Cygnet Kidsgrove Hospital

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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 Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. Staff assessed and managed patient risks, but this information was not consistently shared or discussed with patients. Safeguarding processes were effective, and staff worked well with external agencies to protect people from abuse. However, systems for prescribing, administering, recording, and storing medicines were not safe or reliable. In addition, patient safety incidents were not always fully or consistently recorded across all relevant records.

The service was in breach of the legal regulations in relation to safe care and treatment (Regulation 12).

We have not awarded this service a score for Safe.

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

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

All staff we spoke with were able to describe which incidents required reporting and understood the correct reporting procedures. Staff had completed relevant training, including ‘Reporting an incident on Datix’, which had a compliance rate of 95%, and ‘Reviewing an incident on Datix for managers’, which had a compliance rate of 100%.

We reviewed 6 patient files, 5 incident reports, and 3 months of incident data relating to medication errors, from October 2025 to January 2026. Staff reported incidents via an incident reporting system so records were held both within the patient file and as a separate incident report. Most of the incident reports we reviewed had been signed off by the clinical team. However, we identified 27 incident reports across the hospital that had not been reviewed, some of which were more than 3 months old. This was raised with senior leaders, who investigated and confirmed that the incidents had been reviewed but had not been correctly moved to the completed category. This was rectified, and all incidents were subsequently marked as reviewed.

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.

Staff received feedback following the investigation of incidents, both those occurring within the service and those reported externally. They were also provided with a lesson learnt bulletin which was shared via email and discussed in handovers and supervision, which included information about incidents from other Cygnet hospitals and NHS providers.

We reviewed the team meeting minutes and found that incidents were discussed. Lessons learnt and duty of candour were standing agenda items at the clinical governance meetings for the past 3 months. However, decisions and outcomes were not recorded in the minutes, meaning there was no clear evidence of the discussions that had taken place or to show how lessons learnt were disseminated from governance to the staff team.

We reviewed the team meeting minutes and found that incidents were discussed. Lessons learnt and duty of candour were standing agenda items at the clinical governance meetings for the past 3 months. However, decisions and outcomes were not recorded in the minutes, meaning there was no clear evidence of the discussions that had taken place or to show how lessons learnt were disseminated from governance to the staff team.

The service supported staff following incidents. After a serious incident on the ward at the time of our inspection, we saw a structured debrief taking place including members of the multi-disciplinary team (MDT).

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 had structured pathways and governance systems designed to support safe and effective transitions for patients. Comprehensive mental and physical health assessments were undertaken on admission.

Staff told us that the providers' central hub was responsible for assessing admission forms. The service told us they only had one hour to determine whether an admission was appropriate based on information they received from the central hub. Staff reported that low occupancy levels increased pressure to accept people who may not be suitable for the service. They explained that they attempted to mitigate these risks through early MDT reviews, requesting GP summaries, and using structured handovers, but acknowledged that further improvements were needed to strengthen checks at the point of admission.

Staff involved all relevant health and social care services to support continuity of safe care for patients, both during their admission and following discharge. The service had an allocated social worker who liaised with external organisations, including community mental health teams, housing services, and local authorities.

We spoke to 6 patients relatives. One relative of a recently discharged patient told us they were concerned that their family member had been discharged without their knowledge.

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.

The service had systems in place to identify and respond to safeguarding concerns. Staff were trained in Level 2 safeguarding individuals at risk (introduction) with 92% compliance for the hospital. All clinical and ward facing staff were expected to complete Level 3 safeguarding individuals at risk (intermediate). 83% had completed e-learning. Investigations into incidents were completed by ward managers or more senior staff and could also be undertaken by management colleagues from other Cygnet sites when required.

Staff were able to give examples of how they protected 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 with appropriate referrals made.

Staff followed safe procedures for children visiting the service. A dedicated visiting room located off the ward provided a welcoming environment, decorated to a high standard and furnished appropriately to support family visits. The ward operated a booking system to ensure fair access to the visiting room for all families.

Blanket restrictions were in place to maintain patient safety around high risk items. The service documented in their risk register plastic bags as being a high risk item that had a blanket restriction to maintain patient safety. Where such restrictions existed, patients were informed of them and the reasons why and were assessed on an individual basis. Clear posters on the notice board and at the ward entrance explained the ward’s blanket restrictions. The ward operated a locked door policy, which staff explained was necessary to ensure the safety and security of patients, prevent unauthorised access, and support appropriate monitoring of people entering and leaving the ward.

Mental Capacity Act

Staff had completed training in the Mental Capacity Act and Deprivation of Liberty safeguards in principle and practice with compliance of 88%.

Staff had a good understanding of the Mental Capacity Act, including the five statutory principles. They knew where to seek advice about the Mental Capacity Act and the Deprivation of Liberty Safeguards. The service had systems in place to monitor compliance with the Act. Staff audited the application of the Mental Capacity Act and took action in response to any learning identified.

There were no Deprivation of Liberty Safeguards applications made in the last 12 months. A Deprivation of Liberty Safeguards application would be made in order to protect people without capacity to make decisions about their own care. The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were aware of the policy and had access to it.

Staff took all practical steps to support patients to make their own decisions. Capacity assessments were completed in line with the Mental Capacity Act and were both time specific and decision specific. Assessments were only carried out when staff had reason to believe that a patient may lack capacity.

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.

Care plans and a daily risk assessments were completed and held on an electronic system. We reviewed 6 patients risk assessments and care plans whilst on site. Of the 6 patient records, all of them had comprehensive mental health risk assessments completed at the point of admission, with regular reviews undertaken thereafter.

Risk assessments incorporated general risk management strategies, including consideration of self-harm, suicide, exploitation, falls, and substance misuse, alongside documented crisis planning. Updates following incidents were evident in the majority of cases; however, there was 1 instance of delayed or incomplete amendments, where a risk assessment had not been promptly updated following episodes of self-harm.

Evidence of patient involvement in the risk assessment process was consistently absent across all 6 patient records reviewed.

There had been no use of seclusion and long-term segregation for the ward, as there is no seclusion suite on site.

We spoke to 6 patient family members, 5 of which told us that they were not involved in risk management and had concerns that risk was not always effectively communicated especially around leave and discharge planning.

Staff facilitated opportunities for patients to provide feedback about the service. Community meetings were held regularly, and an Expert by Experience visited the ward to gather patient views and provide feedback to the leadership team on any issues raised.

Positive risk-taking was promoted, with staff supporting patients to make informed decisions by considering potential benefits alongside associated risks. For instance, restricted items on the ward were subject to regular review and maintained at the lowest level necessary.

Staff ensured that patients had access to advocacy services. An advocate attended the ward on a regular basis, and their contact details were clearly displayed within the ward environment.

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

The design and layout of the wards meant there were areas accessible to patients that were out of sight of staff. Staff mitigated this by using convex mirrors positioned in corridors to reduce blind spots and by implementing appropriate patient observation levels. There were potential ligature anchor points throughout the ward; however, these had been mitigated and were clearly recorded on a ligature heat map, which also identified where emergency equipment could be accessed. Staff told us they were aware of the locations of ligature points, blind spots and emergency equipment, and they had easy access to personal alarms. Patients also had access to nurse call systems to alert staff

Storage rooms containing emergency equipment, such as ligature cutters and fire safety equipment, were disorganised and cluttered with patients’ belongings. There was no clear system in place to separate patients’ personal items. We were concerned that the volume of items stored in these rooms could prevent staff from accessing emergency equipment quickly in the event of an incident. This was raised with staff at the time, and immediate action was taken to address and mitigate the concerns.

We observed that oxygen supplies stored on the ward for hospital-wide use had run low prior to our visit. Restocking had been delayed due to adverse weather conditions, which prevented the scheduled delivery from arriving. This issue was raised with staff, who were already aware and confirmed that supplies were replenished fully the following day, and had sourced a temporary supply being sought from a sister site in the interim time.

The evidence showed some 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 always work together well to provide safe care that met people’s individual needs.

At the time of inspection, the hospital reported one nursing vacancy across both wards and no vacancies among unqualified staff. Since opening, the service had not used agency staff and reported minimal use of bank staff, accounting for 7% of staffing.

Staff turnover since the service opened was reported as 15%. The service advised that exit interviews were completed for all leavers and that records were maintained. Of those recorded as leavers, 21 staff were either inactive or did not commence employment (including 14 inactive bank staff), two staff moved from permanent roles to bank positions but were recorded as leavers, and seven left due to disciplinary reasons, sickness, or failure to complete probation. A further 12 staff left for a range of reasons, including promotion, career change, work-life balance, moving to another job, or childcare and family commitments.

Managers used a staffing matrix to calculate the number and grade of nurses and healthcare assistants required, adjusting for patient acuity and observation levels. Leaders told us that while they adhered to the matrix, they also responded to the demand and acuity of the ward and had, since opening, made decisions to staff above the levels set out in the matrix.

Qualified staff, worked across both wards, reported some challenges in consistently responding to incidents, administering medicines, completing records, and carrying out other expected tasks within the shift.

Qualified staff reported some challenges in consistently responding to incidents, administering medicines, completing records, and carrying out other expected tasks within the shift. We saw staff from Crocus ward having to respond to incidents on Burleigh ward, leaving less staff available to support patients on Crocus ward. We were told in the morning that Burleigh ward was short staffed due to staff sickness and the ward manager being on annual leave. There was no additional staffing on Crocus ward to account for staff having to support on Burleigh.

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

All patients we spoke with told us that the ward felt short‑staffed. One patient stated that if there were more staff, all their needs could be met. Another patient reported that they were often left waiting outside the nurse’s office for long periods before staff responded to them. This issue was also observed during our visit on several occasions, where patients were seen standing outside the nurses’ office without receiving a response.

However, one staff member told us that “patient Section 17 leave is not cancelled often, but there are occasions when it has to be postponed due to staffing levels”, indicating that staffing pressures had previously had an impact on patient care. Two patients also told us of occasions where their section 17 leave was postponed, due to staff availability. To improve patient experiences the provider were in the process of introducing a morning planning meeting for patients to plan their trips off the ward to reduce patients all requesting leave at the same time.

Staff had received appropriate mandatory training and were up to date with the required modules. The training provided was suitable for the needs of the patient group using the service.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The main ward areas were visibly clean, well-furnished, and well-maintained. Cleaning records were up to date and showed that ward areas were cleaned regularly. Our review of cleaning rotas and records for Crocus ward showed that cleaning took place on weekdays by domestic staff. It was unclear who was responsible for the cleaning at weekends, as we did not see any cleaning rotas or records for weekends.

Staff adhered to infection control principles, including effective handwashing. Handwash facilities and clear handwashing signage were visible throughout ward areas, and hand sanitiser units were positioned at the ward entrance. An infection prevention and control policy was in place, and staff were compliant with the required infection prevention and control training.

We reviewed 3 months worth of infection prevention and control audits, which were completed by the Clinical Manager. We found the audits were thorough, actions were appropriately addressed, and we identified no concerns.

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.

Our review of medication administration records (MAR) found some issues. For example, the MAR did not contain a photo of the person receiving medication. Including a photograph on medication charts gives staff administering medicines additional assurance that they were giving them to the correct patient, which was particularly important given the high turnover of patients. The provider stated that this was because patients had declined to have their photographs taken, however we saw no evidence of this.

Staff did not always follow good practice in medicines management, including the transport, storage, dispensing, administration, reconciliation, recording, and disposal of medicines, and these processes were not always carried out in line with national guidance.

The controlled drugs register had not been fully completed, as there were entries missing the required second signature to witness administration. This occurred across a number of different shifts between 26 December 2025 and 13 January 2026. A staff member told us that on occasions when there is only one nurse on shift and the ward was unsettled, it could be challenging to obtain a second signature for the medication record, but procedures were followed as closely as possible under the circumstances.

There was out of date Oramorph that had not been denatured. This was brought to the providers attention whilst we were on site and rectified immediately.

We saw that there were large stocks of medication which had been ordered repeatedly due to staff not checking stocks prior to requesting more.

One patient told us they were not made aware of what prescribed medication they were taking.

Clinical rooms were largely clean and tidy.