Cygnet Aspen House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last inspection we rated this key question good. At this inspection, the rating has remained good.

Good: Staff assessed the physical and mental health of all patients on admission. They developed care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff assessed mental and physical health needs holistically and there was a multidisciplinary approach to delivering care and treatment. We reviewed 6 care records and found staff developed plans that met the needs identified during assessment. Relatives told us they were involved in providing information about their loved ones and confirmed that the hospital worked with other services involved in their care and supported them with external appointments such as general hospital appointments and supporting their loved ones to funerals, to access church, and shopping.

Care plans were reviewed every month or sooner if required. Monthly ward rounds were in place for all patients and care plans were reviewed as part of this process. ‘Care plan updates’ was a standing agenda item during the hospital’s morning meeting and if any changes were required, these were allocated to a relevant member of the team to update. Compliance in this area was monitored in the hospitals monthly clinical governance meetings.

Care plans evidenced regular physical health reviews were taking place and contact with external partners such as GP’s, dentists, physiotherapists, advocates and social workers was taking place. We observed during 2 ward rounds that patients were given the opportunity to express their opinions. We observed the hospital were alert to recognising and noting patterns in behaviour and undertaking initial screening when these differed from neurotypical expectations. Prior to the patient attending the ward round there was an update from multiple disciplines and patient needs were discussed in terms of therapy, daily living skills, section 17 leave, medication and discharge plans.

We spoke with the nurse who took the lead for physical health care. This member of staff held a monthly well-being clinic, completed a health passport for patients, conducted weekly observation checks, and monitored side effects from anti psychotic medication.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

Staff provided care and treatment interventions suitable for the patient group, The interventions undertaken, including medication and psychological therapies were those recommended by, and were delivered in line with guidance from the National Institute for Health and Care Excellence (NICE).However, as this was a rehabilitation ward we did not observe activities during our inspection and received feedback that the range and variety of activities could be improved to better meet diverse needs. The hospital provided some data to show that activities were offered but patients did not always engage in these activities.

Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. We saw evidence in the records we reviewed that other professionals had input into the patients care such as neurologist, diabetes team, dietician and GPs.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration and referred to speech and language therapy and dietician support when appropriate.

Staff participated in clinical audits. The hospitals audit schedule included 14 audits reviewing aspects of care and treatment including medicines, care records and physical health. The hospital was working towards benchmarking and quality improvement initiatives such as the Triangle of Care (a quality improvement scheme for health and social care providers that promotes safety, recovery and wellbeing by including and supporting unpaid carers) and accreditation for inpatient mental health rehabilitation services (AIMS).

The team included or had access to the full range of specialists required to meet the needs of patients in the service. The staff team comprised of a hospital manager, head of care, consultant psychiatrist, psychologist, occupational therapist, occupational therapy assistant, 2 whole time equivalent (WTE) therapy co-ordinators, 0.5 WTE speciality doctor and assistant psychologist, 9.5 WTE nurses and 19 WTE support workers.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group.

Managers provided new staff with appropriate induction and mandatory training. Staff we spoke with felt that they were provided with the necessary training to undertake their roles but told us they were interested in completing some further training. The hospital provided evidence that they offer a range of additional training for staff outside of mandatory training requirements, such as electrocardiogram (ECG) and venipuncture training.

Some staff informed us that they had not been receiving regular supervision until recently. However, clinical supervision compliance was 97% at the time of inspection and managerial supervision compliance was 98%. Appraisal compliance at the time of inspection was 97% with one member due to complete on return to work. Managers were providing staff with supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development) and appraisal of their work performance at the time of our inspection.

Following our last inspection, we asked the provider to ensure that staff had access to regular team meetings and we identified this was an area that was in the process of being improved. Some staff told us that until recently they did not have regular team meetings in place and when meetings were arranged these tended to focus on issues and were viewed as unsupportive. We reviewed minutes from the last meetings in February and April 2026. We could see a change to the team meeting agenda which included topics such as reflective practice, compliments and discussion of lead roles for staff such as freedom to speak up champion and multicultural lead ambassador.

Mental Health Act

100% of staff had received training in the Mental Health Act. Staff we spoke with had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice, and we spoke with the Mental Health Act administrator in the hospital.

The provider had relevant policies and procedures that reflected the most recent guidance which were accessible to staff on the providers intranet.

Patients had easy access to information about independent mental health advocacy and advocates visit the service.

Staff 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.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.

Staff requested an opinion from a second opinion appointed doctor when necessary.

Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.

Staff completed 6-monthly audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular and effective multidisciplinary meetings, which included people and families as partners in their care. The service invited external partners to these meetings.

Staff shared information about people at effective handover meetings within the team, and the hospital manager, head of care, consultant and nurse attended a morning communication meeting which we observed. These meetings included the handover of information such as people’s presentation, significant events, immediate actions for people, leave and appointments.

The teams had effective working relationships with teams and organisations outside the service, for example adult safeguarding teams, community mental health teams and social workers. Care records evidenced regular contact with these teams. We received feedback from external partners who told us that they were kept informed and information was provided to them prior to meetings. We observed that external partners were invited to monthly ward rounds for patients.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported patients to live healthier lives. We saw evidence in care records that staff supported people to manage any physical and mental health risks, monitor food and fluids, and manage and review medications.

The hospital ensured meal choices aligned with individual health needs, dietary requirements, preferences and cultural considerations. Patients told us the food was good and relatives we spoke with said that the hospital offered variety and met the dietary and cultural needs of their loved ones. We reviewed the external expert by experience report for April 2026 which commented that food continued to receive positive feedback from both staff and service users. Kitchen staff were described as warm, welcoming, and approachable.

We were informed by the occupational therapy team that activities helped to promote a healthy lifestyle for people and that activities were individual needs led, for example walking, sports activities including access to gym equipment, and working with people regarding budgeting and healthy meal planning. However, we were also told that the range and variety of activities could be improved to better meet diverse needs.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff used recognised rating scales to assess and record severity and outcomes, for example physical health monitoring using National Early Warning Score (NEWS) and LUNSERS tool to monitor side effects of medication. The Model of Human Occupation Screening Tool (MOHOST) was utilised by Occupational Therapists to provide them with a holistic overview of a patients occupational functioning.

During our observation of a patient’s ward round we heard about how the hospital monitored medication to support positive outcomes for patients, such as changes to medication to help support a reduction in the side effects of the medication. In addition, patients were risk assessed and supported to self-medicate. We observed how occupational therapy goals were improving outcomes and enabling patients to develop skills, such as using public transport, cooking sessions and budgeting.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff we spoke with were trained in and had a good understanding of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Training compliance at the time of our inspection was 94.4%.

We reviewed 6 care records which demonstrated consideration of a person’s capacity to consent. Capacity assessments were carried out as appropriate and were both time and decision specific. Records demonstrated that best interest decisions were carried out when appropriate and involved the person's family or advocate.

Audits were in place to monitor consent and Mental Capacity Act practices to ensure they were only in place when necessary.

Patients had access to advocacy.