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. Although staff assessed and managed risks to patients this information was not consistently shared with patients. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service did not use systems and processes to safely prescribe, administer, record and store medicines. Patient safety incidents were not always recorded fully across all the services records.

The service was in breach of the legal regulations in relation to safe care and treatment (Regulation 12), Regulation 9 (3)(a) HCSA: Person-centred Care.

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 to, knew what incidents to report and how to report them. Staff undertook training around incident reporting including ‘reporting an incident on datix’ at 95% compliance and ‘reviewing an incident on datix for managers’ at 100% compliance.

We reviewed 5 patient files and 4 incident reports and 3 months of incident reports between October 2025 to January 2026 on medication errors. Staff reported incidents using an incident reporting system so records were kept in the patient file and as an incident report. Most of the reports we saw had been signed off by the clinical team. We noted that 27 incident reports had not been fully reviewed and signed off across the hospital, with some dating back 3 months. This was raised to leaders who reviewed and noted that some cases had not been completed fully. This was rectified and all incidents were marked as reviewed.

Staff understood the duty of candour. However, patients and families did not feel that all staff were open and transparent providing an explanation if things went wrong. We spoke to a family member whose loved one had been involved in an incident; they stated that they were only made aware of an incident as they had called the ward. They felt that the staff member lacked compassion in the way they shared information. One patient told us that they did not get feedback or any outcome when they reported incidents involving staff being verbally abusive to them.

Staff received feedback from the investigation of incidents, both internal and external to the service. They received a lessons learnt bulletin which included details of incidents from other Cygnet Hospitals and NHS providers. Staff we spoke to were able to give examples of where incidents had led to improvements taking place on the ward. Such as changes to the fencing in the garden area and post delivered to the ward being checked for any restricted items. After a serious incident on another ward at the time of our inspection, we saw a structured debrief taking place including members of the multi-disciplinary team (MDT).

We reviewed the team meeting minutes and found incidents were discussed. Lessons learnt and duty of candour were set agenda items at the last 3 months of clinical governance meetings which we reviewed. However, decisions and outcomes were not recorded in the minutes to evidence discussion had taken place or to show how lessons learnt were disseminated from governance to the staff team

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. The referral information we saw in patients’ paper files was detailed and reviewed by the full MDT prior to admission. Staff told us that this information helped them formulate treatment plans ready for the patient which were then reviewed with them fully once admitted. The safety summary in the services risk assessment showed clear evidence that the referral process helped inform risk management.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. There was a social worker and an occupational therapist within the service and members of the MDT liaised with external organisations such as community mental health teams, housing services and local authorities.

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 95% compliance for safeguarding individuals at risk training.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. However, there had been 2 reported incidents were a patient told us that staff directed abusive language at them. This had been followed up internally with the staff members involved with appropriate action taken and a safeguarding referral was raised.

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 19 referrals made for the ward in the last 6 months.

Staff followed safe procedures for children visiting the service. There was a visiting room off the ward, which was welcoming, decorated to a high standard with appropriate furniture to facilitate visits. The ward followed a booking system to ensure that everyone had an opportunity to use the visiting room.

Staff demonstrated awareness of how to protect patients who were vulnerable. Staff we spoke with were clear about their responsibilities and described the process for escalating issues and knew how and when to contact safeguarding leads or the police, where necessary. Safeguarding was discussed during morning handovers ensuring risks were reviewed and actions agreed.

There was a blanket restrictions process in place on the ward, and we saw that this was discussed and reviewed regularly on an individual basis.

Mental Capacity Act

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

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 with clear actions where issues had been highlighted.

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 this 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.

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.

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.

We reviewed 4 risk assessments which were called safety summaries on the ward whilst on the ward which were held in paper files. Care plans and a daily risk assessment were completed and held on an electronic system. Safety summaries were detailed and reflected the patient history but did not evidence how they had involved the patient in their formulation. One safety summary was not in the paper file despite the patient being on the ward for 4 days however, we were told that this had been updated and was on the electronic file.

Daily risk assessments were discussed in morning meetings and were RAG (red, amber, green) rated based on the level of risk following incidents. We saw in 1 patient record that the RAG rating remained green despite the daily notes and incident recording that the patient had displayed risk behaviours. This was raised with a staff member who explained that it had been missed and that it would be immediately rectified. The level of risk should have been increased following the morning meeting and they would look to increase it. Other daily risk assessments we viewed reflected the changes in risk appropriately.

Since opening there had been 31 incidents of restraint on the ward. There had been 10 uses of intramuscular rapid tranquillisation, with 9 of these taking place in January 2026. The ward were able to evidence the reasons for the increase and plans they had in place to manage this.

Two family members told us that they were not involved in risk management and had concerns that risk was not always effectively communicated especially around home visits. We saw that an incident that had taken place on the other ward where a patient had absconded as staff had not checked that the family were at home when escorting the patient. Despite lessons learnt being shared with all staff across the hospital around this incident families were concerned that leave was being agreed before ensuring that the family were able to facilitate a visit.

Staff enabled patients to give feedback on the service they received. We saw that community meetings took place and there was an expert by experience who met with patients on the ward and fed back to leaders any issues raised.

Positive risk-taking was encouraged, with staff focussed on empowering individuals to make informed choices, weighing potential benefits and harms. For example, restricted items on the ward were regularly reviewed and kept to a minimum.

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

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 that 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 through patient observations levels. Staff told us they knew where ligature points and blind spots were and had easy access to alarms and patients had easy access to nurse call systems.

There were potential ligature anchor points throughout the ward that staff had mitigated which were clearly recorded on a ligature heat map alongside where emergency equipment could be accessed.

Storage rooms which contained emergency equipment such as fire safety equipment were disorganised and cluttered with patients’ belongings. There was no clear system in place to separate patients’ personal items, and we saw risk items such as vapes were lying on the floor. It was unclear how patients risk items were being recorded in the storage areas with no clear system of recording. We were concerned about staff being able to access this equipment in an emergency. This was raised with staff at the time and immediate action was taken to mitigate the concerns.

Clinic rooms were equipped with accessible resuscitation equipment and emergency drugs. We noted that oxygen supplies that were stored on another ward within the hospital had run low prior to our visit and there had been a delay in restocking this due to inclement weather. This was raised with staff at the time who ensured that supplies were replenished the next day.

Not all emergency equipment bags had been checked in line with policy. There had been a 2-week gap in recording between 14 and 27 December 2025 and a check had not been recorded since. It was also noted at the time of our inspection that the seal on the emergency bag had also been broken and not replaced. This was raised with staff, and the bag was checked and a new seal applied.

During the inspection a patient had been able to access the clinic room by kicking the door. Staff stated that there had not been identified issues with this door previously. Other doors off the ward had previously required additional work to secure them although we were informed that these had been a different type of door. We reviewed this incident and noted that maintenance had secured the door the following day.

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.

The hospital had 1 nurse vacancy at the time of inspection with no vacancies for unqualified staff. The turnover of staff in the service since it opened was 15%. With 7% of staffing across the hospital coming from bank staff usage with no agency use since opening.

Managers had calculated the number and grade of nurses and healthcare assistants required within a corporate wide staffing matrix. Leaders told us whilst they adhere to the matrix they also responded to demand and acuity of the ward environment and had made decisions since opening, to go above that expected matrix. They were aware of the patient feedback around staffing and had with authorisation from provider leadership been able to increase staff by 1 by no longer having to use a regular staff member to carry out the first one to one observation as per the staffing matrix. They had also increased to 2 nurses per day shift which was also above the current staffing matrix.

Qualified and unqualified staff told us that even with additional staff they found it hard to fulfil their duties. Qualified staff were finding it difficult to respond to incidents, administer medicines, complete records and other duties expected of them within the shift, resulting in them feeling burnt out. Meeting minutes showed this was raised by staff in team meetings and patients in community meetings. Staff told us that issues such as the second signature on the controlled drug record happened as there was not enough staff to witness medications.

Staffing levels did not always allow patients to have regular one-to-one time with their named nurse. We saw this reflect in patients notes where regular 1-2-1 meetings were not consistently recorded. Patients told us this could be difficult due to the ward feeling short staffed and nurses being pulled off to support incidents and patient who were unwell. Patients told us that staff were busy and it was difficult to spend time with them. We observed this during our time on the ward with staff responding to incidents with patients waiting for support when they had requested it.

Patients were accessing one to one psychology sessions once a week and 3 patients and 2 family members all commented that they would benefit from more time and input with psychology. Staff told us that the service had currently frozen recruitment for an assistant psychologist which meant they were under resourced.

Staff and patients told us that staffing issues had resulted in activities on the ward being cancelled. Patients also noted that activities at weekends and evening were not consistent and it dependent on which staff members were on duty as to whether they went ahead. We noted that this had been highlighted as an issue by leaders and actions put in place to ensure that staff carried out activities set by day staff in the evening.

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

Staff were up to date with mandatory training. The training was appropriate for the patient group using the service. Although 1 staff member told us that training had been delayed due to a number of staff needing to be pulled back on to the ward when they should have been on training as they were needed to help cover the ward.

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, had good furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. We reviewed the cleaning rotas and records for the ward and saw that cleaning took place on weekdays but not at weekends.

When reviewing the clinic room on Burleigh ward we noted that the floors and surfaces were sticky and there was debris on the floor. This was pointed out to the nurse who cleaned the area immediately.

Staff adhered to infection control principles, including handwashing. We saw handwash stations and handwashing signs throughout ward areas and there were hand sanitiser units outside ward entrances. There was an infection prevention and control policy in place and staff were compliant with training on infection prevention and control.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Staff did not always follow good practice in medicines management including, transport, storage, dispensing, administration, medicines reconciliation, recording and disposal, and did not always do it in line with national guidance.

The controlled drugs register had not been fully completed with the necessary second signature to witness when medication had been administered. This had happened over a number of different shifts and days in November and December 2025 and been highlighted by the external pharmacist when they had reviewed the records. It had also been highlighted in the medicine audits carried out internally in both November and December 2025. As an outcome of the highlighted issues during our site visit, leaders had implemented a daily ward manager walk around which incorporated areas for attention, including checking of the controlled drug register.

Emergency equipment checks were not completed consistently on the ward with and there was a two-week gap since it had last been checked on 27 December 2025. This was discussed with leadership on site and promptly addressed by the service with additional measures put in place to check these were being regularly completed.

Oxygen supplies stored on the neighbouring ward 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.

A patient and family member told us how medication had run out and the patient had gone without for 4 days. This had resulted in the patient having a seizure before additional medication was sourced. On another occasion a different medication had also ran out before staff realised and had been able to reorder in time. One patient told us how they had had to chase up their own medication with their doctors and that staff don’t tell them in sufficient time when they are running low.

Our review of medication administration records (MAR) found that they did not contain a photo of the person. The presence of a photograph gives staff administering medication assurances that they are administering them to the right person. We were told by the nurse in the clinic room this was due to patients not consenting to having their photographs taken. Whilst patients were able to consent to use of photos and were within their rights to decline this, we reviewed records where at least 1 patient had consented to photos but still did not have one on their MAR. We were not assured that staff who were unfamiliar with the patients (due to staff frequently moving between wards) could ensure they were administering to the right person. We saw one medication error where a patient was administered a medication they had a recorded allergy to. It was not clear if this was as a result of poor recording of allergies or human error.

Medication was stored on disorganised shelves with only a sticky note with a patients first name to identify the basket holding their medication. We saw one medication error where a patient was administered a medication, they had a record allergy to.

Staff did not always consistently review the effects of medication on patients’ physical health in line with the National Institute for Care Excellence (NICE) guidance, especially when the patient was prescribed antipsychotic medication. We saw evidence in patient records that physical health checks were not routinely carried out especially around bowel screening. However, the provider confirmed that they looked into this immediately and robust measures to ensure that these were not missed in the future were put into place.