Cygnet Elms

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

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

This meant people’s needs were met through good organisation and delivery.

The design, layout, and furnishings of the service supported patients’ treatment, privacy and dignity. Staff supported patients with activities outside the service, such as, education and family relationships. The service met the needs of all patients – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support.

We have not awarded this service a score for Responsive.

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

The evidence showed an exceptional standard. The service was exceptional at making sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Care plans were comprehensive, person-centred and co-produced with patients. Staff completed thorough assessments on admission and regularly reviewed and update care plans to ensure they continued to meet patients' needs. Care plans, communication passports and visual discharge plans were accessible to patients. Care records also included personalised documentation, such as ‘about me’ folders, to support staff to deliver individualised care.

We observed a wide range of accessible information, including easy-read health and legal information, developed to support patients in understanding their care, treatment and legal rights. Staff were creative and flexible in adapting their approach to meet individual needs. For example, patients were supported to attend cervical screening appointments using personalised strategies.

Patients and their relatives told us they felt involved in decisions about care and treatment. Staff worked collaboratively with patients and where appropriate, their relatives to ensure they were treated as equal partners in their care. Relatives were invited to contribute to care planning and reviews, where consent from the patient had been obtained. Staff promoted shared decision-making by using accessible communication methods and involving relatives where appropriate and where consent had been obtained. We observed care records consistently reflected patients' views, preferences and aspirations.

The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Between 1 July 2025 and 30 June 2026, the average length of stay was 36.6 months across 12 patients' admissions. Two patients were discharged to supported living placements during this period. We identified one delayed discharge, which records demonstrated was due to legal processes and the transfer of clinical responsibility to community services.

Staff worked closely with external partners throughout each patient’s admission. External professionals were involved in care reviews and discharge planning. Feedback from stakeholders was positive and highlighted effective communication, information sharing and collaborative working.

Patients and their relatives told us staff supported them to maintain important relationships. Both relatives we spoke with described staff as accommodating and told us they were supported to visit their relatives away from the service when appropriate.

The service supported patients to achieve meaningful personal goals during their admission. For example, one patient was supported to get married and maintain their relationship. Staff also supported other patients to maintain healthy relationships with their relatives by allowing flexible visiting arrangements that suit both the patient and their relatives.

Staff demonstrated a good understanding of patients’ individual needs. Where appropriate patients were supported to access education and employment opportunities that prepared them for discharge. For example, one patient was supported to work towards their PhD, with staff supporting them to maintain their educational goals whilst receiving their care and treatment within the service.

The evidence showed an exceptional standard. The service were exceptional at developing appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Patients received information that was tailored to their communication needs. Staff used a range of accessible formats to support patients to understand their care, treatment and rights, supporting them to making informed decisions about their care and treatment. Accessible information included easy-read care plans, visual discharge plans, hospital passports, Talking Tiles and communication passports. We saw examples of easy-read information being developed around individual needs, including physical health, legal information, safeguarding, relationships and bereavement. Information was reviewed regularly to ensure it remained accurate and up to date.

We observed a wide range of easy-read information on offer to patients, developed by the service. These included information about high cholesterol, Ministry of Justice restrictions, relationships, safeguarding and bereavement following the loss of a pet.

Communication grab sheets and grab files were available to provide staff with immediate access to key information about patients’ communication needs and preferences.

Staff kept patients’ relatives updated about their care and treatment where appropriate and consent had been obtained. Information about patient rights, treatment plan, complaints procedures and advocacy services were available in accessible formats, supporting patients to make informed decisions.

The service had effective information governance processes in place to maintain confidentiality and comply with data protection requirements. Staff demonstrated they understood what information needed to share with external organisations and completed statutory notifications appropriately.

The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Patients were encouraged to share their views through regular community meetings. We reviewed community meeting minutes and found patients’ feedback and suggestions were clearly recorded with actions taken in response. Outcomes were then fed back to patients at the next community meeting.

The service involved patients in making the environment their home. For example, patients contributed to the refurbishment of the sensory room and garden area.

Relatives told us they felt involved in their family member’s care and had positive relationships with staff. One relative told us they had regular communication with the service and attended MDT meetings remotely.

Patients and their relatives were given information about how to raise any concerns or make a complaint. Information about advocacy services and the complaints procedure were clearly documented around the service in different formats, depending on each patient’s communication needs. Staff supported patients to raise concerns when required. There had been no complaints referred to the Ombudsman during the last 12 months.

The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

Staff made reasonable adjustments to support patients to access their care needs. The environment was accessible and included a lift to support access between the ground floor communal area and first floor bedroom area. Patients requiring lift access were individually risk assessed and either supported by a staff member with this or given a key to the lift to access it independently, where appropriate.

Health passports contained detailed information to support external healthcare providers, including patients’ communication needs, legal status, and any reasonable adjustments they may need.

The service analysed incident data to identify patterns. Staff told us they had identified peak times that incidents peaked and to combat this they introduced structured activities during these periods to help support patients in distress.

Medical cover was available throughout the day and night. Staff told us doctors attended promptly in an emergency and patients were transferred to the local acute hospital without delay if it was deemed medically necessary.

The service planned patient discharges in partnership with external agencies. Discharges took place when clinically appropriate to support safe and effective transitions.

The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Patients told us they felt empowered to share their views and were actively encouraged by staff to participate in decision about their care. Staff supported patients by promoting a culture where patients felt their views were listened to, respected and acted upon.

The service had policies in place that aligned with equality, diversity and inclusion. These supported staff to recognise and reduce inequalities, protect people with protected characteristics and ensure care was fair and inclusive to all patients. All staff completed mandatory equality, diversity, inclusion and human rights training.

Staff made reasonable adjustments to meet patients’ individual communication, religious, cultural and social needs. Information was available in a range of accessible formats.

The service participated in the organisational Patient and Carer Race Equality Framework (PCREF). This aims to improve experiences and outcomes for people from racialised and ethnically diverse communities by embedding anti-racist practice.

Care and Treatment Review (CTR) meetings completed between august 2025 and May 2026 provided consistent positive feedback, highlighting person-centred care.

The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff developed personalised care plans which reflected patients’ individual wants, needs and preferences. Care treatment, transition and discharge plans were reviewed regularly and updated.

The service worked collaboratively with patients, their relatives, the multidisciplinary team and external agencies to plan care for patients. This promoted continuity of care and supported safe transitions for patients between services.

Discharge planning began early and involved community teams. Staff arranged meetings with future care providers and delivered tailored training to support safe and effective transitions.

We reviewed one patient who had remained on Section 17 leave for around three years due to delays in the transfer of clinical responsibility to community services. Throughout this period, the service continued to work closely with external professionals, attend multidisciplinary meetings and review the patients care and support.

Staff ensured all relevant healthcare professionals were involved in planning care, transitions and discharges for patients, supporting coordinated care.