Cygnet Elowen Hospital

On this page

• 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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

Safety on Nowa ward has improved since the last inspection. Staff now assessed and managed risks to patients and themselves well. Staff now understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well. The wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose.

However, further improvements were required to ensure learning from incidents and concerns were consistently embedded and that staffing levels provided sufficient capacity to meet patients’ needs consistently.

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 service had developed a more proactive and positive culture of safety based on openness and honesty. However, recurring incidents showed that learning was not always consistently embedded and sustained across the service.

The service had not yet consistently demonstrated that learning from incidents was embedded and sustained in practice. Incident records showed recurring concerns relating to observations, medicines management, physical health monitoring and record keeping. Between June and July 2026, we identified repeated incidents involving permanent, bank and agency staff. This included delayed observations, patients being left unattended, medication errors and missed physical health monitoring. Some similar incidents reoccurred after retraining or competency assessments. Leaders could not always demonstrate that actions taken had been effective in preventing recurrence. The recurring incidents meant that learning was not consistently embedded and sustained.

However, the service had made progress and demonstrated a positive approach to learning. The service had a defined process for identifying, communicating and reviewing learning through incidents, audits, complaints, supervision, handovers and governance meetings. Leaders reviewed incident data monthly and took action in response to identified themes. For example, medication errors had reduced following remedial actions taken by leaders.

Staff also described examples of learning being implemented, including changes to meal preparation, CCTV positioning during enhanced observations and the introduction of weekly body maps following learning from pressure ulcers. Staff felt more supported by the new leadership team and were positive about the increased focus on training, specialist knowledge and person-centred care.

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.

We found improvements in the systems used to manage patients’ referral, admission and discharge. Staff used multidisciplinary discussions to consider whether patients’ needs could be safely met by the service and worked with patients, relatives and external professionals to support continuity of care. Leaders had also strengthened information provided to patients about what the service could offer and the admission process.

Staff identified and responded to risks within referral pathways. For example, the MDT recognised that some patients were being referred from the community with dangerously low body mass index BMIs and may have required medical stabilisation in a general hospital before admission. Staff were also reviewing admission criteria to ensure patients were appropriately referred to the service. This showed that staff were identifying risks at the point of referral and considering whether the service was the right setting to meet patients’ needs.

This was an improvement from the previous inspection, when staff did not always identify or mitigate risks during referral, admission and transition processes and did not consistently maintain continuity of care.

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 had completed safeguarding training and understood how to recognise abuse, neglect and other safeguarding concerns, when to make a safeguarding referral and how to work with other agencies to protect patients. Staff could also describe how they would protect patients from harassment and discrimination, including those with protected characteristics. Staff understood the importance of being transparent with patients when safeguarding referrals were made.

People felt safe and confident to raise concerns, knowing that staff would respond appropriately to maintain their safety and wellbeing. Staff actively encouraged people to share their views through engagement with staff across all teams, as well as through community meetings, ensuring their voices were heard and valued. One patient told us “I have raised concerns in the past and staff are very quick to offer support and reassurance.”

Leaders had strengthened safeguarding support since the previous inspection. A new social worker with experience in eating disorder services had joined the service and provided safeguarding support across both wards. Staff described this as providing additional expertise and a different perspective when considering safeguarding concerns and supporting patients with wider social needs.

Mental Capacity Act

Staff had received training in the Mental Capacity Act and demonstrated a good understanding of its principles and their responsibilities.

Staff demonstrated a good understanding of the Mental Capacity Act (MCA) and its five statutory principles. Staff understood the importance of supporting patients to make their own decisions and taking all practical steps to maximise their capacity before making decisions on their behalf.

Staff understood that capacity was decision-specific and could explain when a capacity assessment would be required. They understood that, where a patient lacked capacity, decisions should be made in the person’s best interests and should take account of their wishes, feelings and preferences. Staff knew where to access the provider’s MCA policy and where to obtain further advice when required.

Staff understood their responsibilities in relation to deprivation of liberty safeguards (DoLS) and the need to make an application where restrictions amounted to a deprivation of liberty. The service had arrangements to monitor the application of the MCA and DoLS.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff worked with patients to understand their individual risks and involved them in discussions about their care and risk management. Patients were able to express their views and preferences, and we observed patients confidently challenging staff during ward rounds when they disagreed with decisions. Staff listened to their views and responded respectfully to their wishes and requests.

Staff used multidisciplinary meetings to review patients’ risks and consider their individual needs. Staff understood the importance of identifying risks early and using de-escalation to manage distress and behaviours that could present a risk to patients or others. Staff understood the need to use restrictive interventions only when necessary and proportionately. Staff reviewed blanket restrictions regularly to ensure they remained necessary and proportionate. Staff used the 4Rs approach of rules, reason, rights and review to consider whether restrictions could be reduced. The audit was completed quarterly, with service user representatives involved where possible, and actions were reviewed through clinical governance processes. This provided assurance that blanket restrictions were monitored and that there was an ongoing focus on reducing restrictive practice.

Patients were supported to provide feedback about their care and treatment through community meetings and direct discussions with staff. Staff also supported patients to access advocacy where required.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The ward environment was clean, well maintained and suitably decorated, and the layout enabled staff to maintain oversight of patients and communal areas.

Staff had access to appropriate equipment to support patients safely. Clinic rooms were appropriately equipped, and emergency equipment and medicines were checked to ensure they were available when required. Staff understood the arrangements for responding to emergencies and could access alarms and other safety equipment when needed.

The service had arrangements to identify and manage ligature risks and other environmental hazards. Staff understood the risks within the environment and the measures in place to reduce these. The ward also had appropriate arrangements to protect patients’ privacy and maintain safe use of the environment.

The hospital environment had been purposefully designed to support patients’ safety, dignity, independence and recovery. Cygnet Elowen Hospital had been recognised in the Project of the Year (Refurbishment) category at the 2026 Design in Mental Health Awards following the transformation of the former nursing home into a specialist eating disorder and mental health service. The environment included flexible spaces, natural light and design features intended to create a calm and less institutional setting. The refurbishment had involved collaboration and co-production and considered the specific needs of the patient group, including principles from the Autistic SPACE framework.

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff to provide high quality, consistent care to patients. However, staff worked well together to provide safe care that met people’s individual needs.

Staffing levels did not always support the service to provide care to the best possible standard and to meet patients’ individual needs consistently. Staff turnover was high, at 89.47% in 2026 up to the report date, with many staff leaving within their first year of working for the service. Both nurses and support workers roles experienced high turnover, and the service continued to use bank and agency staff to fill staffing gaps. Staffing gaps had been affected by the provider’s decision to stop its sponsorship scheme. This was a provider-level decision and was not made by the Elowen leadership team. Leaders had taken action to improve staffing. They continued to recruit additional staff and completed a recruitment day shortly before our inspection, which they described as a positive. Despite these efforts, high turnover and continued staffing gaps meant the workforce had not yet become sufficiently stable.

Patients and the independent advocate told us that staffing pressures affected the support available to them. Patients reported missed 1:1 sessions with named nurses or key workers, reduced access to Section 17 leave and limited supervision during mealtimes. Patients also told us that some bank and agency staff were less familiar with their individual needs and ward routines. One patient told us “The regular staff are fab, and you can tell they really do care. Some of the bank or agency staff are really good too, but some have an inconsistent approach.” This affected continuity and consistency of care.

However, staff worked well together and supported each other to provide safe care. Staffing arrangements allowed leaders to respond to changes in patients’ needs, and there was sufficient staff available to respond to immediate safety needs. Medical cover was available day and night, with access to emergency medical support when required.

Staff had completed mandatory training, although some role-specific training remained below the expected level. Staff worked well together and demonstrated an understanding of the needs of patients with complex eating disorder needs.

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.

We found a good standard of infection prevention and control. Ward areas were clean, well maintained and suitably furnished. Staff kept equipment clean and maintained it appropriately, with cleaning records completed and up to date.

We also inspected the kitchen, which was located in a separate building. The kitchen was clean and well maintained, and records showed that it was regularly checked. Staff followed infection prevention and control procedures, including appropriate hand hygiene.

Patient’s were confident in the infection prevention and control measures in place and felt assured that staff took appropriate steps to protect them from the risk of infection. One patient told us, “The place is always very clean, it’s really nice. The cleaning ladies come around all the time, and they always make time to have a chat, they’re really lovely.”

The service made sure that medicines and treatments were safe and met patients’ needs, capacities, and preferences. They involved patients in planning, including when changes happen.

Staff followed good practice in medicines management, including the safe storage, administration and recording of medicines. Staff understood their responsibilities and managed medicines in line with relevant procedures.

Staff supported patients to be involved in decisions about their medicines and treatment. Where patients had capacity, staff explained the purpose of their medicines and involved them in discussions about changes to their treatment. Where patients lacked capacity, staff followed the relevant processes under the Mental Capacity Act 2005 and Mental Health Act 1983.

Care and treatment plans reflected patients’ level of understanding and demonstrated their involvement in decisions about medicines and treatment. Staff also monitored patients’ physical health in relation to their medicines and understood the importance of identifying and responding to potential side effects.