Cygnet Joyce Parker 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

At our last assessment we did not rate this key question. This is the first rated assessment for this service. We looked for evidence that people were protected from abuse and avoidable harm.

This key question has been rated as 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 did not complete risk management plans for all patients. Managers had not identified all ligature risks and blind spots. We were concerned about the potential impact of patients coming to harm due to unidentified risks and poor risk management.

However, staff were now taking the emergency bag to ligature incidents. Staff were now using de-escalation techniques and only using restraint as a last resort. Leaders improved safeguarding practices. There were enough trained staff to safely care for patients.

The service was in breach of regulations for safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders ensured safety was a top priority that involved everyone, including staff as well as people using the service. Staff told us they learnt from incidents through debriefs involving patients, discussions in daily meetings and from learning shared by the provider.

Staff did not overlook or ignore risks. They were dealt with willingly as an opportunity to put things right, learn and improve. Leaders carried out ligature ‘drills’ to enable staff to learn and be more responsive. On Brook ward managers reviewed relational and physical security following an assault on a member of staff during a multi-disciplinary team (MDT) meeting. The MDT room setup has been changed to create more space and ensure an easier exit.

Leaders ensured incidents were appropriately investigated and reported. The provider reported 686 incidents between 1 November 2024 and 31 January 2025. The most common incident type was violence and aggression at 544. We reviewed 19 incident records; staff reported incidents correctly and managers investigated when required. Ward managers completed after action learning reviews following incidents and discussed these with staff. We reviewed incidents and manager reviews on Beck ward. The manager showed examples of where they shared learning with staff from their review of incidents, for example, recording details in the right sections of the incident report form. We reviewed Closed Circuit Television (CCTV) footage of an incident that a ward manager escalated for review and a second opinion. Leaders investigated this incident and identified learning in relation to staff response and what they could do to prevent situations like this occurring again.

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 learned lessons from safety incidents or complaints, resulting in changes that improved care. Examples included the provider updating their post ligature observations policy and procedures following an incident whereby a patient experienced physical impact some hours after the initial incident and strengthening mental health act processes following an incident involving a detained patient. Cygnet focused on different safety themes for learning each month, February 2025 was focused on how easy it was to hide blades. We saw evidence of this being shared and discussed with staff. Leaders implemented the Patient Safety Incident Response Framework (PSIRF). This approach encouraged greater learning for staff and people using the service.

The provider did not always manage or monitor people's safety. However, they were working with partners to establish and maintain safe systems of care and ensure continuity of care, including when people moved between different services.

Staff did not always ensure safety was a priority throughout people's care journey. During our initial site visit we identified not all patients had risk management plans and managers had not identified all ligature risks. This posed a risk to patients' safety whilst at the service.

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. Staff discussed all patients in ward morning meetings reviewing their presentation for the previous 24 hours, then updated risk assessments and care plans accordingly. We observed morning meetings on all wards which evidenced this.

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. Staff invited the patient's community team to attend the admission meeting and risk formulation was developed from this and the information provided. Staff kept the community team updated with any risks that may be contained within the ward environment but of concern once the patient is back out in the community. We reviewed the care records for a patient on Blythe ward which evidenced this approach.

Staff planned and organised care and support with people, together with partners and communities in ways that ensured continuity. Staff liaised with community teams to ensure appropriate care and support for patients continued following discharge from the service. Leaders gave an example of a patient who did not have appropriate accommodation to move into, the discharge was delayed until this was sorted, and crisis team support was in place. For patient safeguarding referrals, staff copied in the patient's home area safeguarding team to any communications with the local safeguarding team. Staff let the home team and local authority know when the patient was being discharged back to their home area.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Quality Statement Score: 3

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately.

Staff demonstrated a strong understanding of safeguarding and how to take appropriate action. Staff described situations where they raised safeguarding concerns and ensured they were referred to the local authority. Staff told us leaders ensured they understood safeguarding was everyone's responsibility. 97% of staff completed level 2 safeguarding training,

The provider had effective systems, processes and practices to make sure patients were protected from abuse and neglect. Staff discussed safeguarding concerns at the ward morning meetings. Managers took these to the daily hospital wide flash meeting for discussion and action. Ward managers and doctors were the safeguarding leads on each ward and supported staff to complete safeguarding referrals to the local authority. Leaders told us they had done a lot of work with staff to take ownership of safeguarding concerns, advising staff to ‘see it, say it, report it'. Staff told us since the previous inspection of the service when it was CAMHS, there were lots of discussions about being bystanders and the consequences for not reporting abuse being the same as for the abuser. We reviewed the hospital director's updated safeguarding spreadsheet which they shared with the local authority and local mental health trust safeguarding lead.

Leaders demonstrated a commitment to taking immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way. We spoke with 3 local external stakeholders involved with safeguarding processes within the local health and social care system. They told us leaders at the service shared a regularly updated spreadsheet that detailed safeguarding referrals to identify any themes. They identified improved internal processes for the escalation and response to safeguarding concerns. At the time of the inspection, they had no concerns about how the service was managing safeguarding concerns. They also told us leaders at the service kept them updated on any incidents and actions taken. We spoke with an advocate who visits the service. They told us staff were better at responding to safeguarding concerns, but they were not always informed in a timely manner and the patient's voice was sometimes lost. They were working with staff to address this. We reviewed monthly reports from the independent advocate. They stated in the November 2024 report that "the independent advocacy service was made aware of 4 new safeguarding matters. All matters have been investigated and dealt with appropriately at this time."

The provider ensured safety for any children visiting the service. There were visiting facilities available outside of the ward area and staff risk assessed any planned visits from children.

The provider ensured safeguarding systems, processes and practices meant that people's human rights were upheld, and they were protected from discrimination. During our previous inspection of the service when it was CAMHS, we identified incidents where staff were dragging young people during incidents of restraint. We reviewed CCTV footage of 7 restraint incidents and did not find any evidence of this. Leaders implemented a new CCTV review process. Previously this was completed by one person. Ward managers now reviewed CCTV footage of all incidents involving restraint and of any safeguarding incidents. Ward managers completed a CCTV review document that was attached to the incident record. Ward managers escalated any concerns, even minor, to senior leaders for a further review. Leaders conducted random samples of ward managers CCTV reviews. We reviewed a sample of 16 ward manager CCTV reviews. We saw examples of managers escalating to leaders for further review. Managers noted positive practice and made amendments to records where staff had not recorded correctly, for example, length of time of restraint, type of holds used. Learning from this was shared with staff.

Restrictions on the wards were in line with expectations for an acute and PICU service. We reviewed blanket restrictions on each ward. Staff completed and regularly reviewed blanket restriction logs for each ward with patients. Each restriction included a risk reason and detailed the impact on patients. Staff reviewed individual patient restrictions daily, for example, seclusion and enhanced levels of observations, with the aim to reduce and remove as soon as possible.

The provider did not always work well with people to understand and manage risks.

We saw staff involving patients in meetings about their care, where risks were discussed. However, staff did not always record in patient records how they involved the patient in discussions about risk. We reviewed care records for 12 patients. Staff completed risk assessments for all patients. During our initial site visit we identified 6 of the 12 patients reviewed did not have risk management plans and staff only completed these when a patient had access to unescorted Section 17 leave. We discussed risk management processes with leaders following our first site visit. On our return visit leaders shared updated care plans for patients which incorporated a new section detailing risk management and safety plans for staff to follow in relation to identified risks. The plans also included details of any restrictive interventions, for example, observation levels. We reviewed a sample of 7 care records and saw staff updated these to include risk management plans and the patient's view on their risks. Staff were rating identified risks, which was not in line with current National Institute for Health and Care Excellence (NICE) guidance. However, staff were completing risk formulations, and the provider was working on plans, in conjunction with stakeholders, to implement changes to risk management processes in line with guidance.

Following the last inspection of the service when it was CAMHS and concerns identified in staff response to ligature incidents, the provider updated medical emergency protocols for psychiatric emergencies. Staff were now taking the emergency bag to all ligature incidents. Staff were able to describe this to us and we viewed CCTV footage of a ligature incident that evidenced this happening.

Most risk assessments were person-centred, proportionate, and regularly reviewed with the person, where possible. However, in 1 care record for a patient on Blythe ward we found staff used punitive language in relation to management of risks.

Staff only used restraint as a last resort. If staff used restraint, it was lawful, for a legitimate purpose, safe and necessary, and staff always followed best practice. The service took a proportionate approach to imposing restrictions on patients. Patients' care plans reflected any foreseeable risks that may need restrictions. The provider reported 686 incidents between 1 November 2024 and 31 January 2025. Of these, 186 involved the use of restraint. This was due to the high acuity levels of patients on the wards. Blythe reported the most with 95, Beck 62 and Brook 29. Five of these restraints were in the prone position. Blythe reported 4 prone and Beck reported 1. There were 11 incidents where staff administered rapid tranquillisation. The provider reported 16 episodes of seclusion and 1 episode of long term segregation between 1 November 2024 and 31 January 2025. We viewed CCTV footage of 7 restraint incidents that occurred over the last 30 days. Staff used correct safety holds and followed positive safety intervention practices, for example, attempting de-escalation first and ensuring a staff member was taking a lead role. We spoke with an advocate who visited the service. They told us use of restrictive practices; seclusion, restraint and rapid tranquillisation had greatly reduced as staff became more confident in de-escalating patients.

The provider 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.

Staff cared for patients in environments that were not always safe. Whilst staff completed risk assessments of the care environment, we identified ligature risks and blind spots that staff had not recorded on the service ‘ligature anchor point and blind spot risk assessment’. On Brook ward we identified potential ligature points in the courtyard. Patients were able to freely access the courtyard, and this space was not observable from all parts of the lounge. We were unable to find assessments of the courtyard areas for any of the wards in the risk assessment. We found a blind spot in the seclusion bathroom and two potential ligature anchor points on Beck ward, which managers had not identified. We escalated these to the manager, who took immediate action to rectify.

The courtyard door lock on Beck ward was broken, which meant the door had to be left unlocked. This could pose a risk if the courtyard was deemed unsafe for any patients to freely access. The provider advised this was fixed the day after our site visit. On Brook and Beck wards we identified patient food items in the fridge (accessed via staff) that were opened and not labelled. Managers disposed of the food items during our visit. Staff were completing other required safety checks in the kitchen.

Blythe ward seclusion room was occupied during our visit, so we were unable to view this. Staff could not observe all areas of Beck ward seclusion room. We identified a blind spot in the bathroom. The seclusion room had two way communication and a visible clock. The room was very cold during our visit and the ward manager advised the heating controls were not working. We escalated this to leaders who temporarily decommissioned the seclusion room until these issues were sorted out. The provider advised these issues were resolved following the inspection.

We found all wards were clean and tidy. A patient on Brook ward told us that the ward was the best kept mental health ward he had ever been on. Staff maintained up to date cleaning records. Clinic rooms were clean, tidy and temperature controlled.

Staff did not always maintain equipment. On Blythe ward we found staff had not calibrated the blood pressure monitor and thermometer. On Brook ward staff last calibrated the blood pressure machine in March 2023. However, clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people's individual needs.

Leaders set staffing levels using the provider's staffing matrix. Leaders explained the staff matrix was based on Cygnet's matrix for acute and PICU wards, which was benchmarked against acute and PICU services nationally. They advised all wards were currently overstaffed (there should have been 12 support workers per ward and wards had 25, 30 and 34). All shifts were running above numbers, with an extra 211 shifts filled for January 2025. We reviewed staffing levels on each ward during both days on site and they were in line with the expected numbers, with sufficient staff to complete required observations and safety interventions. However, on one day we observed that a staff member was moved from Beck ward to Brook ward and during the morning meeting on Beck ward staff were unsure if they would be able to facilitate a patient's leave due to staffing numbers. Most staff voiced concerns that there were not enough staff to meet patient need, including access to Section 17 leave, and the matrix was based on numbers rather than acuity levels. Following high level feedback that staff and patients told us leave was cancelled due to staffing levels, leaders asked Cygnet's independent expert by experience to meet with all patients and discuss Section 17 leave being cancelled due to lack of staffing on the wards. The expert held 1:1 discussions with 16 patients, 4 patients were unable to engage. Of the 16 patients that engaged, 5 said their leave was cancelled. Of these 5, 1 patient was not prescribed leave due to presentation and 1 was too unwell to go out. Patient records stated the other 3 patients had accessed leave during the time they had reported it had been cancelled. On Beck ward we observed staff were very busy, constantly responding to patient needs, with some patients becoming agitated if staff were unable to respond immediately. We reviewed monthly reports produced by the expert by experience. The November 2024 report stated "One of the most prevalent concerns raised by staff is the feeling of inadequate staffing levels on the wards. Many staff members expressed that they often feel overwhelmed and unable to provide the level of care appropriate for the service users. This situation has led to increased stress among staff. Whilst this concern has been noted, this is likely due to the teams being used to the level of staffing proportionate for CAMHS". We discussed this with leaders who acknowledged that the change from CAMHS to an adult acute/PICU meant less staff were required and this had been difficult for staff to adjust to. Leaders had agreed to keep the wards running above numbers to support staff with the changes. Ward managers advised they were able to request additional staff if patient acuity increased. We completed a detailed analysis of staffing across all wards for January 2025. This included reviewing daily shift planners, planned numbers, actual numbers, number of patients and levels of observations. We identified most shifts were over planned numbers, with 1 night shift being 1 staff member short. Staff raised a concern with us regarding an incident on Beck ward where they said there were not enough staff to manage an incident safely and that staff did not respond from other wards. Leaders told us this was raised with them and investigated. We viewed the CCTV footage of this incident during our visit and observed 7 staff to be present on the ward, with 2 staff out of action from injuries sustained. This left 5 staff to manage the incident, which was dealt with effectively. We saw 2 staff from the other wards arrive to support in good time.

The provider reported a vacancy rate of 12.5% for qualified posts across all wards from 1 November 2024 to 31 January 2025. There were no vacancies for unqualified staff with the provider over recruiting to these roles. For the same period the provider reported no use of agency staff and bank staff filled 10% of qualified shifts and 16% of unqualified shifts. Staff sickness was an average of 1.8% and turnover 4%. The provider reported no shifts were unfilled for this period.

Staff received training that was appropriate and relevant to their role. The provider reported a training compliance rate of 98% for mandatory training across all wards. The provider shared details of specialist training provided to staff. These included training for dysphagia, clinical risk management, learning disability and autism (Oliver McGowan), ligature risk, promoting human rights, physical healthcare, and relational security. All staff completed an induction as part of the change from CAMHS to adult acute/PICU. Staff told us they were supported with additional training and shadowing shifts at other Cygnet acute and PICU services to help them with the transition.

Staff received the support they needed to deliver safe care. Staff told us they could access individual and group supervisions. Managers facilitated daily ward meetings and safety huddles for staff. As of 7 March 2025, the provider reported a compliance rate of 91% for clinical supervision, 88% for management supervision and 92% for appraisals.

We assess and manage the risk of infection and detect and control the risk of it spreading.

Staff adhered to infection control principles, including handwashing.

Leaders told us about a patient with an infection that required barrier nursing. They ensured measures were in place to keep other patients and staff safe. These measures included personal protective equipment and additional cleaning processes. Housekeeping staff spoke with the patients about how they would like their room to be cleaned.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Staff appropriately involved patients in decisions about their medicines. Two patients on Blythe ward told us they discussed the impact of side effects and subsequent changes to their medication with the doctor.

The provider ensured patient’s medicines were appropriately prescribed, supplied and administered. Staff on all wards checked the temperature of the clinic room every day. Medicines were appropriately stored. Staff checked medicines at risk of misuse at every shift handover. The pharmacist visited weekly to check stock expiry dates, however we could not find an up to date stock list on Blythe ward. Wards had an appropriate controlled drugs cupboard and a controlled drugs officer, at the time of the inspection there were no controlled drugs on the wards. Staff monitored fridge temperatures daily and these checks were audited by the ward manager and clinical team leader. However, on Beck and Brook wards we were concerned there was no safeguard in place to prevent the fridge being turned off accidentally.

We reviewed prescription charts for 17 patients, staff were not inappropriately controlling patients’ behaviour with medicines. We saw evidence in care records that staff regularly reviewed patients’ medication.