Cygnet Hospital Hexham

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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 people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was a risk that people could be harmed.

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.

We scored the service as 2. The evidence showed some shortfalls. Lessons were not always learnt to continually identify and embed good practice.

Systems were in place to review quality across the service, and there was a culture of learning within the hospital. Regular incident reviews, structured audits and debrief sessions were used to gather feedback from people and staff. Incidents were reviewed to identify whether changes were required to reduce the risk of them reoccurring. Any learning was documented, and action plans were developed and shared with staff.

However, we could not be assured that identified actions were always completed. For example, following a fire incident in January 2025, it was identified that some staff did not know the location of fire extinguishers or the zonal evacuation procedure. The resulting action plan stated the hospital would increase the frequency of fire drills and strengthen fire safety training during staff induction and refresher sessions. Evidence was not available during the inspection to demonstrate that all required actions had been completed.

In addition, learning had not been shared across the organisation that labels used for leave medicines did not meet legal requirements. The registered manager took immediate action to address these issues during our inspection.

Despite these shortfalls, there was evidence of a culture committed to learning, compassion and continuous improvement.

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.

A referral and admission process was in place. This ensured admissions into the hospital were safe and well‑coordinated. Pre‑admission checks were completed, including a review of referral information, confirmation of legal documentation, and preparation of the patient’s room and care file.

On admission, staff completed a comprehensive checklist covering medication reconciliation, MHA documentation, property checks, physical health screening, risk assessments and communication with carers where appropriate.

Personalised care plans were developed with involvement from the patient and the multidisciplinary team (MDT). Daily MDT meetings and ward rounds supported regular review of needs, risks and progress. Patients were kept informed through routine updates, and where consent had been given, carers were also kept up to date. Patients had access to advocacy services to support their involvement in these processes. Staff promoted health and wellbeing through physical health monitoring, dietary support and a therapeutic activity programme.

Staff worked proactively with internal MDTs and external health and social care partners to ensure patients experienced safe, well‑coordinated care. MDT and ward round meetings included social workers, bed managers, community mental health teams and advocacy services. Patients, carers and external professionals were invited to contribute to care planning and discharge decisions.

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.

Systems were in place to ensure safeguarding concerns were responded to appropriately. Staff understood their safeguarding responsibilities and knew how to report and escalate concerns. Safeguarding training compliance was high across both wards. On Fisher ward, staff achieved a completion rate of 97%, which exceeded the provider’s key performance indicator of 95%. Compliance on Franklin ward was slightly below the target, with a completion rate of 93.3%. A safeguarding policy was in place and staff could refer to this if they needed to clarify the actions they should take.

Safeguarding processes were supported through weekly multidisciplinary meetings. Staff consistently used the provider’s internal system to report concerns and worked effectively with external agencies, including local authorities, the police and community mental health teams. Staff were able to describe how they protected patients from harassment, bullying and discriminatory behaviours. Records showed appropriate action was taken in response to incidents of abuse, including those involving patients with protected characteristics.

Staff understood how to recognise adults at risk. Safeguarding risks were routinely incorporated into personalised care plans. Advocacy services were routinely involved to ensure patients’ voices were heard.

Policies were in place for children visiting the service, and risk management and safeguarding expectations were clearly embedded within these.

Restraint and restrictive practices were monitored and reviewed to ensure they were safe. Incidents of restraint were documented and subject to managerial review. We did identify 1 restraint record where staff indicated de‑escalation techniques had been used but no narrative was recorded to describe what these were. As a result, the record did not evidence what actions staff took before restraint was applied.

Blanket restrictions were reviewed and supported by a whole‑service approach to reducing restrictive practice, including the use of sensory suites and non-restrictive interventions.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Over the previous 12‑month reporting period, the service recorded 443 episodes of rapid tranquilisation. As part of our review, we examined the frequency and distribution of these incidents across the 2 wards. Franklin ward reported 239 episodes, while Fisher ward reported 204. Audits were completed to understand how often individual patients required rapid tranquilisation and whether appropriate post‑incident monitoring had taken place.

During the same period, there were 1,516 incidents of restraint across the service. Fisher ward reported 521 incidents, and Franklin ward reported 995. The registered manager informed us that 5 incidents involved the use of prone (face‑down) restraint. There had been no incidents of long‑term segregation. One restraint record we reviewed lacked detail regarding the actions taken by staff. The record stated that de‑escalation techniques had been used before restraint; however, the narrative did not explain which techniques had been attempted or why they had been unsuccessful.

There were 24 episodes of seclusion affecting 16 patients over the last 12 months. Of these, 2 patients experienced 3 episodes each, 4 patients experienced 2 episodes, and 10 experienced a single episode.

Risks were not always adequately assessed or documented. Although patients’ views were routinely gathered during assessments and advocacy was used effectively to support people to express their views, this involvement did not consistently influence decisions related to risk. We reviewed 9 care records and found that while care plans were personalised, using patients’ own words and reflecting their preferences, the records did not always show how these views informed the provider’s approach to managing risks or altered risk-related decisions.

Evidence also showed occasions where patients did not fully understand the reasons for restrictions placed upon them. Documentation did not consistently record how staff explained these decisions or responded to patients’ concerns. One patient told us they were unsure why planned leave had not taken place, describing a “level of miscommunication”, while another raised questions during MDT reviews about observation levels and access to restricted items. However, carers gave positive feedback about their involvement, although 1 carer did tell us they felt the service was, at times, a little too risk‑averse.

We identified further shortfalls in the assessment of risks associated with medicines. While the provider understood the requirements for pregnancy prevention when prescribing sodium valproate, the risk assessment forms we reviewed did not contain sufficient detail to demonstrate that all relevant risks had been fully considered.

Patients were empowered to be involved in planning their care. They were encouraged to contribute to decisions and shape their own plans. Documentation demonstrated patient participation and agreement, and where individuals chose not to be involved, this was recorded. Patients were also given opportunities to provide feedback about their experiences, including through surveys and questionnaires. One patient told us, “I felt very much part of the care team. Staff took time to get to know me, and we even had a conversation about what type of restraint would work best for me. This made me feel valued and demonstrated their care and compassion.”

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment.

Staff carried out regular risk assessments of the care environment. This included ligature and blind‑spot assessments alongside daily safety checks. Identified risks were monitored, and the ward layout supported effective observation. Where blind spots had been identified, these were mitigated through observation protocols.

Ligature risk assessments were in place and measures were in place to reduce identified risks. For example, reduced‑ligature fittings, anti‑barricade doors and enhanced observations were used to mitigate any fixtures that could not be fully eliminated. The hospital complied with national guidance on eliminating mixed‑sex accommodation, with both wards operating as women‑only environments. Staff had access to personal alarms, and nurse call systems were available to patients.

The seclusion room on Franklin ward met required standards, enabling clear observation, supporting 2‑way communication and containing a toilet and clock to maintain orientation.

Clinic rooms were suitably equipped, clean and secure, with accessible resuscitation equipment and emergency medicines that were checked regularly and maintained in line with policy requirements.

However, there were shortfalls in the completion and oversight of some health and safety documentation. During the inspection, we noted gaps in records such as fire safety checks, water temperature monitoring and maintenance logs. In several areas, documentation was incomplete or not available for review, meaning the provider could not demonstrate full compliance with expected health and safety monitoring processes.

During our inspection, building work was taking place across parts of the hospital to improve the environment for both patients and staff. This included planned refurbishment intended to enhance safety, dignity and the overall therapeutic setting.

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 well together to provide safe care that met people’s individual needs.

Appropriate staffing arrangements were in place to meet the needs of the patients. Staffing levels, sickness, turnover and vacancy information showed a generally stable workforce, and managers took action to ensure safe cover despite periods of increased acuity and observation requirements.

The provider reported a 15.72% turnover rate for the period from September 2024 to August 2025 and an average sickness absence rate of 2% over the same 12‑month period. Vacancy levels were low, with only 1 vacant post for a housekeeper, and 6 support workers in recruitment and 3 already in induction. This was expected to further decrease the need for temporary staff.

Managers reviewed staffing levels each day, adjusting the mix and numbers of staff on duty based on changes in patients’ risks, needs and observation levels. For example, staffing ratios for escorting people to hospital and Section 17 leave were increased to maintain safety. Enhanced observations were reviewed regularly, and staff could be redeployed across wards when required.

There was evidence showing the impact of staffing on Section 17 leave and activity planning. Over 12 months prior to the inspection, Fisher Ward reported 9 cancellations in 2024 and 10 in 2025, while Franklin Ward had 0 cancellations in 2024 and 6 in 2025, where escorted leave or activities were unable to go ahead due to staffing pressures. However, these recorded cancellations were infrequent overall. Patients confirmed that leave and activities were rarely cancelled and alternative plans were usually made.

Recruitment processes were safe. Pre‑employment checks were completed in line with legislation and the provider’s policy, and records showed that new staff, including agency workers, received an appropriate induction before working on the wards. The use of bank and agency staff remained low overall but increased temporarily in response to a small number of patients requiring sustained high‑level observations. Managers were actively recruiting to reduce the need for temporary staffing, and induction records confirmed that agency and bank staff received suitable local orientation.

Training, supervision and appraisal figures were consistently high, with most mandatory training reported in the high 90% range, supervision compliance at 96%, and appraisal completion at 98%.

Patients and carers consistently told us that staff were caring, respectful and supportive. Most patients said there was usually someone available when they needed help and described having 1‑to‑1 time with their named nurse. We did receive feedback of occasional delays of waiting to speak with a member of staff when they were occupied in the office; however, this was not described as a persistent issue.

Medical cover was sufficient. Responsible clinicians attended ward rounds, and on‑call arrangements ensured that a doctor could attend the wards promptly in an emergency.

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.

Infection prevention and control (IPC) was supported by systems of good practice, including the completion of regular audits. The provider had policies in place that outlined the actions staff were expected to take. All staff on Fisher ward had completed IPC training and 95.7% of staff on Franklin ward had completed this training.

The hospital environment was clean and tidy and staff maintained equipment to a high standard. Audits were routinely completed to monitor compliance with the provider’s infection control policy, ensuring that cleaning schedules, equipment checks, and environmental hygiene met the required standards.

Staff used handwashing facilities appropriately, and hand hygiene audits showed high compliance rates. The use of “I am clean” stickers and up-to-date cleaning records further demonstrated adherence to infection control protocols.

We scored the service as 1. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines were stored securely with access restricted. The trolley used for medicines administration was well organised and clean. There was a process in place to check expiry dates of medicines however for 1 short-dated medicine, once opened, we saw there was no date of opening recorded so we were not assured it was in date and safe to use.

Although the service had a medicine stock list, we saw that there were excessive quantities of medicines in the stock cupboards with multiple boxes of the same medicine open. We could not therefore be assured that the ordering and oversight of medicines use was effective due to the excessive quantities in stock.

Patch application records including body maps were not in place to ensure patches were rotated in line with manufacturer's guidance. We discussed this with management and following the inspection we were told body maps had been implemented.

Controlled drugs were stored securely however 1 controlled drug stock balance was not correct and this had not been identified by staff prior to inspection.

All staff had completed online medication management and administration training. However, only 62% had completed their medicines competency training with 2 members of staff being overdue.

As part of the discharge process, dispensing medicines for discharge/transfer occurred from stock items on the unit. Boxes and labels were provided from the pharmacy, and the labels were handwritten by staff. The unit had a leave and discharge medicines checklist; we were provided examples of completed checklists. There was no patient identifiable information on the checklists, and it did not contain information about which medicines were supplied or quantities and there was no date. There was no local policy or standard operating procedure to guide staff in the safe process of dispensing medicines or how to check this and staff competency had not been assessed. The handwritten medicines labels did not meet legal requirements as they did not contain the address of where the dispensing of medicines had taken place. Following the inspection action was taken to rectify this.

These issues constituted a breach of Regulation 17 Good governance.

Medicines were administered in line with handwritten medicines administration charts. The charts we looked at were completed in full with patient identifiable information and allergies. A pharmacist visited the service regularly to review medicines charts, and we could see where checks had been recorded.

We saw that rapid tranquilisation (the use of intramuscular medicine when urgent sedation with medication is needed) had been used for people at the service. The monitoring of the people’s vital health signs post administration was documented in line with the providers policy.

The provider had a High Dose Antipsychotic (HDAT) monitoring form (HDAT monitoring is required when a person is prescribed medicines greater than 100% of the British National Formulary (BNF) maximum dose) and policy. At the time of inspection, no people at the service were prescribed High Dose Antipsychotic Therapy.

Incidents including medicines related incidents were reviewed on a monthly basis with themes and trends identified. Medicines incidents were discussed as part of the clinical governance meetings. We were shown lessons learnt bulletins for medicines incidents that had occurred so that learning could be shared.