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.

Staff did not share risks and observation levels consistently with the team. There were not enough staff to ensure that patients’ needs were responded to, and staff were conducting enhanced observations for longer than the recommended duration. The service did not manage patient safety incidents well and did not ensure that staff were inducted onto the ward, knew how best to support patients and knew where the emergency equipment was. However, staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

This service scored 38 (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 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 1. The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Prior to the assessment, there had been an incident where a key broke in the nurses office door, meaning staff could not gain access to the emergency equipment. During the assessment, action had not been taken to relocate the emergency equipment into a location that was accessible if the lock failed. We reviewed information provided about other incidents involving the locks and found 2 previous incidents of locks failing on the ward. There was also an incident following the assessment, where a patient was locked in their room as the key and anti barricade system did not work and emergency services had to be called. This meant learning from incidents regarding the locks had not been actioned to avoid a reoccurrence and keep patients safe.

All staff we spoke to, knew what incidents to report and how to report them.

Staff reported all incidents that they should report. We saw datix incidents had been completed by staff. However, we saw a datix report that was brief and did not include the required level of detail to explain contributory factors of the incident.

Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation if and when things went wrong. Records showed there had been one incident of moderate harm and staff had followed the duty of candour requirements.

Staff did not always receive feedback from investigation of incidents, both internal and external to the service. We saw an email to staff involved in a medicines error and their managers, to advise of actions taken following the incident and changes in practice for staff to action. However, we reviewed the recording of a ligature incident, the incident was not accurately recorded and actions taken were not shared with staff. The datix report stated that “Staff managed to get a ligature cutter from another ward as they could not access our office”. The review of the incident by the ward manager stated that no concerns or issues were raised about the incident. No feedback had been given to the staff member reporting the incident. The reason for staff being unable to gain access to the ward office and any action taken was not recorded in the datix report and was not handed over from the senior nurse on shift.

Staff received a lessons learnt bulletin which included details of incidents from other Cygnet Hospitals and NHS providers. A presentation had also been created for staff to share the learning from within the service and externally to the service.

We reviewed the team meeting minutes and found incidents were discussed, however previous incidents regarding keys were not discussed and recorded.

We reviewed the last 3 team meeting minutes and saw that staff were debriefed and received support after a serious incident. However, actions were not clear, they included “Emergency red bag and ligature cutter locations reviewed.” The outcome was not recorded and this meant staff not at the meeting would not understand from the meeting minutes the action taken.

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

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes did not always ensure that all essential information about the patient was received to determine if the patient’s needs could safely be met. There was a central referral system in place. Assessments were completed by a central team at the provider. This meant staff from the service were not involved in the assessment for new referrals.

Staff did not always involve all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Stakeholders told us that the service were not proactive with providing updates, the stakeholders had to approach the service for updates. However, external teams were invited to ward rounds and could join remotely.

Most patients told us that their experiences on the ward were worse compared to previous placements they had been in, for example, the service did not continue with what had worked well in previous placements, for example the use of ice packs to assist patients when they were distressed. There was also differences about items patients could have access to compared to previous rehabilitation wards.

Patients told us their named nurse worked nights, therefore they found it difficult to speak with them, patients said staff were too busy to spend time with them and respond to their requests.

Patients told us their treatment and staff interventions were not always explained to them and that staff did not follow their care plan.

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, with 100% compliance for the introduction to safeguarding training. Staff knew how to make a safeguarding alert, and did that when appropriate.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Records showed involvement with the local authority regarding safeguarding concerns.

Staff followed safe procedures for children visiting the service. There were 2 visiting rooms off the ward, which were welcoming, decorated to a high standard with appropriate furniture to facilitate visits. Visitors were required to book in advance for the visit to ensure a room could be booked.

Information was available for patients about the use of force, the leaflet included why holds and physical intervention may be used. The welcome booklet to the ward explained the blanket restrictions in place, including items that were not allowed on the ward. There had been 19 incidents of restraint on the ward and 15 uses of intra muscular rapid tranquillisation, for 3 patients. The use of restrictive practice was discussed and monitored at the local clinical governance meetings. A blanket restrictions audit had taken place in August 2025, restrictions identified were restricted access to outside space as the ward was upstairs, restricted access to the laundry as it was off the ward and restricted access to the sensory room due to environmental risks that were waiting action.

Mental Capacity Act

97% of staff had had training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, minutes showed discussions took place in team meetings.

There was a Mental Capacity Act policy in place which staff had access to.

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.

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 do not 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 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 3 risk assessments during the assessment.

There had been 19 incidents of restraint on the ward, none were in the prone position. There had been 15 uses of intra muscular rapid tranquillisation, for 3 patients since the service opened in April 2025. There had been no use of seclusion and long-term segregation for the ward since the service opened.

Staff involved patients in care planning and risk assessment. Patients told us they were shown their care plans, however some had given feedback on the care plans and were waiting to see if their views had been included.

Staff did not always communicate with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. We reviewed 3 care plans for patients who were diagnosed autistic or in the process of being assessed for autism, their communication section of the care plan did not always advise staff how best to enable patients to communicate and how staff should respond if patients were overwhelmed or finding it difficult to communicate. However, positive behaviour support plans and one page profiles were in place which included strategies for staff to use if patients were distressed.

Staff were not always provided with all necessary information regarding risks of patients. We observed the evening handover on 11 September 2025, risks were not handed over to staff and the handover records did not include risks for 3 of the patients. Handover records had conflicting information regarding observation levels. This meant staff were not provided with consistent information about observation levels and may not have observed patients at the prescribed levels.

Staff did not enable patients to give feedback via surveys, the only completed surveys were for the acute and PICU wards. Community meetings took place most weeks, however the minutes were not always saved with the correct date on, actions were not always carried over to the following week, and it was not always recorded if the actions had been achieved or not.

Staff ensured that patients could access advocacy. Advocates attended the ward and their contact details were displayed on the ward.

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 carried out regular risk assessments of the care environment. The most recent ligature and blind spot audit had been completed in August 2025. However, the ligature risk assessment did not include the outside space which had a ligature risk of a drainpipe. The sensory room was locked due to a ceiling projector that posed a ligature risk and was awaiting boxing in, however there was a free standing lamp in the room which was not included in the ligature risk assessment.

The heat map which is a document aimed at identifying areas of high risk on the ward and location of emergency equipment, was blurry and had a different symbol for ligature cutters than the ligature risk assessment which would have made it confusing for staff to follow. The ligature risk assessment was over 140 pages long which made it difficult for staff to read and familiarise themselves with.

Ward layout did not allow staff to observe all parts of ward. However blind spots were recorded in the blind spot audit.

Staff had easy access to alarms and patients had easy access to nurse call systems apart from the kitchen and dining room. This meant patients could not call for assistance from these rooms.

There had been 3 incidents involving keys breaking in doors, or locks not working, resulting in delays in accessing emergency equipment, patient being unable to leave their room and a staff room not being secured. Leaders had not ensured the environmental risks were addressed to avoid a reoccurrence of similar incidents. Leaders had not relocated the emergency equipment following delays in accessing this prior to the assessment.

Clinic rooms were equipped with oxygen. Emergency equipment was stored in the staff office. Staff checked the resuscitation equipment and emergency drugs 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 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.

The service had one nurse vacancy and 5 support worker vacancies, the roles had been recruited to, however the recruitment checks were in process. The turnover of staff in the service since it opened in April 2025 was 11%. There had been 169 hours of staff sickness since the service opened. Agency staff usage was 7% in May 2025, 11% in June 2025, 13% in July 2025 and 11% in August 2025. Bank staff usage was 1% in May 2025 and 3% in August 2025.

Managers had calculated the number and grade of nurses and healthcare assistants required. However, there were not enough staff allocated to the shifts to ensure that the service followed NICE (National Institute for Health and Care Excellence) guidance NG10: Violence and aggression: short-term management in mental health, health and community settings which states “1.4.20 Ensure that an individual staff member does not undertake a continuous period of observation above the general level for longer than 2 hours.” We reviewed staff allocation records for 6 dates in September and found that on each date staff were conducting enhanced observations of patients at 1:1 or 2:1 levels of observation for 3, 4, 5 and 6 hours of continuous observation. This meant staff did not have a break in this time and were expected to provide constant observation to patients for prolonged periods of time.

Qualified staff shared with us how difficult it was to fulfil their duties as there was one registered nurse allocated to the majority of shifts, they were finding it difficult to respond to incidents, administer medicines, complete records and other duties expected of them within the shift, resulting in them staying on beyond their shift. Minutes showed this was raised by staff in team meetings. The debrief book also included concerns raised by staff of the ward being short staffed and the impact on them including not being able to take their break.

When agency and bank nursing staff were used, those staff did not always receive an induction and were not always familiar with the ward. We reviewed the daily staff allocations and found of 14 agency staff working on the dates reviewed, 11 did not have an induction in place. This meant we were not assured staff had been told and shown how to respond in an emergency.

We reviewed an incident where staff were unable to access the office for emergency equipment, staff were not aware of the location within the ward of other emergency equipment, resulting in them going to other wards for equipment. The ward manager had introduced a see and sign document for all staff regarding the location of the ligature cutters and heat map, however this had not been completed with all staff and was not dated. This meant we were not assured that all staff knew where the emergency equipment was stored and the risks within the ward environment.

A qualified nurse was not present in communal areas of the ward at all times.

Staffing levels did not always allow patients to have regular one-to-one time with their named nurse. Patients told us this could be difficult due to the ward being short staffed or their named nurse working nights.

Patients told us that staff shortages meant staff were really busy and it was difficult to spend time with them.

Patients were accessing 1:1 psychology sessions and a pamper session in the salon on the day we visited.

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

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service.

We reviewed a sample of supervision records and found there was no supervision records for all of the dates of managerial supervision recorded in the system for 4 staff members. Clinical supervision dates were recorded on the system from the debrief book. The only record of clinical supervision was the debrief book. Staff recorded in the debrief book at the end of each shift their summary of the shift. We saw entries for 7 dates and these entries were very negative with staff reporting feeling stressed, unsupported, burnt out, short staffed and unable to take their break. This meant we were not assured staff received appropriate support and supervision to enable them to carry out their duties safely.

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 did not always follow the dress code policy, we saw staff with false nails, nail varnish and watches on.

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

All ward areas were clean, had good furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing.

We do not always 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 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff did not always follow good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did not always follow national guidance. We found a patient had an allergy to Promethazine listed on 2 out of 3 of their medicine cards, it had been crossed off on one of the medicine cards. They had also been prescribed and administered Promethazine. This meant the prescriber was not accurately recording allergies and staff had not raised this as a concern. We raised this with the medical director who resolved this whilst we were on site.

A patient had been administered an intramuscular medicine which was not authorised, when asked, the service told us the consultant had authorised this under section 62 of the Mental Health Act, however the records did not include evidence of this.

PRN (as and when required medicines) protocols were referred to in patients’ records, however the protocols were not available with the medicines cards for staff to refer to.

Medicine records were difficult to read as there were several medicines that had been stopped and crossed out, these medicine cards could have been condensed to improve ease of administration. Dates of administration were difficult to read.

Staff reviewed the effects of medicines on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication.