Cygnet Kenney House

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

This is the first assessment for this newly registered service. This key question has been rated Requires Improvement.

Requires improvement: This meant people’s needs were not always met.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We do not always make sure people are at the centre of their care and treatment choices or decide, in partnership with them, how to respond to any relevant changes in their needs.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

The service had several new staff completing the recruitment and onboarding process. This was partly to ensure that there were enough female staff, as patients often requested female staff members for observations.

Staff usually discussed care plans and Positive Behaviour Support plans with patients and ensured that their views were recorded and a copy of their care plans was offered to them. Patients were invited to attend their ward rounds and express their wishes, feelings and preferences to the multi-disciplinary MDT team. However, we attended a ward round on Billington ward and saw that the patient was not fully included in the discussion about their care and treatment. There were external professionals who had attended via Microsoft teams who were also not invited to provide their feedback.

Staff supported patients to access the advocacy service so that they could obtain independent support and representation if they wished. However, on one occasion, the advocate was not included in ward round attendance despite informing ward staff of the purpose of the visit.

We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

When appropriate, staff ensured that patients had access to activities that were of interest to them.

Staff supported patients to maintain contact with their families and carers.

Staff supported patients to access their chosen place of worship within the community. A chaplain visited the wards and there was a multi faith room on site. Staff escorted patients with leave to places of worship in the community.

We provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed. We saw evidence that the service was in regular contact with locals safeguarding teams, commissioners and the Care Quality Commission.

Information governance systems included confidentiality of patient records. All records were stored on an electronic system. Staff had undertaken general data protection regulation (GDPR) as part of their mandatory training.

The service complied with the Accessible Information Standard (AIS). This is a law that requires NHS and adult social care organisations to ensure that people with disabilities, impairments or sensory loss can access and understand information and receive communication support.

Staff ensured that patients could obtain information on treatments, local services, patients’ rights, how to complain and so on. This information was displayed on patient notice boards in the communal area on each ward.

The information provided was in a form accessible to the patient group. Easy read leaflets and leaflets translated into other languages were available on request.

Staff ensured carers, families and commissioners were regularly updated about the patient’s progress. With the patient’s consent, staff involved carers in care planning, discharge planning and invited them to all patient review meetings. Staff informed families of incidents when they occurred.

We make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. We involve them in decisions about their care and tell them what’s changed as a result.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Patients had raised 11 complaints since the service opened in May 2025. Baldock had the highest number of complaints at 9 whilst Billington had received 2.

Of the complaints raised, 36% were pending outcomes as they were still under investigation, 36% were partially upheld, 7% were not upheld, 7% were upheld and 14% were withdrawn.

There were no complaints referred to the Ombudsman since the service opened.

The key theme from the complaints was therapeutic interventions, of which quality of care was the primary subcategory. A complaint from a patient on Baldock ward was about staff not carrying out observations correctly. Although elements were found not to be substantiated, there were recommendations arising from the investigation. This included a see and sign care plan for the patient, provided to the staff regarding risks and mitigations, prior to observations being allocated.

Patients knew how to complain or raise concerns. There were posters and leaflets on the ward and staff supported patients to make their complaint.

When patients complained or raised concerns, they received feedback on the outcome of the investigation.

Staff protected patients who raised concerns or complaints from discrimination and harassment. This was through maintaining confidentiality and adherence to data protection.

Staff knew how to handle complaints appropriately. Staff that we spoke with were able to explain the process and knew how to escalate complaints to the right person.

Staff received feedback on the outcome of the investigation of complaints and acted on the findings. Following a complaint about staff attitude and behaviour towards a patient, managers created a standing agenda item for team meetings on the importance of staff professionalism towards patients, carers and commissioners. Part of this was the requirement for staff to always introduce themselves properly to visitors to the service.

We make sure that everyone can access the care, support and treatment they need when they need it.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

There were no patients with mobility issues on either of the wards that we visited. However, one of the wards was on a ground floor and both wards were wheelchair friendly as were patients' en suite bathrooms.

Staff told us that they could provide walking aids and shower chairs if a patient had mobility issues.

There was adequate medical cover day and night, a doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital.

Staff ensured patients had access to post-discharge care for example, S117 aftercare, community mental health services and crisis services.

Staff planned for patients’ discharge, including good liaison with care managers/co-ordinators. Care coordinators and other relevant professionals were invited to discharge planning meetings. We saw evidence on patient records that discharge planning was undertaken and referrals were made to appropriate services.

The hospital had been open for five months at the time of the assessment and there were no delayed discharges.

We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views. Community meetings took place weekly on each ward. We attended a community meeting and observed that patients were encouraged to give their views and that staff listened to them and gave them a response.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

Staff were trained in equality, diversity, inclusion and human rights. Training compliance for equality and diversity was 100% on Billington ward and 97% on Baldock ward. All staff had received the appropriate mandatory training on learning disability and autism and compliance was 100% on Billington ward and 97% on Baldock ward.

We support people to plan for important life changes, so they can have enough time to make informed decisions about their future, including at the end of their life.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff supported patients to make decisions about their care and treatment and their future wishes for example do not attempt cardiopulmonary resuscitation (DNACPRs.)

Staff created personalised care plans to account for patients' needs, wishes and feelings. Staff generally ensured that all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs.