Cygnet Grange

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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

This means we looked for evidence that patients were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection and assessment, the rating has changed to 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 patients could be harmed. The service did not always detect and control potential risks in the care environment, the service did not always assess or manage the risk of infection and patients. Staff did not always complete Intermittent observations at unpredictable intervals, reducing effectiveness and increasing risk.

However, lessons were learned from safety incidents, the service worked with patients and healthcare partners to establish and maintain safe systems of care, staff demonstrated a strong understanding of safeguarding and how to take appropriate action and staff assessed and understood risks.

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 evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Lessons were learned from safety incidents, resulting in changes that improved care for others. Staff told us they learnt from incidents through debriefs and post incident reflective practice. Senior leaders described actions they implemented to enable improved communication with patients’ families following a serious incident that occurred at the service.

Risks were not overlooked or ignored. They were dealt with willingly as an opportunity to put things right, learn and improve. Staff focused on the antecedent to any incident to try and prevent reoccurrence. Staff looked at what was happening before an incident and reviewed the communication needs of the patient to support learning and improvement.

Incidents were appropriately investigated and reported. The provider reported 161 incidents between 01 May 2025 and 01 April 2026. Of these, 12 incidents were unwitnessed patient falls. The provider advised all patients had been or were under the falls team, all had care plans, risk assessments and policies and processes were followed which included CQC notifications, duty of candour and safeguarding reporting where necessary. There was 1 choking incidents with no harm caused. The provider advised all patients involved were referred to the Speech and Language Therapy (SaLT) team and risk assessments and processes were in place. Other incidents included safeguarding concerns between patients and physical health concerns.

The evidence showed a good standard. The service worked with patients 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 patients moved between different services.

Safety and continuity of care was a priority throughout patients’ care journey. Staff kept patients safe through effective risk management, and clear processes that supported safe admission and discharge pathways. Staff demonstrated a good understanding of their responsibilities in maintaining a safe environment and responding to individual needs. Although discharges were infrequent, evidence from the most recent discharge showed that staff planned transitions effectively, involving appropriate external agencies and family members. Staff shared information promptly, and preparations were made to ensure the receiving service had all necessary details to continue with the patient’s care safely and effectively.

There was a strong awareness of the risks to patients across their care journeys. The approach to identifying and managing these risks was proactive and effective. During the inspection, staff assessed 1 patient as requiring a higher level of observation and this was implemented immediately. Most records demonstrated that staff completed routine observations consistently. Staff we spoke with were able to describe how they would escalate concerns and implement higher observation levels if required, ensuring that patients at increased risk would be monitored effectively. However, our review of observation records showed that some intermittent observations had been recorded at fixed 15‑minute intervals. This was not in line with National Institute for Health and Care Excellence (NICE), guidance or the provider’s policy, which require intermittent observations to be carried out at irregular intervals to reduce predictability and maintain their effectiveness in monitoring patient safety.

Care and support was planned and organised with patients, together with partners and communities in ways that ensured continuity. There was a robust and thorough pre‑admission process. Care notes contained appropriate assessments and screening information demonstrating that the service only accepted admissions when it could safely meet an individual’s needs. This included gathering relevant information from referrers, reviewing clinical history, and considering environmental suitability and staffing capacity before agreeing to admission. Staff told us this process reduced risk by ensuring they could meet the needs of patients admitted to the service.

The evidence showed a good standard. The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ 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 demonstrated a strong understanding of safeguarding and how to take appropriate action. The provider reported a compliance rate of 100 % for staff training in safeguarding. A healthcare assistant (HCA) said they would raise any safeguarding concerns with the nurse in charge and if they did not respond appropriately, they would escalate to the hospital director.

There were effective systems, processes and practices to make sure patients were protected from abuse and neglect. Senior leaders described the processes for reporting safeguarding concerns, including referrals to the local authority, reporting to the police and notifying CQC.

Staff demonstrated a clear understanding of the Deprivation of Liberty Safeguards (DoLS) and this was only used when it was in the best interest of the patient. All six care records reviewed showed a clear understanding of the Deprivation of Liberty Safeguards (DoLS). DoLS applications were only made when considered to be in the patient’s best interests. Relevant documentation, including assessment outcomes and best‑interest decision‑making records, was present in the care files of those subject to an authorisation.

Mental Capacity Act

• The provider reported 100% of staff received training in the Mental Capacity Act.
• Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles
• The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.
• Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.
• Staff took all practical steps to enable patients to make their own decisions.
• For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.
• When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the patient’s wishes, feelings, culture and history.
• Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies.
• The service had arrangements to monitor adherence to the Mental Capacity Act.
• Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

The evidence showed a good standard. The service worked with patients 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 and seclusion only after attempts at de-escalation had failed. They provided care to meet patients’ needs that was safe, supportive and enabled patients to do the things that mattered to them.

Staff assessed and understood risks. We reviewed three care records which showed that risks to patients’ health, safety, and welfare were identified, monitored, and managed effectively. Staff used a range of recognised risk‑assessment tools, including the Health of the Nation Outcome Scales (HoNOS) to support understanding of behavioural and mental health needs. These were used alongside other assessments such as Waterlow pressure area risk assessments, moving and handling assessments, choking risk assessments, and wheelchair‑user assessments. Records showed that risks were regularly reviewed and updated, ensuring patients received safe care based on ongoing assessment and effective risk‑management practices. The provider completed risk assessments for all activities taking place at the service, with appropriate mitigations where required.

When patients communicated their needs, emotions, or distress, staff responded in a positive and supportive manner that upheld their rights and dignity. Staff demonstrated a clear focus on understanding the underlying causes of distress and used these interactions as opportunities for learning and future improvement.

Senior leaders reported that staff consistently applied a trauma-informed approach when supporting patients in distress. This approach centred on building meaningful relationships, understanding individual histories, and recognising how past experiences may influence current behaviours. Staff utilised a range of de-escalation and diversion techniques tailored to each patient.

For example, 1 patient with a known interest in gardening was supported during periods of distress by being encouraged to engage in meaningful activity in the garden. Staff involved the patient by asking for their ideas and input into managing gardening tasks and projects, which helped to reduce distress, restore a sense of purpose, and promote engagement. The provider reported no use of rapid tranquillisation over the past year. Rapid tranquillisation (RT) is the use of medication to quickly calm or lightly sedate an acutely agitated individual. It is a last-resort restrictive intervention used only when de-escalation fails and the patient poses an imminent, serious risk of harm to themselves or others. The provider reported no use of seclusion or long term segregation.

Restraint was only ever used 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 provider reported staff used deescalation techniques and disengagement techniques were always used as a first response. Staff used restraint 7 times between 01 November 2025 and 01 May 2026. We reviewed restraint incidents for March and April 2026. The provider had not reported any use of restraint as a safety intervention in the records reviewed. We saw evidence in these records that staff used deescalation techniques to diffuse situations when patients were distressed. Senior leaders told us a lot of work had been undertaken on the use of force in regard to personal care for patients who were refusing this. Staff included family in completing care plans for patients requiring use of holds to deliver personal care. The plans included use of regular staff providing this support to ensure consistency. The provider advised staff never restrain patients in the prone (face down) position.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. Arrangements to monitor the safety and upkeep of the premises were ineffective. While comprehensive environmental risk assessments had been completed and documented with appropriate mitigations, these were not consistently translated into practice, and environmental risks were not always identified or addressed in a timely manner. We identified multiple environmental maintenance hazards that presented avoidable risks to patients. An accessible bathroom had a loose-fitting bath panel, creating an exposed sharp edge that could cause injury. A cupboard door in the multi-faith room was hanging off its hinges and was not safely secured, posing a risk of harm. In the day room, two screws were exposed and protruding from the wall, increasing the risk of injury. In addition, several display boards were unsecured and not locked in place, creating further potential hazards. These issues indicated a lack of robust oversight and timely maintenance response. We escalated these concerns to senior leaders during the inspection. Immediate action was taken to make the accessible bathroom safe. Leaders acknowledged gaps in permanent maintenance provision and advised that the service was recruiting a replacement maintenance staff member following the recent retirement of the previous permanent post holder. After the inspection the service told us a staff member was now in post. They also confirmed that additional environmental concerns, such as external and garden maintenance, required reporting and following up. The manager told us they had requested a contract gardener to routinely attend the service. After the inspection the service told us they were now in post.

Despite these shortfalls, senior leaders managed ligature risks effectively. Ligature risk audits were completed jointly with maintenance and health and safety teams. Identified risks were mitigated through a range of measures, including; installation of anti-ligature fittings, completion of individual patient risk assessments, implementation of enhanced observation levels where required, use of alarm systems and the development of person-centred care plans.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were sufficient staffing levels and an appropriate skill mix to support the delivery of safe care to meet patients’ needs. Leaders advised that the baseline staffing model consisted of one registered mental health nurse (RMN) and six healthcare assistants (HCAs) during the day shift, and one RMN and four HCAs at night. Additional staffing could be accessed to meet the needs of individual patients where required. On the day of inspection, there was an additional staff member on duty to support activities due to the ward round taking place.

The provider reported no vacancies across qualified, unqualified, medical, therapy, or ancillary roles. Between 1 April 2025 and 1 March 2026, the service utilised both qualified and unqualified bank staff to maintain safe staffing levels, with an average of 6% of qualified shifts and 15% of unqualified shifts covered by bank staff. Although the provider reported a relatively high use of bank staff, these were predominantly regular bank staff who were familiar with the patients and the service. This meant that staffing gaps were covered by staff who knew the patients well, supporting continuity of care, consistency in service delivery, and the ability to respond to patients' individual needs.

The provider reported a low average sickness rate of 2% between 1 May 2025 and 1 April 2026. However, staff turnover during the same period was 20%.

Staff received training appropriate to their roles. Mandatory training compliance was reported at 93%. Staff also accessed a wide range of specialist training, with 32 different courses completed between 1 April 2025 and 1 April 2026. These included dementia awareness, Huntington’s disease, positive behavioural support, trauma-informed care and acquired brain injury.

Staff were supported to deliver safe care through access to supervision, appraisal and ongoing professional development. The provider reported that 88% of staff were up to date with supervision (clinical and managerial), and 96% were up to date with appraisals.

Training was delivered on an ongoing rolling programme, with previous sessions including subjects such as Korsakoff’s syndrome, autism, and dyspraxia, alongside a wide range of other relevant topics.

The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found that the approach to assessing and managing the risk of infection was not always effective. We reviewed paper cleaning records, which were mostly up to date and indicated when areas had received a deep clean. However, during our site visit we observed multiple areas of the environment that were not clean and did not meet expected hygiene standards. These concerns indicated inconsistent cleaning practices and insufficient oversight of environmental cleanliness, increasing the risk of infection.

We identified the following issues; dust and hair were present in a bath, and the bath panel was broken. The seal around a toilet was visibly dirty. Paint on stair handrails was peeling and worn, preventing effective cleaning. Floors were visibly dirty, including edges of flooring where dirt had accumulated. Radiator covers were unclean. A shelf above the fish tank was dusty. The floor behind the water dispenser in the communal lounge had not been cleaned. Food stored in a fridge was undated or beyond its use-by date. In addition, the food serving hatch was in a poor state of repair and did not meet infection prevention and control (IPC) standards.

These findings demonstrated a failure to maintain a clean and hygienic environment and highlighted weaknesses in cleaning regimes, monitoring systems, and adherence to IPC requirements.

We found that 2 bedrooms had not been cleaned following recent patient discharges. One of these bedrooms contained a broken bed base and curtains hanging off the curtain track. The service told us they would not admit patients to a room awaiting refurbishment.

Staff told us that maintenance colleagues had advised that deep cleaning should not take place as the rooms were awaiting refurbishment. This approach meant the rooms were left in an unacceptable condition and not maintained to a safe or hygienic standard. However, since our inspection the service told us that all patient bedrooms upon discharge are now deep cleaned within 24 hours of a patient being discharged.

We reviewed housekeeping records for the previous three months, which indicated that all areas had been cleaned as required. However, this was not consistent with the conditions observed during the inspection. This discrepancy suggested that cleaning records did not always accurately reflect the cleanliness and maintenance of the environment and indicated a lack of effective oversight, assurance, and timely follow-up to identify and address concerns.

Despite these concerns, we found that some areas of the ward were generally clean and well maintained, the provider told us that some new furniture had been ordered for the lounge area.

We observed staff were compliant with ‘bare below the elbows’ guidance. Staff were also able to describe appropriate use of personal protective equipment (PPE) and hand hygiene practices in line with infection prevention and control procedures.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

We found that patients’ medicines were appropriately prescribed, supplied and administered. Prescribed medicines were available, and we saw that these were administered in line with prescribed instructions.

We reviewed prescribing practices and saw that antipsychotic medication dosages were generally low. This indicated that there was no culture of over-sedation within the service, and medicines were used in a considered and person-centred way.

We also saw evidence of individualised medication care planning. For example, 2 patients had personalised care plans which included pictorial representations of their medication to support understanding and engagement. Records also demonstrated that detailed, treatment specific capacity assessments had been completed, supporting appropriate decision making in line with the Mental Capacity Act. However, we found that not all medication records contained a photograph of the patient. Only 2 of the 6 medication folders we reviewed included a patient photograph. While there was a documented explanation for the absence of a photograph in 1 case, no rationale had been recorded for the remaining 3. This meant there was a potential risk of misidentification and indicated that documentation standards were not consistently maintained. It also highlighted gaps in oversight and the effectiveness of governance and assurance processes relating to medicines management.