Cygnet Kenney House

We assessed the Acute ward for adults of working age and psychiatric intensive care unit at Cygnet Kenney House from 9 to 10 September 2025.

We assessed the service as it had recently opened in April 2025 and as such had not been rated. We had also received intelligence about the service.

Cygnet Kenney House is registered with CQC to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and treatment of disease, disorder or injury. The service had an interim Registered Manager.

We visited the following wards as part of the assessment:

Baldock ward, an adult acute ward for women with 16 beds.

Billington ward an adult psychiatric intensive care unit for women with 12 beds.

At this assessment we assessed 2 assessment service groups; Acute wards for adults of working age and psychiatric intensive care units where we assessed 33 quality statements and rehabilitation wards where we assessed 33 quality statements.

We rated the service as Requires Improvement. At this assessment of the acute wards for adults of working age and psychiatric intensive care units we identified 2 breaches of regulations: Regulation 12 Safe Care and Treatment and Regulation 18 Staffing. These were in relation to:

Food and fluid charts were not completed in full; staff were on long periods of enhanced observations which were longer than the recommended guidance, there was a lack of evidence of inductions and observation competencies for agency staff, and there were occasions when prescribed medication was unavailable for over a week and expired medication was given to a patient.

We issued a warning notice under section 29 of the Health and Social Care Act 2008. This was because the service had failed to comply with Regulation 18 Staffing. During the assessment we found that the provider did not have enough suitably qualified, competent, skilled, and experienced staff deployed to keep service users safe and to meet the needs of service users. The provider had not ensured that there were complete records to show if agency staff working on Billington ward and Baldock ward had received an induction into the ward, including how best to support service users. The provider had also not ensured that staff were working no more than two consecutive hours on enhanced observations without a break.

Mental Health Act and Mental Capacity Act Compliance Summary

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. The compliance rate for Mental Health Act training was 100% of staff on Billington ward and 94% of staff on Baldock ward. Staff had easy access to administrative support and legal advice on the implementation of the Mental Health Act and the Code of Practice. They explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

The service displayed a notice to tell informal patients that they could leave the ward freely.

Staff had received training in the Mental Capacity Act and deprivation of liberty safeguards. Compliance rates were 100% on Billington ward and 94% on Baldock ward Staff had some understanding of the Mental Capacity Act, particularly the five statutory principles.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and how access to it.

Staff knew where to get advice from within the service regarding the Mental Capacity Act, including deprivation of liberty safeguards (DOLS). They spoke to the qualified staff or contacted the Mental Health Act office for advice and guidance.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately.

We assessed the Acute ward for adults of working age and psychiatric intensive care unit at Cygnet Kenney House from 9 to 10 September 2025.

We assessed the service as it had recently opened in April 2025 and as such had not been rated. We had also received intelligence about the service.

Cygnet Kenney House is registered with CQC to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and treatment of disease, disorder or injury. The service had an interim Registered Manager.

We visited the following wards as part of the assessment:

Baldock ward, an adult acute ward for women with 16 beds.

Billington ward an adult psychiatric intensive care unit for women with 12 beds.

At this assessment we assessed 2 assessment service groups; Acute wards for adults of working age and psychiatric intensive care units where we assessed 33 quality statements and rehabilitation wards where we assessed 33 quality statements.

We rated the service as Requires Improvement. At this assessment of the acute wards for adults of working age and psychiatric intensive care units we identified 2 breaches of regulations: Regulation 12 Safe Care and Treatment and Regulation 18 Staffing. These were in relation to:

Food and fluid charts were not completed in full; staff were on long periods of enhanced observations which were longer than the recommended guidance, there was a lack of evidence of inductions and observation competencies for agency staff, and there were occasions when prescribed medication was unavailable for over a week and expired medication was given to a patient.

We issued a warning notice under section 29 of the Health and Social Care Act 2008. This was because the service had failed to comply with Regulation 18 Staffing. During the assessment we found that the provider did not have enough suitably qualified, competent, skilled, and experienced staff deployed to keep service users safe and to meet the needs of service users. The provider had not ensured that there were complete records to show if agency staff working on Billington ward and Baldock ward had received an induction into the ward, including how best to support service users. The provider had also not ensured that staff were working no more than two consecutive hours on enhanced observations without a break.

Mental Health Act and Mental Capacity Act Compliance Summary

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. The compliance rate for Mental Health Act training was 100% of staff on Billington ward and 94% of staff on Baldock ward. Staff had easy access to administrative support and legal advice on the implementation of the Mental Health Act and the Code of Practice. They explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

The service displayed a notice to tell informal patients that they could leave the ward freely.

Staff had received training in the Mental Capacity Act and deprivation of liberty safeguards. Compliance rates were 100% on Billington ward and 94% on Baldock ward Staff had some understanding of the Mental Capacity Act, particularly the five statutory principles.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and how access to it.

Staff knew where to get advice from within the service regarding the Mental Capacity Act, including deprivation of liberty safeguards (DOLS). They spoke to the qualified staff or contacted the Mental Health Act office for advice and guidance.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately.

We assessed Harben ward, a High Dependency Rehabilitation ward for women with 16 beds on 11 September 2025.

This is the first assessment of the service, we assessed 33 quality statements.

There were 7 patients on the ward at the assessment.

We found 2 breaches of regulation at this assessment: 12 Safe Care and Treatment and 18 Staffing. We took enforcement action in relation to regulations 12 and 18. The breaches of regulation were in relation to staff responsiveness to incidents, medicines management, staffing levels and allocation of staff and ensuring staff receive an induction into the ward they are working on and receive regular supervision.

Mental Health Act and Mental Capacity Act Compliance Summary

Staff received training in Mental Health Act awareness, with 94% compliance. Staff had easy access to administrative support and legal advice regarding the implementation of the Mental Health Act and its Code of Practice. Patients had easy access to information about independent mental health advocacy.

Staff received training in the Mental Capacity Act, with 97% compliance. Staff had a good understanding of the Mental Capacity Act. Staff took all practical steps to enable patients to make their own decisions. We saw a detailed capacity assessment regarding a patients use of a mobile phone.

Requires Improvement

We rated the service as Requires Improvement. We found 2 breaches of the regulations in relation to safe care and treatment and staffing.

Staff did not ensure patients were receiving safe care and treatment and they did not ensure there were enough staff to be able to respond to patient’s needs. Staff were conducting enhanced observations for longer than the national guidance recommends. Staff were not consistently inducted onto the ward and incidents showed staff were not aware of the location of emergency equipment.

Not all environmental risks were assessed and mitigated.

Governance systems and audits were not effective in identifying or addressing areas for improvement.

However, staff knew how to protect people from abuse and improper treatment. Patients had individualised cared plans and were receiving interventions from the multidisciplinary team which followed best practice.

We assessed Harben ward, a High Dependency Rehabilitation ward for women with 16 beds on 11 September 2025.

This is the first assessment of the service, we assessed 33 quality statements.

There were 7 patients on the ward at the assessment.

We found 2 breaches of regulation at this assessment: 12 Safe Care and Treatment and 18 Staffing. We took enforcement action in relation to regulations 12 and 18. The breaches of regulation were in relation to staff responsiveness to incidents, medicines management, staffing levels and allocation of staff and ensuring staff receive an induction into the ward they are working on and receive regular supervision.

Mental Health Act and Mental Capacity Act Compliance Summary

Staff received training in Mental Health Act awareness, with 94% compliance. Staff had easy access to administrative support and legal advice regarding the implementation of the Mental Health Act and its Code of Practice. Patients had easy access to information about independent mental health advocacy.

Staff received training in the Mental Capacity Act, with 97% compliance. Staff had a good understanding of the Mental Capacity Act. Staff took all practical steps to enable patients to make their own decisions. We saw a detailed capacity assessment regarding a patients use of a mobile phone.

Requires Improvement

We rated the service as Requires Improvement. We found 2 breaches of the regulations in relation to safe care and treatment and staffing.

Staff did not ensure patients were receiving safe care and treatment and they did not ensure there were enough staff to be able to respond to patient’s needs. Staff were conducting enhanced observations for longer than the national guidance recommends. Staff were not consistently inducted onto the ward and incidents showed staff were not aware of the location of emergency equipment.

Not all environmental risks were assessed and mitigated.

Governance systems and audits were not effective in identifying or addressing areas for improvement.

However, staff knew how to protect people from abuse and improper treatment. Patients had individualised cared plans and were receiving interventions from the multidisciplinary team which followed best practice.