Cygnet Acer Clinic

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

Safe- this means we looked for evidence that patients 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. This meant patients were safe and protected from avoidable harm. 

Staff managed risks to patients’ safety and wellbeing through incident reviews, risk assessments, safe medicines management, safeguarding processes and physical health monitoring. Patients received care in a clean, safe environment. 

However, concerns remained about staffing pressures, continuity of care due to temporary staff, and some physical healthcare risk management documentation. Leaders had started to address these issues through recruitment, workforce planning and care plan reviews. 

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.

Staff promoted a proactive and positive culture of safety based on openness and honesty. Staff knew how to recognise and report incidents and leaders had systems in place to review incidents, identify themes and monitor the effectiveness of actions taken. Staff received feedback from incidents and lessons learnt were shared through governance meetings, handovers, supervision, emails and learning bulletins.

Leaders monitored incidents through a range of governance processes, including daily reviews of incidents, three-times weekly situation reports, incident trend and theme meetings, local clinical governance meetings, regional governance meetings and operational governance processes. Individual risk management plans were reviewed regularly and were used alongside incident trend analysis to assess the effectiveness of actions taken.

Service leaders maintained a lesson learnt tracker and could demonstrate how learning from local and corporate incidents was communicated and acted upon. Staff completed audits to monitor compliance and leaders reviewed outstanding actions through governance systems. Examples included changes to admission documentation, additional staff training, competency assessments and ongoing audit processes to provide assurance that actions had been implemented.

Whilst incident data showed a high number of self-harm and ligature incidents, leaders were able to demonstrate how they reviewed these incidents, identified patterns and adapted risk management strategies. For example, leaders identified that one patient was involved in over half of all reported incidents and implemented enhanced observations, reviewed the effectiveness of these arrangements and altered observation times when incident patterns changed. Leaders also described actions taken to manage specific risks, including restricting access to items associated with self-harm and reviewing incident trends following these interventions.

Leaders monitored the impact of actions through incident reviews, audits and governance processes. They were able to provide examples where changes in practice were associated with reductions in incidents and demonstrated ongoing oversight of risk through regular reviews of incident data and individual risk management plans. Incident data for September showed a reduction in incidents compared with the previous month, which leaders linked to enhanced risk management measures and increased individual support.

Staff understood the principles of duty of candour and leaders reviewed incidents through established governance processes. Staff were offered support and opportunities to reflect following incidents through debriefs, supervision and governance discussions. 

Staff worked with a range of internal and external professionals to support safe care pathways and continuity of care. Leaders described regular multidisciplinary involvement in care planning, treatment reviews and discharge planning. Staff shared information about patients for example through handovers, daily safety summaries and ward rounds to support continuity of care and ensure staff understood patients' needs and risks. 

The service worked with commissioners and safeguarding teams and community services when planning patients' care and future discharge arrangements. Stakeholders confirmed they were invited to meetings and involved in discussions relating to patients' care and discharge planning. 

Referral and admission processes had improved and staff told us there were fewer inappropriate admissions. Commissioners described the provider as responsive and collaborative and did not raise concerns regarding care planning, treatment or discharge arrangements.  

Leaders explained that delays in discharge could occur when securing suitable community placements and support arrangements. One commissioner reported difficulties achieving a shared understanding of realistic discharge options and described occasions where progress towards discharge had stalled.  

The service worked with patients and partner agencies to help them stay safe whilst supporting their independence and recovery. Some patients occasionally felt unsafe due to the behaviour of other patients, particularly during periods of increased ward acuity. However, most patients felt safe on the ward.  

Staff understood safeguarding processes and knew how to identify, report and escalate safeguarding concerns. Staff described how safeguarding concerns were managed and reported through managers, safeguarding leads and electronic incident reporting systems. Patients were supported to keep safe. One staff member said, “I feel patients are kept safe because their observational checks are always appropriate according to individual risks and also randomised to avoid prediction”. Staff demonstrated an understanding of how to identify patients at risk of harm and worked with other agencies when required to safeguard people. 

Safeguarding and safety concerns were reviewed through daily multidisciplinary meetings, incident reviews and governance processes. We observed comprehensive multidisciplinary discussions that considered incidents, risks, mental health needs, physical health needs and safeguarding concerns. Staff worked closely with healthcare partners and external agencies, including specialist health services and crisis teams, to support patient safety and continuity of care. 

Mental Capacity Act 

Mental Capacity Act training compliance was 92.7%. Staff had access to Mental Capacity Act policies and guidance and leaders monitored learning through governance processes, audits and lessons learnt reviews. Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards. Staff took all practical steps to enable patients to make their own decisions. For patients who had impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes and feelings. The service had arrangements to monitor adherence to the Mental Capacity Act. from it. 

Staff did not always have clear written guidance to support the consistent monitoring and management of identified physical health needs. For example, asthma and catheter care risk management plans did not always contain sufficient information about signs of deterioration, when concerns should be escalated or the actions staff should take in response. This increased the risk of inconsistent monitoring and delays in recognising changes in patients' physical health. Leaders reviewed and updated the affected documentation following feedback during the assessment. 

However, staff used individual risk assessments and safety formulations to protect patients from harm whilst promoting recovery and independence. Risks associated with self-harm, suicide, ligature use, self-neglect and aggression were reviewed regularly through multidisciplinary processes. Staff balanced safety with least restrictive practice, with restrictions and enhanced observations applied on an individualised and risk-led basis. Incident trends, restrictive interventions and risk management strategies were routinely reviewed through governance processes. Patients were involved in decisions about potential risks and their safety for example in ward rounds.  

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

Staff had systems to identify and manage environmental risks. They completed regular environmental risk assessments, for example ligature risk assessment and equipment checks and were aware of environmental risks within the service. The ward layout enabled staff to observe patients effectively, and environmental risks were regularly discussed and adjusted in response to incidents and changes in individual risk. There were effective fire safety procedures in place.  

Staff had access to a range of safety systems and technology to support the delivery of safe care. These included alarm systems, with additional staff from neighbouring wards allocated alarms and pagers to provide rapid support during incidents. The service had also introduced silent alarm systems linked to pagers to help reduce incidents and anxieties within the patient group. CCTV was installed throughout the service to support safety and monitoring. All doors operated via electronic key fob access, which enabled staff to individualise or restrict access when risks increased. Staff also had metal detection equipment available to support searches of patients and bedrooms when required. These measures helped staff maintain a safe environment and respond promptly to emerging risks. 

Patients were consulted about the environment to ensure adaptations and reasonable adjustments are made to meet their individual needs, for example during “community meetings” (patients’ meetings).  

Although planned staffing levels were generally maintained, the use of bank and agency staff affected continuity of care and meant patients did not always receive support from staff who knew them well. Staff and patients raised concerns about staffing and the use of temporary staff. One staff member told us that staffing levels were mostly sufficient but described occasions where the ward experienced staffing pressures. Patients consistently raised concerns regarding staffing levels and the use of agency and bank staff. Patients told us that unfamiliar staff did not always know their individual needs. Some patients said this left them feeling less supported, particularly during periods of increased distress or risk. As a result, patients did not always receive support from staff who were familiar with their individual risks, triggers, recovery goals and support needs, which are important components of rehabilitation care. 

External stakeholders raised similar concerns. One stakeholder told us that bank and agency staff did not always have sufficient knowledge of individual patients’ behaviours, warning signs, and known triggers to provide the safest and most effective support. Advocacy feedback identified the use of agency staff as a recurring issue raised by patients and reported concerns regarding continuity of care, particularly during night shifts. Leaders recognised these concerns and described actions they had taken in response, including recruiting additional staff, requesting female agency staff where possible and requiring agency staff to complete local induction requirements before undertaking observations. 

However, leaders did have systems in place to determine and review staffing requirements. Leaders considered patient acuity, observation requirements and planned activities when allocating staff. The service used bank and agency staff to maintain planned staffing levels and leaders described actions taken to improve continuity, including recruiting additional staff and requesting regular agency staff where possible. 

Staff received supervision, appraisal, training, and support appropriate to their roles. Mandatory training compliance was good, supervision compliance was above 90%, and 90% of staff had received an appraisal within the previous 12 months. Staff spoke positively about teamwork and support from colleagues and managers. 

The service supported new staff through induction, role specific training, and competency processes. Leaders described ongoing recruitment activity to strengthen the workforce and reduce reliance on temporary staff. Staff demonstrated the skills and knowledge required to support patients within a mental health rehabilitation environment. 

Staff assessed and managed the risk of infection and took appropriate action to reduce the risk of transmission. Ward areas were clean, well-furnished and well maintained. Staff maintained equipment appropriately and kept it clean. Cleaning records were up to date and demonstrated that ward areas were cleaned regularly. Staff followed infection prevention and control principles, including effective hand hygiene, and demonstrated a good understanding of procedures for preventing and controlling infection. These arrangements supported a safe and hygienic environment for patients, staff, and visitors. Patients told us that the ward of environment was mostly clean, and we found no concerns regarding cleanliness of the day of our visit.  

Staff made sure medicines and treatments were safe and met patients’ needs, capacities, and preferences. Patients were involved in discussions about their medicines and treatment, including when changes were made.  

Staff followed good practice in medicines management, including the safe storage, administration, recording, and disposal of medicines, in line with national guidance. Staff monitored patients' physical health and reviewed the effects of prescribed medicines regularly, including for patients prescribed antipsychotic medication. Staff completed appropriate physical health checks and acted on concerns when identified. 

Pharmacists provided support and oversight of medicines management processes and worked alongside the multidisciplinary team to promote the safe and effective use of medicines. Medicines audits were completed regularly and helped staff identify and address areas for improvement.