Cygnet St. Williams Also known as Cygnet Behavioural Health Limited

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question as good. At this assessment the rating remained as good. This meant people were safe and protected from avoidable harm.

All areas of the service were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There had been no serious incidents within the service in the last 12 months.

All staff knew what incidents to report and how to report them. Staff had reported incidents including medicines errors, violence and aggression and self-harm.

Staff understood the duty of candour. They were aware of the need to be open and transparent and gave patients and families a full explanation if and when things went wrong. There had been no duty of candour reports made within the service in the last 12 months.

Staff received feedback from investigation of incidents, both internal and external to the service. We saw evidence within minutes of staff meetings that managers routinely shared learning from incidents with staff. Lessons learned were also disseminated through communication books, during supervision sessions and via governance forums too.

Safety improvements had been made within the service. For example, following a fortnightly medication count, the number of Canagliflozin 300mgs tablets were found to be down by 1 tablet. The following changes were implemented as a result of this:

• Nursing staff were required to check every patient’s medication chart at every medication round to ensure patients received correct doses
• Nursing staff were required to re-familiarise themselves with the provider’s administration of medication guidance to ensure that they were following the correct procedures when completing medication rounds.

There had been improvements to the handover process for agency staff. These included:

• An Introduction of an “Essential Information for My Shift” document, detailing critical patient information to prevent gaps in care
• A mandatory induction for agency staff who had not worked at the service for a period of time or at all to ensure they were familiar with patients’ needs and local protocols during the first hour of their shift.

Staff told us that managers provided them with debriefs and support after a serious incident.

We scored the service as 3. The evidence showed a good standard. The service worked with people 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 people moved between different services.

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. A nurse assessment team visited the patient prior to admission to undertake an assessment of their needs. The assessment team’s report was sent to the service with details of the patient’s brain injury, needs and history. The report was then looked at by the service’s multidisciplinary team to determine if the patient’s needs could be met. If there were any doubts, members of the multidisciplinary team visited the patient to undertake a further assessment. If the patient’s needs could not be met, a referral was sent to an alternative appropriate placement.

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. These included social workers and the patient’s home team.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate.

In the last 12 months, staff had sent 39 safeguarding referrals to the local authority.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies such as local authority safeguarding teams and the police.

Staff followed safe procedures for children visiting the service. Any child visits needed to be discussed with the multidisciplinary team and agreed in advance.

There were very few blanket restrictions in place within the service at the time of our inspection. These related to rooms and areas where there were risk items such as sharps, potential ligature points or risk of scalding. However, some patients were able to access these areas independently if risk assessed to do so.

Mental Capacity Act

All staff within the service had completed their mandatory training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies. Staff had sent 4 of deprivation of liberty safeguards applications to the local authority in the last 12 months to protect people lacking the capacity to make specific decisions about their own care.

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 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 person’s wishes, feelings, culture and history.

There was a Mental Health Act administrator who worked within the service. They monitored staff adherence to the Mental Capacity Act via audits and shared any identified learning with staff when needed. They also provided advice and guidance to staff about the use of the Act when required.

We scored the service as 3. The evidence showed a good standard. The service worked with people 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 only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We looked at six patients’ risk assessments and risk management plans during our inspection. We saw evidence that staff had assessed patients’ risks and created risk management plans which mitigated the risks identified. Risks included self-harm, use of sexualised comments and behaviours towards staff and other patients, substance misuse, physical health conditions, racist abuse, risk of falls and violence and aggression.

We saw evidence in care records that staff involved patients in care planning and risk assessments.

Staff had regard to the Use of Force Act and its guidance and complied with requirements. Staff used de-escalation techniques so that restraint was used as a last resort.

There were 73 instances of restraint in the last 12 months which related to 6 patients in total. None of these were in the prone position.

Staff had used rapid tranquilisation 13 times in the last 12 months which related to 2 patients in total.

The service did not use seclusion, and no patients had been placed in long-term segregation in the last 12 months.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff enabled patients to give feedback on the service they received via surveys, community meetings and the provider’s complaints process.

Staff ensured that patients could access advocacy.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff did regular risk assessments of the care environment.

There were blind spots within the areas used by patients. However, these were mitigated by the presence of staff and use of mirrors.

There were potential ligature anchor points but staff had mitigated the risks adequately via the use of restricted or supervised access and patient observation levels accordingly.

The ward complied with guidance on eliminating mixed-sex accommodation as the service was for male patients only.

Staff had easy access to alarms and patients had easy access to nurse call systems.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We looked at health and safety documentation during our inspection. There were personal emergency evacuation plans in place for patients to be used in an event in which the service building needed to be evacuated such as a fire or a bomb scare. A risk assessment of the building had been completed days before we arrived for our inspection. We looked at maintenance records which evidenced that issues with the premises had been identified and addressed or in the process of being addressed. Gas, fire, electrical, portable appliance testing, legionella and lift service certificates were in place and in date. The mobile hoist and a sling used within the service had been inspected in July 2025.

A regional quality management audit had been undertaken of the environment in August 2025. The key findings were:

• Health and safety, fire and water risk assessments were in date and accessible
• The service was clean, tidy, and free from odours
• Furniture was in good condition
• Cleaning schedules followed national cleaning standards
• Infection control protocols were adhered to
• Reception, communal areas, bedrooms, bathrooms, and staff areas were well maintained and free of clutter
• Kitchens and dining areas were clean and equipped and food was stored safely.

We scored the service as 3. 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.

Managers had calculated the number and grade of nurses and healthcare assistants required to deliver safe care and treatment. The minimum staffing numbers were 5 support workers and 2 nurses per day shift and 4 support workers and 1 nurse per night shift.

There were sufficient numbers and grades of staff within the service to deliver safe care and treatment and meet patients’ needs. These included:

• a hospital manager (registered manager)
• a clinical manager
• support workers
• nurses
• a speech and language therapist
• a dietician
• a physiotherapist
• a psychologist
• a therapist
• a consultant
• housekeepers
• a maintenance supervisor
• an administrator
• a receptionist
• a Mental Health Act administrator
• a practice nurse
• activities coordinators
• catering staff.

The average staff turnover within the last 12 months was 23.21%. This related to 13 members of staff, some of whom had left to work elsewhere and others who had been dismissed.

The average staff sickness absence rate within the last 12 months was 4.2%.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. In the last 12 months, 432 shifts were covered by bank staff and 569 were covered by agency staff. [RB1]

When agency and bank nursing staff were used, they received an induction and were familiar with the ward.

The hospital manager could adjust staffing levels daily to take account of patients’ individual needs.

We spoke with 4 patients and 3 carers who confirmed that they or their loved ones had regular access to one-to one time with their named nurse. However, during a regional quality management audit, it was identified that some of the nursing team were not categorising one-to-ones as they should. This meant it was difficult for the provider to identify when a one-to-one had taken place. All nursing staff had since been informed that they must record in the correct section of the care records system when a one-to-one had taken place. The provider had introduced a weekly audit to monitor how staff were recording one-to-ones for assurance purposes.

In the last 12 months, no ward activities or escorted leave had been cancelled due to staffing issues within the service.

There were enough staff to carry out physical interventions such as restraint safely and staff had been trained to do so. Staff told us they felt confident in managing violence and aggression within the service.

There was adequate medical cover day and night. There was 1 whole-time equivalent doctor in the service, and 11.06 whole-time equivalent other medically trained staff within the service. There was an on-call doctor who could attend to any medical emergencies during the night. The emergency department at the local acute hospital was only 10 minutes’ drive away from the service.

Staff had received and were up to date with appropriate mandatory training. At the time of our inspection, the overall compliance rate for mandatory training was 98%.

The training programme was appropriate for the patient group using the service. It included:

• Safeguarding
• Basic and intermediate life support
• Responding to emergencies
• Oliver McGowan training in learning disabilities and autism
• Naso gastric tube
• Physical health
• Physiological observation
• Awareness of self-harm and suicide
• Awareness of neuropsychiatry
• Clinical risk management
• Medicines management
• Health and safety.

Managers within the service had access to leadership training.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. All areas of the service building were clean, had good furnishings and were well-maintained.

Staff adhered to infection control principles, including handwashing.

We scored the service as 3. 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.

Staff followed good practice in medicines management in relation to the transport, storage and disposal of medicines. We found staff dispensed and administered medicines in line with national guidance. Staff undertook the reconciliation of patients’ medicines when they were admitted to the service.

We looked at 8 patients’ prescription charts. We saw evidence that staff supported patients to self-medicate, information about patients’ medication regime was clear and capacity was clearly recorded. Patients’ allergies were clearly recorded where applicable. T2 and T3 forms matched the patient’s prescription charts. T2 and T3 forms are legal documents under the Mental Health Act 1983, used for authorising medical treatment for detained patients. A T2 form signifies patient consent for medication after two months, while a T3 form grants approval for non-consented treatment by a second opinion appointed doctor.

We looked at 6 patients’ care records during our inspection. All 6 records contained evidence that staff reviewed the effects of medication on patients’ physical health regularly and in line with the National Institute for Health and Care Excellence guidance, especially when the patient was prescribed a high dose of antipsychotic medication. We also attended a multidisciplinary team meeting, during which, all patients currently using the service had their medication reviewed.