Cygnet Kenney House

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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.

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

Inadequate: This meant people were not safe and were at risk of avoidable harm.

Our rating for the safe domain has been moderated to Inadequate. This is due to the concerns identified and detailed in the issued warning notice. These concerns are significant enough to limit the rating in this domain to inadequate.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

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

There had been several adverse events specific to this service. One included a patient putting a sticky substance in their bedroom door lock, making it impossible to re-open when they closed it. Another staff member was able to open the door using an anti-barricade key. On another occasion the key broke in the lock when a staff member was opening the office door. An out of hours locksmith was contacted to replace the lock as it was not possible to remove the broken key. As there were several incidents whereby keys had broken in the locks, impacting on access to bedrooms and the office, the maintenance team replaced all existing keys with a stronger set to minimise the reoccurrence of keys breaking in locks.

All staff knew what incidents to report and how to report them. The service had a policy on incident reporting and management. Staff gave us examples of what incidents to report and recorded incidents on the electronic incident management form.

Staff reported all incidents that they should report.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. There had been no duty of candour requirements on the acute and psychiatric intensive care (PICU) wards.

Staff received feedback from the investigation of incidents, both internal and external to the service. Senior managers from Cygnet Healthcare sent all ward managers a bulletin which contained learning points arising from the investigation of incidents. Examples of learning points included incorrect recording of safeguarding, hiding contraband items within a mattress and self-harm using aerosol sprays.

Staff met to discuss that feedback. Feedback was discussed at staff handovers, staff meetings, morning meetings and at supervision.

Following a medication error whereby staff administered expired medication to a patient, a new protocol was put in place. Weekend staff were required to complete a medication audit to be shared with all staff and the Mental Health Act team to ensure that similar errors did not occur.

Staff were debriefed and received support after a serious incident. This included attendance at reflective practice sessions and proactive support from the psychology department.

We do not always work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. There was a new system in place whereby new referrals went to the Cygnet bed hub for consideration. All information was then sent to the local ward teams, including physical health screening mental health act status and historical and current risks.

Staff usually involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Care coordinators were invited to patients' meetings. However, we did see one example of them not being fully included in the discussion during an observed ward round. Staff made referrals to social services, the GP and specialist health services such as the diabetic team when required.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. There was a safeguarding policy in place and staff escalated any safeguarding concerns to a qualified nurse and spoke to the local safeguarding team for support. Safeguarding training was mandatory, and compliance was 95% on Baldock ward and 100% on Billington ward.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. An example of this was ensuring the wellbeing of a transgendered patient on the ward.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. There was regular liaison with the local authority and children’s services for patients who had children that were being cared for elsewhere.

Staff followed safe procedures for children visiting the service. There were two visiting rooms off the wards in which visits took place.

Managers carried out a quarterly audit of blanket restrictions on each ward. Between April 2025 and September 2025 there were 208 incidents of restraint on Billington ward and 126 incidents of restraint on Baldock ward. Managers maintained and reviewed a restrictive practice dashboard.

Mental Capacity Act

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

There were no DOLS applications (safeguards to protect people without capacity to make decisions about their own care.)

The provider had a policy on the Mental Capacity Act, including DOLS. 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. They spoke to the qualified staff or contacted the Mental Health Act office for advice and guidance.

Staff took practical steps to enable patients to make their own decisions. Patients were involved in the development of their care plans, risk assessments and personal behavioural support (PBS) plans. Patients told staff what their triggers were and how best staff could support them at difficult times.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. We reviewed 8 patient records and saw that staff routinely carried out assessments of capacity.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Where it had been agreed with the patient, staff consulted with family members who knew their relative well.

Staff knew how to make deprivation of liberty safeguards applications if required in the future.

The service had arrangements to monitor adherence to the Mental Capacity Act. There were two Mental Health Act administrators who ensured that the correct procedures and paperwork were in place.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it. The Mental Health Act administrators sent emails to the registered clinician and nursing staff where corrective action was required.

We do not always work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were 208 incidences of restraint on Billington ward and 126 on Baldock ward between April and September 2025. Between June and August 2025 rapid tranquillisation was administered 28 times on Billington ward and 22 times on Baldock ward. Between June and August 2025, seclusion was used on five occasions on Billington ward only. There was no use of long-term segregation on the acute and PICU wards.

We reviewed 8 risk assessments during the assessment. Staff involved patients in care planning and risk assessment. We saw evidence of patients’ views in six out of the eight records reviewed. There was one instance where it was recorded that the patient did not want to engage in the process and one instance where the care plans were not reflective of the patient's diagnosis of autism and there were no reasonable adjustments in place. Patients and carers were invited to patient meetings and in one instance we saw recorded that the patient had not consented to carer involvement.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Staff printed out leaflets on diagnosis, medication and side effects. There was a system in place for communication using visual documents and a traffic light system for patients to identify to staff how they were feeling.

Staff enabled patients to give feedback on the service they received. There were weekly community meetings on each ward at which patients could express their views. We observed a community meeting on Baldock ward during the assessment and saw that patients were encouraged to express their views.

Staff enabled patients to make advance decisions (to refuse treatment, sometimes called a living will) when appropriate.

Staff generally ensured that patients could access advocacy. The independent mental health advocate attended the wards regularly and supported patients at meetings when they had requested this. On one occasion the advocate was not brought to Baldock ward for a patient meeting despite informing staff of why she was there.

We do not detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Staff did regular risk assessments of the care environment. On each shift a staff member was allocated to security tasks. The security nurse was responsible for daily environmental checks of the ward. Fire risk assessments were in place and up to date and there were designated fire wardens within the service.

The ward layout did not allow staff to observe all parts of Billington and Baldock wards. There was a blind spot behind each lounge door and in the garden. Staff mitigated this by being present in the garden, doing a full visual sweep of the garden and through prescribed patient observations. However, we saw from the observation records that staff were on long periods of observations of up to five hours without a break. The National Institute for Health and Care Excellence NG10 recommends “that an individual staff member does not undertake a continuous period of observation above the general level for longer than 2 hours.”

There were up to date ligature risk assessments on each ward which identified all potential ligature points, level of risk and adequate mitigation. The risks were colour coded into low medium and high, however the medium and high colour coding was very similar making it difficult to distinguish between the two and unclear what the risk level was.

The wards were for female patients only.

Staff had easy access to alarms and patients had easy access to nurse call systems in their bedrooms and in communal areas.

The seclusion room allowed clear observation and two-way communication and had an ensuite bathroom and a clock. There were controls for dimming the lighting and changing the temperature and there was access to an outside space so that a patient could get fresh air and exercise.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We do not make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There were 9 qualified nurses and 18 support workers on Billington ward and 8 qualified nurses and 26 support workers on Baldock ward.

Between April and June 2025 sickness absence was highest on Baldock ward. Shifts were covered by bank and agency staff and by offering existing staff overtime.

Between April and September 2025 staff turnover was 15% on Billington ward and 18% on Baldock ward.

The use of agency staff was highest in July 2025 at 35% on Billington ward and 39% on Baldock ward.

Managers had calculated the number and grade of nurses and healthcare assistants required. Managers increased staffing levels according to fluctuating ward acuity and according to the level of observations required to keep patients safe.

The number of nurses and healthcare assistants matched this number on all shifts.

The ward manager could adjust staffing levels daily to take account of case mix. We saw that additional staff were brought in to cover leave, appointments, staff training and observations.

When agency staff were used, we saw a lack of evidence of induction, so we were not assured that those staff were familiar with the ward, the patients and the risks. There were 10 missing inductions for agency staff who had worked on Baldock ward and 4 missing inductions for agency staff who had worked on Billington ward.

A qualified nurse was always present in communal areas of the ward.

Staffing levels allowed patients to have regular one-to-one time with their named nurse. However, one patient told us that her named nurse worked nights and was often very busy.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

There were enough staff to carry out physical interventions for example, observations, restraint and seclusion safely and although staff had been trained to do so, compliance rates were lower than expected.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had received mandatory training which was appropriate for the patient group using the service. However, there were individual elements of training on both Billington and Baldock wards where rates were less than 75% including safety intervention advanced training and safety intervention refresher training.

We do not always assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

All ward areas were visibly clean, had good furnishings and were well-maintained by the maintenance department. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. We reviewed the cleaning rotas and records for each ward and saw that daily cleaning, and regular deep cleans of specific areas was taking place.

Staff adhered to infection control principles, including handwashing. We saw handwash and handwashing signs throughout ward areas and there were hand sanitiser units outside ward entrances. There was an infection prevention and control policy in place and staff were compliant with training on infection prevention and control. The provider had a policy which stated that staff were required to have the ability to be bare below the elbow. However, some staff were wearing thick long-sleeved tops which may have been difficult to roll up the arms if required and one staff member was wearing a coat on Baldock ward.

We do not make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 1. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Staff did not always follow good practice in medicines management including, transport, storage, dispensing, administration, medicines reconciliation, recording and disposal, and did not always do it in line with national guidance. The ward doctor or the nurse in charge completed the reconciliation of medicines when patients were admitted to the wards. The service used a local pharmacist who attended the wards fortnightly, completed medication audits and provided information on any required actions. The pharmacist also provided staff training on pharmacology. However, there were two occasions when prescribed medication was unavailable for over a week from the pharmacy which impacted patients. A new protocol was put in place because of this. On another occasion, staff gave a patient expired medication and a new audit process was put in place as a result.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with the National Institute for Care Excellence (NICE) guidance, especially when the patient was prescribed a high dose of antipsychotic medication. We saw evidence in patient records that physical health checks were routinely carried out and that physical health was monitored following the administration of rapid tranquillisation.