Cygnet Kidsgrove Hospital

We assessed Cygnet Hospital Kidsgrove on the 12, 13, 16 and 19 January 2026 and asked for, and reviewed data related to the assessment.

Cygnet Hospital Kidsgrove was registered on 6 May 2025 to provide the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of disease, disorder or injury. The hospital had a Registered Manager in place.

The hospital provides acute care for adults of working age on Crocus ward, a 20 bedded female ward. The ward provides support for women with an acute episode of mental illness and require an emergency admission who are detained under the Mental Health Act, or on an informal basis.

We carried out this inspection as the hospital was a newly registered service that had not yet been inspected. We assessed the assessment service group (ASG) acute wards for adults of working age and psychiatric care units, as part of the overall location where we also inspected the ASG for personality disorder services.

We undertook an unannounced, comprehensive inspection of this service, looking at all five key questions to assess if services are safe, effective, caring, responsive and well led.

We rated the service as Requires Improvement. The hospital was in breach of 2 regulations: safe care and treatment (Regulation 12), and good governance (Regulation 17) .

The provider did not always ensure that medication administration was recorded following their own policy and NICE guidelines. For example, controlled drugs records were missing a second signature.

The provider did not always operate effective systems and processes to make sure they assessed and monitored their service. We saw that there were repeated incidents of the same issues across 3 months of audits that we reviewed.

The hospital was clean, well maintained and care was delivered in a suitable environment. Care plans and risk assessments guided safe practice were updated regularly although they lacked patient involvement.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

Staff had completed their mandatory Mental Health Act awareness training with 94% compliance across the hospital. Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff were aware of their designated Mental Health Act administrators, and the necessary policies and procedures were in place.

Patients had access to independent mental health advocacy. Care plans recorded that patients had their rights under the Mental Health Act explained in an accessible way, with support from other professionals when required. However, some patients did not recall having their rights explained or understanding the reason for their detention.

Staff stored copies of patient's detention papers appropriately, ensuring they were accessible to all staff who required them. Staff ensured that patients were able to take Section 17 leave (permission to leave the hospital) when it had been authorised. We saw that staff documented this authorisation clearly.

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 regarding the Mental Capacity Act, including deprivation of liberty safeguards. The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act.

Staff took all practical steps to enable patients to make their own decisions. Capacity assessments were completed in line with the Mental Capacity Act, which were time and decision specific. Assessments were only undertaken when staff had reason to believe that someone lacked capacity.

No applications for Deprivation of Liberty Safeguards had been submitted within the previous 12 months. Such applications are required when a person lacks the mental capacity to make decisions about their care and may need legal safeguards to ensure their rights are protected. The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were familiar with this policy and knew how to access it.

Staff kept up to date with training in the Mental Capacity Act, which was mandatory for all care staff. At the time of our inspection, training compliance was 96.4%.

We assessed Cygnet Hospital Kidsgrove on the 12,13,16 and 19 January 2026 and asked for, and reviewed data related to the assessment.

Cygnet Hospital Kidsgrove was registered on 6 May 2025 to provide the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of disease, disorder or injury. The hospital had a Registered Manager in place.

The hospital provides a personality disorder service on Burleigh ward, an 11 bed highly specialised personality disorder rehabilitation service. The ward provides specialised support for women with a personality disorder and other complex needs.

We carried out this inspection as it was a newly registered service that had not yet been inspected. We assessed the assessment service group (ASG) personality disorder services.

We undertook an unannounced, comprehensive inspection of this service, looking at all 5 key questions to assess if services are safe, effective, caring, responsive and well led.

We rated the service as Requires Improvement. The service was in breach of regulation 9, person centred care.

The hospital was clean, well maintained and care was delivered in a suitable environment. Care plans and risk assessments guided safe practice were updated regularly although they lacked patient involvement.

The ward did not always follow their policies and NICE guidelines in relation to the administration of controlled drugs. The lack of a second signatory for controlled drugs was noted on records for the previous 2 months.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were, and relevant policies and procedures were in place. Mental Health Act training had been completed by 94% of staff at the time of inspection.

Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had access to independent mental health advocacy. Care plans documented that patients had their rights under the Mental Health Act explained in a way that they could understand with support from other professionals when needed. However, not all patients could recall having their rights read or understanding the reason for their section.

Staff stored copies of patients' detention papers correctly and so that they were available to all staff that needed access to them.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted. We saw that staff clearly documented where this had been granted.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, including the five statutory principles. Staff knew where to get advice regarding the Mental Capacity Act, including deprivation of liberty safeguards. The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act.

Staff took all practical steps to enable patients to make their own decisions. 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. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.