Cygnet Hospital Sheffield

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• 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 as good. At this assessment the rating has remained good. This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

The service ensured that all young people were safeguarded based on individual risk, with both a social worker and social work assistant assigned to each of the three wards for oversight and management of complex safeguarding issues. The service ensured that all young people understood what risk meant to them and supported young people to take positive risks with the support of the multi-disciplinary team, which helped them to prepare for discharge into the community and take control and responsibility of their lives.

The service made sure young people knew what safeguarding was and why it was important. The service provided information in a way young people could understand to help them identify when safeguarding might be involved and how this kept them safe.

The service fostered a culture of openness and transparency, ensuring that stakeholders, external care teams, family members and the young person knew if and when something went wrong, and promoted learning from any incidents to improve safety.

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.

We scored the service as 3. The evidence showed a good standard. The service had a strong, proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Data showed that there were 34 serious incidents in the last 12 months across the CAMHS wards, however these incidents were recorded as no actual harm or low harm, but they were recorded as serious incidents under the Serious Incident Framework. This included incidents such as self-harm, aggression towards staff and absconding whilst on Section 17 leave. Incidents were shared with the provider collaborative (a partnership of two or more NHS trusts working together, often with independent sector partners, to improve specialised care pathways, such as mental health or acute services. They aim to deliver higher quality, consistent care across regions by managing budgets and services collaboratively, reducing health inequalities) and a review of incidents showed that these were always managed well, with learning outcomes involving discussions with patients. Incidents were shared with the local authority where appropriate.

All staff knew what incidents to report and how to report them, including when to make a safeguarding referral. This was further supported by an allocated social worker and social work assistant based on each ward. Staff reported all incidents that they should report and had a clear understanding of duty of candour. They were open and transparent and gave both young people and carers full explanations if and when things went wrong, including making notifications to share information. The service completed daily situation reports, known as SITREP meetings where leaders met each morning to discuss incidents over the last 24 hours, staffing levels, any enhanced observations and daily actions. Leaders discussed the level of harm of incidents and actions taken as a result to support the young person.

We observed meetings where each ward manager discussed their own patients with a comprehensive understanding and oversight of their individual wards. The meeting also ensured that safeguarding referrals had been made and shared with the local authority, and that investigations of incidents were undertaken to identify learning. When incidents occurred, staff undertook physical and neurological observations of the young people concerned, as well as body maps. Staff made reports to the police where appropriate and there was a designated police liaison officer linked with the service who visited regularly to break down barriers.

Debriefs were completed with staff, young people and other relevant parties. An example of this was when a teacher who witnessed an incident of aggression during school time was included within the debrief process. Incident logs included the dates of incidents, the ward, safeguarding reference numbers, description of the incident, immediate actions and the severity, if rapid tranquilisation was used, if neurological observations were required and if a CQC or local authority notification was made. The daily SITREP meeting ensured that if a debrief had been indicated, that this had been actioned and the names and designations of those who attended were recorded. Leaders also discussed incidents that occurred whilst young people had been on Section 17 leave, to determine if family support was also indicated.

The service discussed any initiation of long-term segregation or seclusion that had commenced and ensured records were up to date where these had been initiated or discontinued. The service also looked to end seclusion or segregation at the earliest possible opportunity. This was evidenced in seclusion ending in the early hours of the morning as a young person had been able to safely engage with staff, as opposed to waiting until the morning.

The service had strong management of risks between the mixed sex wards. Learning from a previous incident had led to the embedding of safety strategies including staff immediately redirecting young people to ensure safety. The service discussed and actioned learning, such as no lone working with some young people due to presenting risks and enhanced observations, ensuring both staff and young people were protected.

We scored the service as 3. The evidence showed a good standard. Staff always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service’s referral and admission process was comprehensive and robust, ensuring that all essential information about the young person was received to determine if the patient’s needs could safely be met and determine the correct level of support that would be required. The service involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge by ensuring meetings were attended by the wider multi-disciplinary team, the young person and their families where appropriate.

The service continuously assessed individual needs and risk and where indicated, could transfer young people between wards to provide them with the most appropriate environment. The service had demonstrated this in transferring a young person who required enhanced care to a different ward in the hospital, to ensure the environment best met their needs. This worked in line with their care plan which stated that they needed to be placed in a low stimulus environment, as recorded in their care plan.

The service maintained good communication with community mental health teams and local authorities, to ensure that transitions from hospital back into the community were well managed, safe and provided continuity of care. Feedback from stakeholders told us that the Integrated Care Board were always involved, updated and consulted on transitions, discharges and changes in need. Stakeholders told us that communication was excellent, and this ensured seamless transitions into the community, including staff from the service supporting potential placement providers with guidance and support to build up to safe discharges.

We scored the service as 4. The evidence showed an exceptional standard. The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

The service had a robust and thorough approach to safeguarding. Each ward had a social worker and social work assistant allocated for oversight of any safeguarding issues or concerns. We spoke with staff who demonstrated a strong knowledge of issues that effected young people. The service worked collaboratively in terms of policies and procedures, involving social care professionals in the development of these. The service ensured there was access to domestic abuse support, advice regarding internet safety and keeping people safe on the internet. Staff told us that they regularly follow the news to ensure they kept up to date on any new issues arising amongst the younger population, to have better oversight of new and emerging risks. Cygnet had a designated lead for safeguarding who provided the service’s social work team with quarterly supervision which was available sooner if required.

Safeguarding was a high priority for the service, and they had developed a working relationship with a dedicated police liaison officer for complex issues and to develop rapport with young people, breaking down barriers for young people to be able to feel safe to disclose information and feel safe doing so. The service knew when referrals required further escalation and maintained good relationships with the local authority who held oversight of the services safeguarding cases. Safeguarding was an agenda in all meetings, to ensure referrals had been made, recommendations were being followed and that these were reflected in care plans where appropriate to support the young people in the service. Staff told us that careful consideration was given to this with regards to what information was included in care plans to protecting young people reliving trauma when these were reviewed with named nurses.

Social workers on the wards also supported in providing training to staff, for example around boundaries and safeguarding, sexual safety training and reviewing induction materials for new staff. Social workers on the wards also provided immediate responses to safeguarding issues and held an open door policy for all staff for advice. Staff also provided support in the debrief processes to determine any safeguarding issues. The safeguarding leads reviewed CCTV if required where an alert had been raised and reviewed this with a restraint trained member of staff.

The service had a policy for children visiting the hospital and liaised with external social care colleagues to advise of any risks. Children did not have visits on the wards, but there were appropriate rooms available for family visiting which were supervised by staff. The service also had a contingency plan if no social workers were available, with senior leaders covering any safeguarding concerns, as they were level 4 trained in safeguarding children and adults. There was also a Gillick Competence lead for Cygnet who could provide advice and support to staff.

The service ensured that professionals who were new to working with the hospital were supported in understanding the main issues around young people’s safety and incidents such as self-harm, seclusion and what long term segregation is. The service had developed relationships with local children’s hospitals to ensure care was robust if a young person required treatment at a general hospital whilst admitted to one of the wards.

Mental Capacity Act

On Pegasus ward, 100% of staff had completed training in the Mental Capacity Act, on Unicorn ward 93% and on Griffin ward 88%. Staff had a good understanding of the Mental Capacity Act, particularly the five statutory principles. Most young people were admitted under sections on the Mental Health Act, however, where young people were admitted informally, Deprivation of Liberty Safeguard referrals were made. The hospital had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were aware of the policy and had access to it via their electronic system. All staff knew who the Mental Health Act administrator was and how they could get extra advice when required.

Staff actively encourage young people to be involved in decision making where possible and where not possible, staff considered best interests' decisions, whilst recognising the importance of the person’s wishes, feelings, culture and history. For young people who had impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions and involved the Gillick Competence Lead (a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment) for the provider when required. There were arrangements in place to monitor and audit the services’ compliance with the Mental Capacity Act. Staff acted on any learning that resulted from these audits.

We scored the service as 3. The evidence showed a good standard. The service always worked well with people to fully understand and manage risks by thinking holistically. They provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them. Staff assessed and managed risks to young people 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.

We reviewed 10 care records across three wards, including risk assessments, discharge plans and care plans. Staff involved young people in care planning and risk assessments which was evidenced within care plans and captured the multidisciplinary teams' views and assessments. Young people told us they were involved and had access to a copy of their care plans.

We spoke with the advocacy agency who corroborated that young people felt involved in their care and understood why certain restrictions were in place during their admission. Young people had expressed to the advocacy that they felt involved and valued in their care and were always invited to meetings. All care plans we reviewed evidenced that young people were involved and that the wider multi-disciplinary team were involved, including the young person's community teams and social workers.

The service had a process called My Say Requests, which allowed young people to express their wishes towards their care and treatment, ensuring their voice was heard. This was part of the ward round agenda. These requests were also discussed in daily ward reviews. Young people were able to have their advocate present at any meetings and feedback from young people told us that they always felt involved and listened to. Staff also enabled young people to give feedback through a number of forums, including patient community meetings, during 1:1 sessions with their named nurse, through complaints and compliments feedback and following any incidents where debriefs were given.

Data showed a significant reduction in rapid tranquilisation on Griffin ward since the adoption of the new model of care. Unicorn has remained stable with reasonably low use for the population type. Reduction in rapid traquilisation remained an area of focus for Griffin Ward and regular support from the Positive and Safe Lead was given. The service as a whole had seen an increase in seclusion which reflected the change in referrals since accepting admissions via the psychiatric intensive care unit (PICU) pathway of predominately young people experiencing psychosis and complex presentations. There was evidence that the service was completing further analysis into the ethnicity and neurodiversity of young people that required seclusion. Any use of seclusion was audited by the Positive and Safe Lead.

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. We reviewed all three wards and did not find any significant issues. Ward managers completed daily walk arounds, and this also included a member of staff completing a security checklist. An external regional manager completed an environmental check every 6 months for quality assurance purposes. The service had a team of onsite maintenance staff who were able to respond to any environmental risks or damages in a timely manner and all staff knew how to escalate any concerns with the environment. Staff undertook regular risk assessments of the care environment and actioned any repairs, concerns and feedback from young people.

There were blind spots on the wards which were mitigated by the use of safety mirrors, closed circuit television and staff observations. Staff had recorded where there were ligature risks within the environment and details were held in accessible files on the wards. The files included photographs of specific areas, guidance for ligature cutters and all staff were able to tell us where these were located All young people had their own bedrooms with ensuite facilities. The wards were all accessible with ramp and lift access should a young person require this. The wards were spacious, with various rooms that offered more quiet areas, separate male and female lounges, access to outdoor space and a large communal area with seating, a television and a visual view from the nursing office.

All staff had access to alarms and there was a procedure and policy in place for staff to respond to incidents. We reviewed the services two seclusion suites, which met the criteria and guidance, including clear unobstructed vision of the suite, two-way communication, toilet facilities and a clock visible for the young person. The suites were in good condition and well maintained. Staff had access to relevant seclusion documentation.

We scored the service as 4. The evidence showed an exceptional standard. The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Across all three wards, staffing levels were exceptionally good. The service was over recruited for nurses across the hospital. There was 1 full time clinical team leader due to start in April 2026 as part of over recruitment. The service had no nursing vacancies at the time of inspection. Cygnet Hospital Sheffield was fully recruited against the core staffing for the wards. The service had revised the staffing budget for 2026 against the average special nursing requirements for 2025 to over recruit across all the CAMHS wards to further reduce agency use. At the time of our inspection, there were 15 support worker vacancies, with 19 support workers going through recruitment checks prior to induction and 21 bank staff completing pre-induction checks. At the time of our inspection, the service was already above safe staffing levels on each ward.

Both average turnover and sickness absence rates remained low over the last 6 months. Turnover rates were 7.85% for the service and were significantly lower than the average turnover for NHS mental health services. Absence rates had reduced over a 12-month period and at the time of our inspection were at 5%, in keeping with national averages. The number of unfilled shifts between March 2025 and February 2026 across the CAMHS wards remained low with no unfilled shifts breaching minimum staffing levels. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

Senior managers had calculated the number and grade of nurses and support workers required based on clinical need and levels of observations required. The staffing numbers could be adjusted as required to ensure there were enough staff to maintain young people’s safety. Staffing level requirements were discussed at daily morning meetings to determine if increases or decreases were required. Managers ensured that there were skilled staff across the wards and staff were able to move between wards if and when required. A minimum of two qualified nurses were present on each ward.

Staff we spoke with told us there was always enough staff to carry out physical interventions, for example, observations, restraint and seclusions safely. All staff we spoke with told us they felt they had enough training to do their jobs well. Young people we spoke with were very complimentary about staff and felt they knew exactly how to support them, especially when they were distressed. Young people told us they always were able to speak to staff when they needed to and knew who their named nurse was.

Each ward had their own consultant psychiatrist. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. Each responsible clinician had been in the service for over 4 years. Each ward also had a speciality doctor. The service had an out of hours cover rota in place which included both doctors and ward managers, clinical manager and hospital director being on call.

Staff had received and were up to date with appropriate mandatory training. Mandatory training across the three was appropriate for the patient group using the service and no training was below 75% completion. Service level KPI’s were 90% and 95% for certain safeguarding training.

We scored the service as 3. 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. Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. All three wards were clean, had good furnishings and were well-maintained. Where there were any damages, these were reported to the onsite maintenance team who completed repairs and maintenance work in a timely manner.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly by core teams designated to each ward. We spoke with the head of housekeeping for the service who advised that each ward received daily deep cleans, as well as the general areas of the hospital. The head of housekeeping completed weekly audits to ensure all cleaning tasks had been completed and additional monthly audits were also completed. The service was overseen by an infection prevention control nurse to ensure that the wards were adhering to infection control principles, including handwashing. All staff had received mandatory training in infection prevention and control, with 100% completion rates on two wards and 96.7% on the other.

We scored the service as 3. 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 were made to their medicines.

Staff followed good practice in medicines management, including the transport, storage, dispensing, administration, medicines reconciliation, recording, disposal and did it in line with national guidance. Staff reviewed the effects of medication on patients’ physical health regularly and in line with the National Institute for Health and Care Excellence guidance, especially when the patient was prescribed antipsychotic medication. We reviewed all three wards’ clinics and 15 medication records during the inspection which were in line with good practice.

All clinic room environments were clean and tidy, with up-to-date cleaning records. Actions from cleaning audits had been completed by staff and both room and most fridge records were up-to-date, accurate and available. The temperature recording of the treatment room on Griffin ward had been missed on 3 occasions in February, however there were no other missed recordings in the previous 3-6 months, and this had been appropriately dealt with via monthly audit and feedback. All clinic equipment was present, correct, appropriately maintained and checked regularly in line with service policies. Ligature cutters were available in the nurses' offices and throughout the wards. All staff were able to point out these locations.

All medicines were stored appropriately, and all cupboards were appropriately locked. The cupboards were well organised, and all medicines were appropriately labelled. All stock medicines were appropriately stored. Expiry dates were checked on 10 stock items per ward and there were no out-of-date medicines noted. Stock lists were up to date and available. All staff were aware of controlled drugs policies and procedures. Controlled drugs were checked and audited appropriately with weekly oversight from the pharmacist. Only 1 ward had a current prescription for a controlled drug this was checked and the count was correct.

The medicines fridges were locked, clean and tidy. The temperatures were in the appropriate range and checked daily. The practice development team audit the records weekly and address any concerns via individual feedback. Appropriate emergency equipment was available in treatment rooms (emergency grab bags). Oxygen was available, in date and full. Defibrillators were available, fully charged with adult and paediatric pads. Written evidence of daily and weekly checks. All staff asked were aware of where the medicines and emergency equipment were stored. Waste was well managed on all wards. Sharp bins available, annotated with dates of opening, and not overfilled.

Staff we spoke with were diligent in their approach to medicines management and understood the importance of diligence and oversight in the safe administration of medicines. We looked at 5 prescription charts on each ward (15 total). There were no omissions or issues to note. All records were appropriately signed and dated. Medication charts were easy to read and accurate. There was no evidence of over-prescribing or over-reliance on ‘as required’ medication and both consent and allergies were noted where appropriate. Mental Health Act documentation such as T2/T3 forms matched prescription charts (T2 forms are completed by a clinician when the patient consents after 3 months of detention, while T3 forms are completed by a Second Opinion Appointed Doctor (SOAD) when the patient cannot or does not consent).