Cygnet Sherwood Lodge

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 this assessment we rated this key question Good. This meant people were safe and protected from avoidable harm.

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.

Description: 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.

We scored the service as 3. The evidence showed a good standard of care.

Staff demonstrated a proactive and consistent approach to safety and learning. All incidents, including near misses and allegations, were reported through an electronic incident reporting system. Staff who witnessed incidents completed reports promptly, and this was confirmed to be standard practice across the service.

Learning from incidents was routinely shared during daily meetings and handovers and further reviewed through clinical governance processes. Staff were able to provide examples of learning following safeguarding concerns, such as incidents involving risk-taking behaviours during community leave. This led to increased collaborative working with external partners to reduce the likelihood of recurrence. One staff member told us, “Learning lessons from incidents is so important for the service, and the people we support. Learning is shared throughout the service which helps us to improve.”

Staff felt confident and supported to raise concerns and participated in regular post-incident debriefs. People were also offered debriefs where appropriate. In addition, staff attended regular incident and risk review meetings, which contributed to improvements in risk monitoring and management, this supported people’s safety whilst promoting independence, recovery and rehabilitation.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3. The evidence showed a good standard of care.

People felt supported and reassured throughout admission, transfer, and discharge processes, which helped to lessen anxiety during periods of change and transition. They were provided with information about their care and treatment in a range of formats to meet their individual communication needs.

A structured admission process was followed, with comprehensive assessments completed on admission and reviewed regularly. People were involved in the process as much as possible, and any additional information gathered was used to inform ongoing care planning, risk assessment, and treatment to ensure care remained safe and responsive to individual needs.

Staff had effective systems to support safe admissions, transfers, and discharge planning. Referral documentation, including clinical histories, risk assessments, and care plans, was reviewed thoroughly to ensure that individuals were appropriate for the service and that their needs could be safely and effectively met. Staff demonstrated a clear understanding of the importance of robust admission processes.

Leaders emphasised early planning and effective communication across teams. Discharge planning involved close coordination with external services, such as the community forensic mental health team, to support safe, well-planned transitions and continuity of care. Staff worked to minimise delays and prioritised timely discharges wherever possible.

Description: 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.

We scored the service as 3. The evidence showed a good standard of care.

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 daily community meetings, ensuring their voices were heard and valued.

Leaders ensured that staff were equipped with the knowledge, skills, and confidence to act promptly and effectively in safeguarding situations. One staff member told us, “I support my colleagues to ensure all safeguarding concerns are raised and reported to the appropriate authorities. We complete thorough investigations, and I support the hospital managers to complete these.”

Staff demonstrated a strong understanding of safeguarding procedures and were able to identify and respond to concerns effectively to protect individuals from harm. Prompt and appropriate action was taken in response to suspected abuse, neglect, or discrimination, with staff working collaboratively with external agencies, such as the local authority safeguarding team, where required.

Safeguarding concerns were routinely discussed in daily meetings, safeguarding forums, and multidisciplinary team discussions. Designated safeguarding leads supported staff when needed. Staff demonstrated a clear understanding of relevant legislation, including the Deprivation of Liberty Safeguards (DoLS), the Mental Health Act 1983, the Mental Capacity Act 2005, and the Equality Act 2010, and were able to explain people’s rights to them.

The service had robust safeguarding systems, policies, and procedures in place, which upheld people’s human rights and promoted a culture of safety. A review of the safeguarding incidents log for the 3 months prior to our visit identified nine incidents. These were appropriately investigated, escalated to the relevant external agencies in a timely manner, and learning was shared across the service to support continuous improvement.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 3. The evidence showed a good standard of care.

Staff demonstrated a clear understanding of people’s individual specific risks, enabling them to respond promptly and effectively to minimise distress and reduce potential harm. We reviewed 7 risk assessments and found these to be person-centred, with clear involvement from the individual and, where appropriate, their families. Risk assessments were reviewed in line with organisational policy. One family member told us, “The staff are really very good, me and my wife are included in everything. We really feel listened to and heard.”

Staff adopted a proportionate and balanced approach to risk management. The psychology team created safety summaries with people using the service rather than a generic risk stratification approach. Safety summaries were underpinned by the 5 P’s (presenting, predisposing, precipitating, perpetuating and protective factors). The 5 P’s enabled staff to create a holistic picture of each individual’s situation and formulate risk and safety management plans and support based on individual need.

Observations were carried out in accordance with care plans and tailored to meet individual needs. Records confirmed that observations were completed as prescribed. People’s physical and emotional needs were managed effectively, ensuring their human rights were upheld and dignity maintained. Staff responded to periods of distress in a calm and measured way, promoting safety and reducing the likelihood of escalation.

Staff worked collaboratively with people and their families. Care records demonstrated active engagement in multidisciplinary team reviews. Where families were unable to attend meetings in person, they were supported to participate virtually, for example via video calls. Staff across disciplines, including psychology, supported people to understand and manage their risks positively. A range of communication methods was used to support those with additional needs, such as easy-read materials and pictorial or emoji-based formats.

Restrictive interventions, including restraint, were used only as a last resort. These were proportionate, appropriately documented, and in line with best practice. Care and treatment plans reflected any restrictions, which had been tailored to individual risks, avoiding the use of blanket restrictions. Staff promoted a reducing restrictive practice approach, underpinned by positive behavioural support. This focused on fostering a proactive and positive culture, emphasising early intervention and shared understanding of risk rather than reactive management.

Staff demonstrated awareness of equality and human rights legislation when applying any restrictions. Where rapid tranquillisation was used, it was proportionate, appropriately recorded, and in line with best practice guidance.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 3. The evidence showed a good standard of care.

People using the service and staff felt the environment was safe. The premises were clean, well-equipped, and supported the physical, psychological and mental wellbeing of individuals, enabling the safe delivery of care. Equipment was regularly audited, appropriately maintained, safely stored, and used in line with guidance.

Staff demonstrated a clear understanding of how to maintain a safe environment, which included ongoing environmental risk assessments throughout the day and night. This ensured that any risks were identified and mitigated, and included consideration of physical and psychological safety, as well as sensory and sexual safety needs. Staff carried out environmental safety and security checks at the start of each shift to identify any potential risks or hazards. Findings were shared during handover meetings to ensure continuity and awareness. Responsibility for completing these checks was clearly allocated, promoting consistency and accountability.

Ligature risks were appropriately assessed and managed. The use of CCTV supported observations and reduced the risk of blind spots, enhancing safety for people using the service and staff. Staff carried personal alarms to support everyone’s safety and call for help if needed. People using the service had access to staff call systems throughout the environment, including in bedrooms and bathrooms, enabling them to request assistance when needed.

The clinic room was fully equipped, with accessible resuscitation equipment and emergency medicines. These were subject to regular checks and audits to ensure readiness in the event of an emergency. There were several well-maintained outdoor spaces, which were actively used by people. Access was unrestricted, promoting independence, with appropriate safety measures in place, such as, zonal observations by staff to ensure visibility, safety and security.

Description: 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.

We scored the service as 3. The evidence showed a good standard of care.

People using the service felt well supported by staff. One relative told us, “We visit our son regularly and there’s always staff around. They are really engaging and always welcoming. I can honestly say the staff definitely do all they can to keep our son safe.”

Care records we reviewed showed that people were supported to have regular one-to-one sessions with their named nurse, helping to maintain therapeutic relationships, build trust, and promote continuity of care.

Staff were visible throughout the service, including in communal areas. Due to the high number of enhanced observations, a staff member was allocated to staff welfare duties. This involved the allocated staff member checking in with colleagues completing observations to offer support if needed, and to facilitate comfort breaks where required. All staff undertook observational competency assessments to ensure safe and consistent practice. Appropriate medical cover was always in place, with doctors available to respond promptly in emergency situations.

Leaders regularly reviewed staffing levels to ensure they reflected the needs of the service and the individuals they supported. We saw evidence that staffing levels were adjusted in response to changes in need. Staffing rotas confirmed that sufficient numbers of staff, with the appropriate skill mix, were maintained across all shifts. Bank staff were used to ensure the service had the required number of staff to meet people’s needs. Bank staff completed a comprehensive induction and mandatory training prior to working at the service.

We reviewed vacancy rates, staff turnover, and sickness absence for the 6 months prior to our visit and found no concerns. The service was fully staffed and also supported a successful student nurse programme in partnership with local universities.

Recruitment processes were robust, ensuring all staff, including bank staff, were appropriately vetted through Disclosure and Barring Service (DBS) enhanced checks and were suitably qualified, experienced, and competent. Disciplinary, conduct, and capability processes were applied consistently, reviewed regularly, and were proportionate and free from bias.

Staff received regular clinical and managerial supervision. Group supervision was also facilitated across teams. Annual appraisals and personal development reviews were completed. Documentation showed compliance levels met and often exceeded organisational targets, with a 99% compliance rate at the time of our assessment.

Staff were up to date with mandatory training relevant to their roles, with an overall compliance rate of 96.8%. Training included specialist learning disability and autism training. Staff completed “Tier 1” learning disability and autism training online, as well as “Tier 2” face-to-face training, delivered by accredited trainers and co-facilitated by individuals with lived experience. Staff demonstrated confidence and competence in delivering care, and there were clear opportunities for ongoing learning and development at all levels.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 3. The evidence showed a good standard of care.

People using the service expressed confidence in the infection prevention and control measures in place and felt reassured that staff were taking appropriate steps to protect them from the risk of infection. One person told us, “It’s always clean; we have cleaners who are lovely and work really hard. Staff clean around as well.”

Staff adhered to infection prevention and control procedures, including following hand hygiene guidance, using personal protective equipment (PPE) appropriately, and cleaned equipment in line with best practice. During our observations, staff consistently followed these principles between interactions with individuals, including appropriate handwashing, changing PPE, and the safe disposal of waste.

All areas of the service were clean and well maintained. Cleaning records were up to date and demonstrated that regular cleaning and auditing processes were in place, ensuring a safe and hygienic environment. Staff showed a good understanding of their responsibilities in maintaining cleanliness. Hand sanitising stations were available throughout the service, supporting infection control and reducing the risk of harm.

The service had clear and effective processes for identifying and managing infection risks, aligned with current national guidance. Regular infection prevention and control audits were completed, and any identified issues were addressed promptly. Relevant information about infection risks was shared appropriately with staff, patients, visitors, and external partners. Roles and responsibilities for infection prevention and control were clearly defined, and staff received ongoing training in line with organisational policies and best practice.

Description: 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.

We scored the service as 3. The evidence showed a good standard of care.

Staff supported people to be actively involved in decisions about their medicines. Where individuals had capacity, staff ensured they understood the purpose of their medication and involved them in discussions about any changes to their care and treatment. Where individuals lacked capacity, staff followed processes in line with the Mental Capacity Act 2005 and the Mental Health Act 1983. Care and treatment plans reflected each person’s level of understanding and clearly demonstrated their involvement in decision-making regarding medicines and treatment.

Staff completed relevant training and competency assessments, ensuring the safe, effective, and appropriate use of medicines. They followed safe and effective practices across all aspects of medicines management, including storage, dispensing, administration, reconciliation, recording, and disposal. We observed staff administering medicines safely, providing clear explanations and offering support with kindness, dignity, and respect.

Staff regularly monitored the impact of medicines on people’s physical health, particularly for those prescribed high doses of antipsychotic medication, in line with National Institute for Health and Care Excellence (NICE) guidance. Staff followed the principles of Stopping Over-Medication of People with a Learning Disability, Autism, or both (STOMP), and a review of prescribing and administration records identified no concerns.

Medicines, including controlled drugs, were stored securely and managed within appropriate legal frameworks. Controlled drugs were managed safely and subject to regular auditing, with findings used to inform practice and support learning. Temperature checks for storage areas were completed daily, and medicines were within their expiry dates. Unused or expired medicines were disposed of safely. PRN (as-required) medicines were used appropriately and in line with guidance, rather than solely to manage behaviour.

Robust systems were in place to support safe medicines management, including daily and weekly audits by nursing staff and regular audits by the pharmacy team. Where errors were identified, these were addressed promptly, with appropriate actions taken to reduce the risk of recurrence.