Cygnet Elowen 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

Safe- this means we looked for evidence that patients were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

Staff and leaders generally established systems, pathways and transitions that supported continuity of care, with effective involvement of patients, relatives and partner services. Staff understood safeguarding responsibilities, identified concerns promptly and worked with partners to manage and reduce risks. Staff actively involved patients and their relatives in understanding and managing risks through collaborative and person‑centred approaches. Staff managed and administered medicines safely, with appropriate checks, oversight and patient involvement. Leaders usually made sure there were enough staff on shift. Although when the hospital first opened not all staff had the skills or training needed for disordered eating care and meal support, these issues had been addressed by the time of the inspection. Staff and leaders maintained a physically safe environment, but they did not always provide effective oversight of emergency planning arrangements. Staff and leaders responded to incidents and complaints; however, at times learning from these was delayed and reactive rather than used to drive timely improvement.

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.

Staff and leaders did not always use incidents and concerns to drive timely and consistent improvement. Since the hospital opened in July 2025, staff recorded one serious incident on Alina Ward, and the investigation was still in progress at the time of our inspection. Other incidents were mainly related to the use of clinical interventions, such as naso‑gastric feeding, when verbal reassurance did not succeed.

Patients understood how to raise concerns about risks to their safety. However, some patients told us that, based on previous experiences, they did always feel confident staff would manage these concerns effectively. During the early period after the hospital opened, staff and leaders experienced several safety and operational challenges, which affected confidence in the learning culture.

Staff investigated safety events and took action to reduce risks, but they did not always embed learning promptly. Although staff and leaders made improvements over time, progress in embedding learning was slow on some occasions. Staff were able to describe changes they had introduced to improve safety for patients and staff, but repeated issues showed that staff and leaders had missed opportunities to identify learning earlier.

By the time of our inspection, staff and leaders had addressed many of the earlier safety and operational issues, and staff demonstrated a developing culture of learning from incidents that had caused, or could have caused, harm. Staff and patients told us that raising concerns now prompted action and contributed to improvement.

Leaders complied with the Duty of Candour, for example when staff made medication or administrative errors. The Duty of Candour is a legal requirement that requires health and social care providers to act openly and transparently with people receiving care when things go wrong.

Staff prioritised safety and continuity of care throughout patients’ journeys. However, continuity of care at the point of patients’ admission was initially affected by gaps in the staffing skill mix, periods of inconsistent staffing, and limited access to specialist expertise. These early gaps meant some patients experienced delays in therapeutic input, and this affected continuity of care during the early stages of admission.

Over time, staff worked collaboratively with patients, relatives, and external care partners to improve continuity and deliver more joined‑up care during referrals, admissions, and discharges. Relatives of one patient told us they felt fully involved in their family member’s care, and staff consistently included them in planning and decision‑making.

Staff established individual care and transition plans before patients moved between services, which reduced risks and supported continuity. Staff considered discharge planning early to align care with patients’ goals. Referral processes generally ran smoothly, and staff involved relevant partners when required. Staff reported effective communication when patients moved into the ward, and leaders clearly explained referral, admission, and transition processes, including how staff assessed whether they could meet patients’ needs.

Staff shared information to ensure patients received appropriate care and support in line with their individual plans. For example, staff used hospital passports when patients required admission to another hospital. Staff followed policies and guidance to support referrals and provided information to patients to explain available support and ease transitions, for example by explaining referral pathways, outlining what patients could expect at each stage of their care, and providing written information to support understanding during admission and discharge.

Staff completed pre‑assessment paperwork and shared this promptly with colleagues, actively involving patients, relatives, and relevant care partners. This meant staff identified risks early, planned care effectively, and supported a smoother and safer transition into the ward.

Staff communicated patients’ needs effectively through structured handovers, memos, and communication books when patients moved between services. Staff made referrals to partner services in a timely and effective manner, which supported improved continuity of care following the initial challenges at admission.

We did not identify any closed cultures or safeguarding concerns during the inspection. Staff intervened appropriately when patients faced risks of harm. Staff ensured patients and relatives could access safeguarding information, and safeguarding records showed clear processes for reporting concerns, investigating incidents, and recording actions taken. Leaders submitted safeguarding notifications to the local authority and the CQC in a timely manner and maintained oversight of safeguarding actions and learning.

Staff supported patients to understand what being safe meant for them and how to raise concerns about their own safety or the safety of others. For example, by explaining safeguarding processes, displaying clear information on how to report concerns, and encouraging discussions during one‑to‑one sessions and ward meetings. While some patients told us they did not always feel safe on the ward, however they could not give specific examples. Relatives told us they felt their loved ones were as safe as possible. Staff identified and reported safeguarding concerns promptly and followed safeguarding policies.

When patients experienced harm or faced a risk of harm, staff shared relevant information with partner agencies, including the local authority and the CQC. Staff completed safeguarding training and gave examples of actions taken to protect patients from harassment and discrimination, including patients with protected characteristics under the Equality Act 2010. For example, by completing individual risk assessments, and making reasonable adjustments to protect patients’ dignity, privacy, and safety. Staff followed clear procedures to protect children who visited the ward.

Staff complied with the Mental Capacity Act 2005 and completed training in this legislation. Staff assessed patients’ capacity to make decisions and made best interest decisions when required, taking account of patients’ wishes, feelings, culture, and preferences.

During the inspection, we reviewed all patients’ risk assessments and risk management plans. Staff completed these appropriately and addressed patients’ individual risks. Staff involved patients in discussions about their risks and actively engaged them in managing risk, including during ward rounds. A ward round is a regular meeting where patients and the multidisciplinary team, such as doctors, nurses, and therapists, review the patient’s health, care, risks, and progress, and agree next steps in treatment together. We observed three ward rounds where patients raised concerns assertively, and staff responded constructively, demonstrating open dialogue and collaborative risk management. Staff recorded all incidents of restraint accurately.

Staff informed patients about potential risks and how to keep themselves safe. For example, by explaining the risks associated with low weight, electrolyte imbalance and by discussing how staff monitored physical health, meal plans, observations, and leave arrangements to reduce harm.

Staff assessed and managed risks proportionately and involved patients, so they understood decisions made about their care. For example, by explaining why staff increased or reduced observation levels, adjusted meal support, or granted Section 17 leave, during ward rounds.

Staff applied a balanced approach to risk, supporting patients while respecting their choices. For example, the consultant psychiatrist explained how they granted Section 17 leave, stating, “I encourage patients to take leave whenever possible. I carefully consider leave to promote independence and normal daily activities, which supports recovery.” Section 17 leave allows detained patients to leave the hospital for short periods, such as for visits, appointments, or activities, while staff continue to manage safety.

Staff completed person‑centred risk assessments and reviewed them regularly with patients or their representatives. Staff consistently supported patients when they communicated needs, emotions, or distress and used appropriate strategies to reduce the need for restrictive interventions. Staff carried out debriefs and used learning from incidents to improve future care. One patient told us, “Staff are pretty good at de‑escalating situations.”

Staff understood the causes of patients’ distress and applied the least restrictive approach. Staff reflected foreseeable risks and any required restrictions clearly in care plans. For example, by documenting risks related to low weight and self‑harm and clearly outlining any associated observation levels, supervised meals, or restrictions on leave needed to manage these risks safely.

Staff used restraint only as a last resort and followed best practice to ensure it remained lawful, necessary, proportionate, and minimised wherever possible.

Staff and leaders did not always ensure effective oversight of emergency planning arrangements. While the ward environment was generally safe and well managed, patients’ personal emergency evacuation plans (PEEPs) did not consistently support safe and effective evacuation.

Some PEEPs contained excessive information, which made it difficult to quickly identify essential actions required in the event of an emergency. One of the three PEEPs reviewed included inaccurate information about a patient’s mobility, which could have delayed safe evacuation. These issues demonstrated that systems to quality assure the accuracy and suitability of emergency planning were not consistently effective.

Following our feedback, staff reviewed and updated the PEEPs to ensure they contained accurate information and focused clearly on the critical actions needed to keep patients safe.

Otherwise, the environment supported the delivery of safe care. The ward layout enabled effective observation of all areas, and staff identified and managed potential ligature risks. Staff had access to alarms, and patients were able to use nurse call systems when required. Clinic rooms contained appropriate resuscitation equipment and emergency medicines, and staff completed regular checks. Although there was no seclusion room on the ward, leaders had appropriate arrangements in place with other services should patients require this level of support.

When the hospital first opened in July 2025, staff and leaders did not always ensure that staffing levels and the multidisciplinary team (MDT) consistently met patients’ therapeutic needs. Before the inspection, concerns we received from partner agencies, patients and their relatives highlighted that gaps within the MDT limited the delivery of coordinated therapeutic care. Patients and their relatives told us that they did not receive appropriate therapeutic support when they were first admitted. As a result, patients experienced delays in accessing appropriate interventions, and this continued to affect their confidence in the care provided.

Staff with limited or no experience of supporting people with disordered eating cared for patients before completing specialist eating disorder training. As a result, some patients reported that staff did not always fully understand their diagnosis or how best to support them. Although leaders had recognised these gaps and began addressing them, the impact of earlier care arrangements continued to influence current patient experience. Staff were undertaking specialist training at the time of the inspection, and leaders supported them to develop the knowledge and skills needed to deliver specialist care.

Leaders followed recruitment and employment policies and recruited additional staff over recent months and established a full MDT, including nurses, support workers, psychologists, doctors, and dietitians. This improved access to specialist input and strengthened the coordination of care. Staff completed mandatory training with good compliance rates.

Leaders provided supervision, appraisal, and professional development opportunities and took appropriate action to manage poor performance.

Patients reported that staffing levels did not always feel sufficient, particularly when staff responded to other patients requiring urgent attention. However, during our visit, we observed staff available throughout the day to provide therapeutic support and respond to patient needs. Leaders explained how staffing levels supported safe care and staff told us they felt there were enough team members on shift to meet patients’ needs.

Continuity of staff had improved in the weeks leading up to the inspection, and leaders had reduced reliance on agency staff for approximately six weeks, which supported better consistency of care. Staff told us they felt supported to develop their skills and knowledge, and leaders continued to monitor performance and provide targeted support to improve practice.

Equipment was well maintained and clean, and ward areas were clean, well-furnished, and well-maintained. Cleaning records were up to date, demonstrating that the ward was cleaned regularly. Staff adhered to infection control principles, including effective handwashing practices. The service maintained a high standard of infection prevention and control, supporting a safe environment for patients and staff.

Staff managed medicines safely and in line with national guidance, including storage, dispensing, administration, reconciliation, recording, and disposal. They regularly reviewed the effects of medication on patients’ physical health, particularly for those prescribed high-dose antipsychotics, in accordance with NICE guidance.

One patient reported delays in being informed about changes to their medications. However, we saw evidence that overall patients were involved in decisions about their medicines. Staff documented these discussions in care plans, ensuring patients’ preferences were respected.

Staff followed current best practice and professional guidance. Medicines were prescribed, supplied, and administered appropriately, and staff maintained accurate, up-to-date records. They did not use medicines inappropriately to control behaviour. Controlled drugs were stored, recorded, administered, and disposed of safely, with effective oversight. Clear, person-centred guidance supported the safe administration of as-needed (PRN) medicines.

The ward manager implemented strong governance and audit arrangements to oversee medicines management and were proud of the improvements achieved. They appointed a clinic lead to support governance. One staff said, “One of the senior nurses is a clinic lead, that means she is making sure stock is in there, expiry dates are all in check. When pharmacy comes, everything is in order”. Pharmacy audits confirmed that most previous compliance issues had been resolved.