Cygnet Kenney House

Ratings - Acute wards for adults of working age and psychiatric intensive care units

• Overall

  Requires improvement

• Safe

  Inadequate

• Effective

  Good

• Caring

  Requires improvement

• Responsive

  Good

• Well-led

  Requires improvement

Our view of the service

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.

People's experience of this service

During the assessment we spoke with 2 carers and 6 patients. We conducted a Short Observation Framework for Inspection 2 (SOFI2) observation in the service, which is a structured observation which captures people’s experience of care during the on-site assessment. We saw some limited interaction between staff and the patient who was in a communal area on Billington ward.

Of the seven patients that we spoke with during the assessment, two patients said that staff did not respond quickly when they were distressed or needed help and one patient said that she had waited over three hours to be taken on her leave. The remaining patients did not raise concerns about access to leave. Three patients said staff treated them well and behaved appropriately towards them. One patient highlighted that staff used a torch when checking on her during the night to avoid switching on the light and waking her up. One patient said that her named nurse was working nights and was always busy.

One patient told us that she did not feel listened to and that her protected characteristics had not been considered by staff. The patient also raised that nothing ever came of issues raised at community meetings.

There was mixed feedback regarding the range of activities available on the wards and the quality of the food. One patient said that the staff needed to take care with patient allergies and that there was now a universal ban on nuts as a patient had a nut allergy.All the patients knew how to make a complaint and had received information about their rights.

Of the two carers that we spoke with, one said that they felt listened to and that when they were invited to patients' meetings staff explained everything to them. The other carer said that communication with staff was always good.