Cygnet Elms

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Outstanding. At this assessment the rating has changed to good.

Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed 4 care records during our assessment. Staff completed comprehensive mental health assessments for each patient during the admission process. They also assessed the patients’ physical health needs on admission.

Care plans were holistic, person-centred, recovery orientated and focused on meeting people’s need. Care records were updated regularly. Patients’ communication needs and preferences were clearly recorded. Staff regularly reviewed and updated care plans in response to changes in patients’ needs.

Some patients were not always able to be fully involved in decisions about their care due to their presentation. On these occasions, staff supported patients to be involved as much as possible and adhered to the appropriate legal frameworks.

Patient relatives were supported to contribute to care planning and risk assessments where appropriate and where consent had been obtained by the patient.

Patient records demonstrated comprehensive admission assessments, including their registration with a GP, dentist and optician, physical health screening, health passports, health action plans and visual discharge plans.

Accessible care plans were co-produced with patients, according to their communication needs and reviewed on a 4 weekly basis. Care records also included sensory profiles and other assessments to support person-centred care.

We reviewed four care records during our assessment. Care records contained comprehensive assessments, including sensory profiles, Disability Distress Assessment Tools (DisDAT), health action plans and essential lifestyle plans that supported person-centred care.

Patients’ physical health was monitored on a regular basis. Staff used the National Early Warning Score (NEWS2), to ensure changes in patients' health were monitored. Staff also supported patients to monitor their weight by taking monthly waist circumference and Body Mass Index (BMI) measurements. Reasonable adjustments were made to support people to access healthcare. Staff gave an example of a person who experienced anxiety attending appointments who was supported by the service staff to work their way up to attending GP appointments.

One staff member told us how staff completed eating, drinking and swallowing assessments for people with dysphagia. They also told us that patients’ capacity and risk around eating and drinking were appropriately assessed. They gave examples of patients that had individual support plans in place, especially for patients who were at high risk of choking.

The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well

The service had access to a full multidisciplinary team, including psychiatry, psychology, occupational therapy and speech and language therapy. Staff were qualified and had completed specialist training to carry out their roles.

Staff delivered care and treatment in line with NICE guidance, including medication, psychological therapies, rehabilitation activities and evidence-based speech and language interventions.

Patients had access to physical healthcare including routine screening and support with nutrition and hydration where required.

A Stopping Over Medication of People (STOMP) audit completed on 30 June 2026 confirmed psychotropic medicines were prescribed within the recommended maximum dose limit were subject to regular reviews by the MDT.

Staff participated in clinical audits, benchmarking and quality improvement initiatives. Staff told us they received regular clinical supervision, appraisals and attended team meetings.

Care records demonstrated evidence-based approaches to support communication, positive behaviour support and physical health needs, including sensory assessments, communication passports and physical health monitoring.

Mental Health Act

Mandatory MHA training compliance was 100%. Staff had a good understanding of the MHA, the Code of Practice and its principles. The provider had up-to-date policies and procedures in place and staff had easy access to guidance.

Staff explained patients’ rights in a way that they could understanding, using accessible communication methods where required. Records confirmed that patients’ rights were explained on admission and repeated at appropriate intervals.

Patients had access to independent mental health advocacy services, with an advocate visiting the service regularly to provide patients with advice and support.

Staff supported patients to take Section 17 leave where this had been authorised. Leave arrangements were managed safely and reviewed regularly to ensure they reflected patients’ current needs and risks.

Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

We observed an out of hours handover, which was well structured and demonstrated effective sharing of key information between shifts. We reviewed shift handover documents from May and June 2026 and MDT red risk meeting minutes from June 2026, both of which demonstrated effective communication and information sharing.

Staff had regular multidisciplinary meetings and shared information effectively following these at handovers.

The service worked collaboratively with external partners such as local GP services.

We reviewed one patient who had remained on Section 17 leave for approximately three years, due to delays in transferring clinical responsibility to community services. Throughout this period, the service continued to work with external professionals, attend multidisciplinary meetings and maintain continuity of care and treatment.

The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service supported patients to maintain and improve their physical health. Patients were registered with local health services, including a local GP, dentist and optician as part of the admission process. Patients were then supported by staff to attend appointments. The service maintained strong links with the local GP practice and other healthcare partners to ensure patients received timely and coordinated care.

Health assessments were completed regularly by the specialty doctor and physical health nurse. Patients received annual health checks, which were consistently documented in care records.

Staff supported patients to live healthier lives through healthy living advice, smoking cessation support, cardiovascular risk management and access to national screening programmes, including cervical screening. Patients were encouraged and supported with understanding how to monitor their own health. Health promotion information was readily available throughout the ward, including easy to read information developed by the service around specific topics, such as oral health, bowel screening and breast changes awareness.

Patients had access to facilities and activities that promoted healthy lifestyles and independence. With staff support, where required, patients could use the therapy kitchen, onsite gym and beauty salon. We observed patients utilising these facilities during our assessment.

Healthy prepared meals were available, and staff supported patients to make healthier dietary choices. Staff worked with the kitchen team to adapt meals and used visual resources to support patients to understand possible dietary choices.

Patient received routine physical health monitoring, including blood tests, ECG’s and annual health checks, where appropriate.

Health passports contained detailed information to support continuity of care when patients had to attend acute hospitals. These included communication needs, legal status, reasonable adjustments and guidance for external healthcare professionals.

Records demonstrated proactive management of physical healthcare, including communication with GPs to support informed decision making.

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff used a range or recognised clinical tools to monitor patients progress and evaluate outcomes. These included the Health of the Nation Outcome Scales (HoNOS), National Early Warning Score 2 (NEWS2), the Malnutrition Universal Screening Tool (MUST) and the Waterlow scores. Staff routinely monitored patients care using recognised assessment tools and physical health screening to ensure care was delivered in line with national guidance and met patients’ individual needs.

The service had effective systems in place to monitor and improve outcomes for patients. Patients told us they were actively involved in reviewing their progress through regular care reviews and multidisciplinary team meetings.

The service used the DIALOG scale to support collaborative reviews of patients' needs and outcomes. This is a tool used to help people share how satisfied they are with different areas of their life and mental health care, helping identify where they may need any support. Clinical audits also demonstrated ongoing monitoring of quality of care.

The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff supported patients to understand and consent to their care and treatment. Patients were empowered and supported to make their own decisions where appropriate. Staff used accessible language and information, such as easy-read material, developed by the Speech and Language team. This supported patients with understanding their care and treatment options, helping them make informed choices.

Staff took all practical steps to enable patients to make their own decision. Where patients lacked capacity, staff completed and documented decision-specific capacity assessments in line with the MCA. Where patients lacked capacity, staff made best interest decisions that reflected their wants and wishes, involving the patient’s relatives and other professionals where appropriate. We reviewed 4 care records during our assessment. 1 patient had a decision-specific capacity assessment completed and was assessed as lacking capacity. A best interest meeting had been held and all documentation was completed correctly.

For patients detained under the MHA, staff adhered to the correct legal frameworks. Staff ensured detained patients understood their rights using appropriate communication methods and included patients in making decisions wherever possible.

The staff had a clear policy in place for assessing patients’ mental capacity to consent to admission and treatment, aligning with the code of practice. Mandatory training compliance for MCA and MHA was at 100%.