Cygnet Kenney House

Ratings - Long stay or rehabilitation mental health wards for working age adults

• Overall

  Requires improvement

• Safe

  Inadequate

• Effective

  Good

• Caring

  Requires improvement

• Responsive

  Good

• Well-led

  Requires improvement

Our view of the service

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.

People's experience of this service

We spoke with 4 patients, a carer and 2 stakeholders.

Patients told us that they did not feel safe on the ward and at times there were not enough staff to meet patients’ needs. This included not being able to talk with named staff and staff seemed too busy to talk.

When patients were distressed, staff did not always explain what they were doing. Responses from staff were not always helpful to patients, these included; “Don’t cry and stop crying, you are making me sad”. Patients observed staff not completing enhanced observations as prescribed.

Patients told us when they raised concerns, it took a long time to receive a response, and the complaints procedure was not always followed.

Patients were involved in the creation of their care plans. They thought staff were caring. Patients told us they were involved in their ward rounds and felt able to raise concerns and give feedback. Patients told us their physical health needs were being met by the service, or they were supported to access external providers.

Patients were involved in community meetings where they could give feedback about the service.

Stakeholders and carers told us that at times staff were not responsive to their requests. However, they were mostly involved in patients’ ward rounds. They told us that the multidisciplinary team listened to patients and made them feel heard.