they were clinically justified.

Mental Capacity Act

Staff we spoke to had a good understanding of the Mental Capacity Act, and 98.6 % of staff had completed training in the 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. However, capacity assessments were not always completed in line with the Mental Capacity Act and staff did not always assess capacity on a time and decision specific basis.

We reviewed capacity assessments within five care records. We found the quality of capacity assessment and associated records was inconsistent. We saw evidence in one care record that where a patient lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. However, in two records it was not clear that staff had involved the patient in the assessment and recording of their capacity to consent to treatment.

We work to provide care that meets people’s needs in a way that is supportive and enables them to do the things that matter to them. However, we do not always include people in understanding and managing risks. We do not always include historical risk when assessing needs.

We reviewed 5 electronic care records. Staff completed risk assessments on admission, reviewed them during ward rounds and updated them after incidents. Staff identified and recorded changing risks to, or posed by, patients in care and risk management plans. However, in one care plan we viewed historical risk that had not been recorded in risk assessment and care plans, despite this being relevant to the section of the Mental Health Act that they were detained under.

It was not always clear in risk assessments how staff had involved patients in risk assessment and management plans. Risk assessments were completed with the multi-disciplinary team and then shared with patients as part of the multidisciplinary meeting.

Staff supported patients to consider points they would like to discuss in multidisciplinary meetings. Where patients could not engage during the meeting, staff supported patients in informal discussions prior to the meeting to ensure that the patients voice was included.

Staff told us they were committed to reducing restrictive practices. We saw that staff used de-escalation techniques to support patients on the wards. We heard that staff could see a move towards least restrictive practices as their confidence had grown in their roles. Staff told us they made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe.

In the 3 months prior to our assessment (June to August 2025) there were a total of 68 restraints: 6 restraints on Shaw and 62 restraints on Carter. Of these restraints 15 were in the prone position, and the remaining restraints were low level. Data showed an increase in the use of restraint in July and August, staff explained that this was due to the complexity of some of the patients admitted and staff confidence using de-escalation. Additional training and support had been made available for staff, and they had seen a significant decrease in the use of restraint in the following month. Restrictive interventions were reviewed by managers and discussed monthly within clinical governance meetings. Leaders discussed themes and reoccurring issues.

Staff ensured that patients could access advocacy and information on how to access advocacy was displayed in communal areas. The use of advocacy had also been recorded in some care plans where it had been used to ensure that someone had fully understood their rights under the Mental Health Act.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

All communal ward areas were clean, generally well maintained, well-furnished and items were fit for purpose. However, we noted a large number of cracks in the building walls. Staff had identified these and prior to our visit a structural engineer had been to assess the issue. The service had been assured that they did not pose a structural risk to the building and solutions to rectify them were being considered.

Ward corridors were long and clear of obstructions which allowed staff a clear view at all times. Staff had easy access to alarms and patients had easy access to nurse call systems in their bedrooms. The service had completed a ligature risk assessment for the whole building which was detailed and had clear actions. There were ward maps identifying potential areas of risk displayed in staff areas. Staff were aware of ligature anchor points on the ward and mitigated the risks to keep people safe. Patients’ bedrooms were fitted out to a high standard with anti-barricade doors and anti-ligature features. Whilst on site we identified a potential ligature risk in the patient dining room on Shaw ward. The staff were responsive, and they had resolved this prior to us leaving site that day.

The garden area was well-maintained, clean and tidy. Staff informed us that the service had installed higher fences following patients absconding from the ward over the previous fence when the service first opened. They had also installed convex mirrors to allow staff to see blind spots within the garden.

A seclusion room was situated on Carter ward. The room allowed clear observation and two-way communication and had toilet facilities and a clock. There was access to a small private garden area directly off the ward. We were informed that the camera in the seclusion rooms timing was out of sync and therefore currently out of use. This had been reported prior to our site visit, and the issue was resolved during our visit.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. We found that all equipment was in place and were in date or had check stickers on them.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

The service did not currently hold any staff vacancies and the average turnover of staff in the last 12 months since opening was 24.75%. Although staff turnover had initially been high it had significantly reduced and in the previous quarter was 5.63%. Sickness absence ranged from 2.2% to 2.6% in the 3 months prior to our visit. We reviewed staff rotas and noted that a qualified nurse was always present in communal areas of the ward. Managers had calculated the number and grade of nurses and healthcare assistants required using a staffing matrix. From the staff records we reviewed, the number of nurses and healthcare assistants matched the required number on all shifts. However, staff told us they did not feel there was always enough staff to carry out observations safely especially if a patients care needs had changed part way through a shift. They did feel able to go to leaders and ask for more staff but it could be difficult to source staff halfway through a shift. Leaders told us that they had access to staff from across the Cygnet network which allowed for flexibility when requesting additional support, but they would review rotas to ensure staff cover met the acuity of patients on the wards.

The ward manager could adjust staffing levels daily to take account of case mix. When necessary, managers deployed bank nursing staff to maintain safe staffing levels. When bank nursing staff were used, those staff received an induction and were familiar with the ward. The service did not use agency staff at the time of inspection or in the six months prior to our visit.

Staff said shortages rarely resulted in staff cancelling escorted leave or ward activities. All clinical staff irrespective of job role would support with leave when necessary. Staff and patients told us that if it was necessary to cancel leave this would be rearranged. Patients told us that the wards were generally quiet and staff were available. There were enough staff to carry out physical interventions safely such as restraint, and staff had been trained to do so.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

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

Staff ensured that cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff completed infection prevention and control checks and audits to ensure required standards were met. Staff had access to an infection prevention and control policy and support from infection prevention and control leads within the hospital and wider provider. Staff completed infection prevention and control training as part of the mandatory training programme.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Staff followed good practice in medicines management. They followed systems and processes and safely stored, prescribed, dispensed, administered and recorded medicines in line with national guidance. All clinic rooms were clean, and staff had access to all appropriate equipment.

Staff completed medicines records accurately and kept them up to date. We reviewed all patient’s medication and physical health records on the wards at that time. Staff completed them fully and accurately.

Staff followed national practice to check patients had the correct medicines when they were admitted, or they moved between services.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of anti-psychotic medication.

Staff learned from safety alerts and incidents to improve practice. We saw that medication errors were discussed in daily meetings, within clinical governance and lessons learned cascaded.