Cygnet Views

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 patients were protected from abuse and avoidable harm.

At our last inspection, we rated this key question as Requires Improvement. The service had been in breach of legal regulations relating to staffing and safe care and treatment. By the time of this inspection, the service had made improvements and was no longer in breach of regulations.

Staff were aware of patients’ risks and followed individual risk management plans. Risks were more effectively mitigated for patients experiencing acute mental ill health. Patients’ physical health was being monitored, with physical observations recorded consistently. Cleanliness and laundry arrangements had also improved since the last inspection. Managers now had better oversight of staff training.

At this inspection, the rating changed to Good, meaning patients were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

In the past 12 months, no serious incidents or deaths were reported within the service. When incidents, such as episodes of aggression, occurred, staff responded quickly, documented them accurately, and updated care plans and risk assessments accordingly. There was a recent incident where a patient pulled a staff member’s hair resulting in whiplash. During the inspection, we observed that the same member of staff did not have their hair tied back, despite the known risk. During the inspection, we observed that the same member of staff did not have their hair tied back, despite the known risk. We raised this during the visit, and the provider committed to ensure that all staff, including those in leadership roles, followed uniform and personal safety guidance.

Staff demonstrated a clear understanding of their duty of candour. When things went wrong, they communicated openly with people using the service and their families, where appropriate, offering explanations and apologies. Managers and clinical leads regularly provided feedback following investigations, and learning was shared during team meetings and handovers. For example, after a person accessed a staff member’s phone despite having restrictions in place, the service introduced a policy requiring phones to be kept in lockers and prohibited use of personal phones on units. This reduced the risk of unauthorised access and improved safety procedures.

Lessons were learned from the shortfalls identified in the last inspection, and improvements were made, for example, in the admission process and in enhancing environmental safety.

Patients told us they felt their moves between services were well planned and managed. Staff worked as a team to ensure care remained consistent and safe across referrals, admissions, transitions, and discharges. Leaders focused on continuity of care and minimising disruption during every stage of the care pathway.

Since the last inspection, leaders had strengthened the referral process to make sure the service only admitted patients whose needs it could safely meet. The full clinical team, including nurses and support staff, reviewed all referral information and pre-admission assessments. Staff also visited patients in person and spoke with placement teams to check risks, including those related to ligatures, could be managed safely.

Staff held admission meetings and detailed handovers to ensure key risks were identified and understood. Risk management plans were in place from day one and reviewed regularly by clinical teams. During a multidisciplinary team (MDT) meeting we observed, staff worked together to plan care and share key updates, supporting safe and person-centred transitions.

Staff planned discharges carefully, coordinating with other services to make sure patients moved on safely with the right support. When delays occurred, staff recorded the reasons clearly and prioritised finding the most appropriate care, rather than making rushed or unsafe decisions.

Patients told us they felt safe at the service and knew how to raise concerns if they felt unsafe or worried about others. Staff completed safeguarding training and showed a clear understanding of how to identify and report signs of abuse or neglect. They acted quickly when concerns arose and involved external agencies appropriately. Safeguarding was a regular item in staff MDT meetings, supporting a shared and proactive approach to risk.

The service promoted patients’ rights by helping them understand legal protections, including those under the Mental Health Act, Mental Capacity Act 2005, and the Equality Act 2010. Leaders ensured staff had the training, supervision, and confidence to act when safeguarding concerns were raised. The service had clear systems and policies in place that prioritised safety and embedded a strong safeguarding culture.

We reviewed the safeguarding incident log covering December 2024 to February 2025. Records showed staff escalated concerns consistently and without unnecessary delay, following internal and external procedures. The team demonstrated a clear commitment to maintaining a safe and transparent environment.

The external safeguarding lead associated with the service told us that the provider is, “Open and honest” and contacts them for advice when needed. They said concerns are raised in a timely manner, with appropriate paperwork submitted when requested, and that the service is “happy to implement actions from safeguarding concerns.” This reflected strong external confidence in the service’s safeguarding approach.

Patients had access to clear, accessible information on how to keep themselves safe, including easy-read materials. We reviewed five risk assessments and management plans, all of which were person-centred and considered patients' holistic needs, including physical health conditions like diabetes and chronic obstructive pulmonary disease (COPD). Staff regularly reviewed these documents in line with policy, balancing safety with promoting independence by adjusting wellbeing checks and observation levels based on each patient's current condition.

While care plans and risk assessments were generally well completed, some staff struggled to quickly locate hard copies when we requested them during out site visit. Although these documents were available electronically, delays could occur in emergencies or during IT issues, which could risk timely safety actions.

Staff clearly understood individual risks and managed them proactively. We saw records of five restraint incidents and two involving rapid tranquilisation; in all cases, staff used these interventions only as a last resort and in accordance with best practice and legal requirements. Staff respected patients' dignity and human rights, aiming to reduce restrictive practices over time through regular reviews, debriefs, and updated care plans.

Patients and their families were actively involved in discussions about risks and care planning. Records showed patient participation in multidisciplinary team (MDT) reviews, with access to their care plans.

External professionals confirmed that risks were effectively identified and discussed at MDT meetings, with plans implemented appropriately. One stakeholder noted: "Patient risk assessments are reviewed at least daily during morning meetings, and handovers to advocacy regarding risks are always thorough." This feedback reflected a culture of effective risk management.

Staff conducted regular environmental risk assessments to identify and address potential hazards. However, not all safety concerns were identified or addressed prior to our inspection. Corridor doors had glass panels, and staff reported incidents where patients kicked and broke the glass, posing a safety risk. Sharp-cornered mirrors were present in patients’ rooms, which created a risk for individuals with increased risk of ligature and self-harm. This had not been included on the provider’s risk register prior to our assessment. Following our feedback, new, safer mirrors have been quoted and approved for purchase. Due to cost and lead times, this work is still in progress.

At the time of the last inspection, it was identified the design and layout of the hospital were not suitable for people experiencing acute mental ill health or those with a history of using fixed ligatures. Since then, the service has made improvements to reduce these risks. Provider completed a ligature risk assessment, including heat maps highlighting high-risk areas and the locations of ligature knives. Leaders routinely reminded staff of these risks during team meetings, and all new staff received guidance on where ligature knives are kept during orientation walk rounds. Additionally, provider replaced all bedroom doors with doors that include observation panels, enhancing the ability to monitor patients safely.

Clinic rooms were fully stocked with resuscitation equipment and emergency drugs, which staff checked regularly to ensure they remain ready for use. Staff had access to safety alarms and we saw that when they were used, staff responded immediately.

Leaders and staff considered psychological safety alongside physical safety. The occupational therapists aimed to create a sensory modulated environment and one that is physically safe. Sensory equipment, such as rocking chairs and sensory lights, helped create environments tailored to individual patients’ needs.

Despite these improvements, ongoing risks remained, and some hazards were not fully addressed before our assessment.

The service maintained safe and effective staffing levels that consistently met patients’ needs. Over the three months prior to our inspection, planned staffing levels were achieved both day and night, with no shifts falling below the required minimum. Typically, two nurses and four support workers were on duty during the day, and one nurse with four support workers at night. This allowed for one-to-one support and enhanced observations when needed. Additional staff were deployed flexibly to respond to changes in acuity. Patients and staff told us that staffing levels generally supported continuity of care, with therapeutic activities and Section 17 leave proceeding as planned in most cases.

The provider had not used agency staff since June 2022. At the time of the inspection, bank nurses from within the wider Cygnet network were covering maternity leave for a senior nurse and staff nurse, ensuring continuity of care. The multidisciplinary team included a hospital manager, head of care, doctors, psychologists,occupational therapist and speech and language therapist and assistantand two activity coordinators, offering a consistent and well-rounded approach to patient care. New staff completed a structured induction, and all team members, including bank staff, received ongoing training and support.

Supervision and appraisal compliance exceeded 90%, with staff reporting they felt well supported in their roles. Managers identified learning needs and promoted development, including specialist training in learning disabilities. Although only one nurse held a formal qualification in learning disabilities, other staff had relevant experience and had completed supplementary training to meet patients' individual needs.

While patients had shared feedback with partner agencies that some night staff occasionally used mobile phones or appeared to sleep during shifts, managers had addressed this concern multiple times through supervision and monitoring. They continued to take action to ensure night staff maintained high standards of vigilance and professional conduct. Leaders responded promptly and robustly to concerns and upheld safe recruitment and disciplinary procedures.

The service had effective systems to manage and reduce infection risks, following national guidance and best practice. Patients and visitors reported that the environment felt clean. Staff understood their infection and prevention control (IPC) responsibilities, and most areas were clean, well-maintained, and appropriately equipped. Cleaning schedules were current, with records confirming regular cleaning across the unit. Equipment was generally well maintained, with visible and in-date ‘clean’ stickers where required.

However, we observed a nurse perform a blood sugar check without wearing gloves. A second nurse was present but did not intervene to correct this practice. Additionally, some environmental areas were dusty, and radiators showed rust, which could compromise hygiene and cleaning effectiveness. The hospital environment also required cosmetic upgrades to improve the overall appearance and help maintain a clean, safe space. We raised these concerns with the provider, who committed to addressing them promptly with staff.

The service clearly defined IPC roles and responsibilities and communicated relevant information to patients, families, and partner agencies as necessary.

The service had safe and effective systems in place for managing medicines. Staff followed national guidance for prescribing, administering, storing, and disposing of medication. Controlled drugs were securely managed, and staff completed all required checks and records accurately.

Patients with mental capacity were actively involved in decisions about their treatment and understood the purpose of their medicines. For patients who were unable to participate fully due to learning disabilities or cognitive conditions, staff followed best-interest decision-making processes in line with the Mental Capacity Act (MCA) and Mental Health Act (MHA). Care plans clearly reflected each person's level of understanding and outlined the support they needed to take their medication safely.

Staff complied with legal requirements under the MHA and ensured correct authorisation for treating detained patients. Where appropriate, staff included family members or advocates in medication-related decisions. Staff also monitored the effects of medicines, including side effects from high-dose antipsychotic prescriptions, and followed National Institute for Health and Care Excellence (NICE)guidance to ensure physical health was routinely checked.

Medicine information was communicated effectively during care transitions, and we found no evidence of medicines being used to control behaviour inappropriately. One external stakeholder told us, “I have always found the team helpful and thorough with medication changes or updates—there is clear communication and a strong rationale behind clinical decisions.”