Cygnet Newham House

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 has remained as good. This meant people were safe and protected from avoidable harm.

All wards 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.

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 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 or were in progress. For example, the temperature in the nurses’ office had risen to 30 degrees on some occasions, leading to the emergency crash bag being moved elsewhere. The senior leadership team had, therefore, agreed to fit air-conditioning within the nurses’ office.

A patient had been able to keep a lighter in their bedroom and smoke unsupervised against the provider’s policy because staff had failed to follow the signing in and out procedure. Managers met with the staff concerned to reinforce the importance of adhering to the procedure for lighters and all staff were made aware via an email.

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

Managers conducted after-action reviews following incidents within the service. Following a diarrhoea and vomiting outbreak on 13 October 2025, an Infection prevention and control (IPC) after action review was undertaken to ensure risks to people using the service and staff were identified, managed, and reduced. The review recognised that while policies were in place, there were delays in isolating symptomatic staff and patients and opportunities to strengthen early reporting, communication, and consistency of IPC practice. In response, immediate safety actions were implemented, including exclusion of symptomatic staff until they had been symptom-free for 48 hours, barrier nursing of affected patients, reinforced use of personal protective equipment, strengthened hand hygiene compliance, enhanced environmental and touch‑point cleaning, and clearer communication to staff and cleaners during the outbreak. An action plan with clear responsibilities and timeframes was agreed and overseen by the IPC lead and management team.

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.

The service undertook a structured neuro‑psychiatry patient pathway mapping and service improvement event in June 2025 to strengthen the safety, consistency and effectiveness of care systems across admission, treatment and discharge pathways. Multidisciplinary teams reviewed the pathway from referral and pre‑admission assessment through to transition and discharge, identifying risks including variable pre‑admission information, gaps in neurological and communication assessments, and inconsistencies in discharge planning. In response, standardised pre‑admission processes, checklists and prompt tools were developed, alongside a clear, linear representation of the model of care, which supported staff, patients and carers to understand where individuals were within their care journey. Discharge and transition planning were reinforced through service specifications, early planning and testing of changes via plan-do-study-act cycles. The plan-do-study-act cycle is a four-stage framework used for testing and implementing small-scale changes to improve a process. It is a core component of the model for improvement, acting as a "trial-and-error" mechanism to build knowledge before rolling out major changes. This work generated clear improvement actions focused on safer handovers, reduced variation, improved communication and strengthened co‑production, supporting safer transitions and continuity of care across internal teams and external services.

The service undertook a quality improvement project to address significant discrepancies identified between what was recorded in the service’s prescription charts and the patient’s GP record. An initial audit in February 2024 found that only 5.3% of patients had fully reconciled medication records. In response, the team implemented a structured medication reconciliation process, including the creation of a regularly updated Excel medication tracker, systematic communication of medication changes to the GP practice, reconciliation at admission, weekly updates, and joint checks with the GP during bi‑weekly visits. By the re‑audit in November 2024, accuracy had improved substantially, with 61.5% of patients’ GP and Kardex medication records fully aligned, and remaining discrepancies largely attributable to very recent changes. The project demonstrated a marked improvement in monitoring prescribing accuracy, strengthened inter‑service communication, and enhanced the safety and reliability of medication management for patients.

Quality Statement Score: 3

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 66 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, and these were reviewed regularly. 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

At the time of our inspection, 95% of staff had completed their mandatory training in the Mental Capacity Act and deprivation of liberty safeguards.

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 3 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 4 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, physical health conditions, 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 only as a last resort.

There were 253 incidences of restraint in the last 12 months, relating to 14 patients in total; 41 of which were in the prone position. The service did not use seclusion.

There were 61 incidences of rapid tranquilisation in the last 12 months, relating to 5 patients in total. The service had placed 1 patient in long-term segregation within the last 12 months. They were transferred back to their original placement due to the service not being set up to address the high risks associated with their behaviours that challenge.

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 observations.

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.

The service was for female patients only and as such, complied with guidance on eliminating mixed-sex accommodation.

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.

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

• an activities coordinator and occupational therapist
• psychologists
• nurses
• catering, maintenance and housekeeping staff
• a clinical manager and clinical team leader
• a consultant neuropsychiatrist
• a speciality doctor
• speech and language therapists
• administrative staff
• a physical health nurse
• a mental health law practitioner.

One patient told us that the service was sometimes short staffed which meant her requests for help were not always responded to quickly. However, at the time of inspection, the service had 7 support worker vacancies, with two posts already filled and a further five staff recruited shortly afterwards in December 2025, resulting in all substantive vacancies being filled. The service had an established staffing complement of 46 support workers, with approval from finance to over‑recruit by an additional 7 posts in response to service need and ongoing observations.

The provider demonstrated a proactive and sustained recruitment approach, including a continual recruitment drive using a values‑based model. Recruitment afternoons involved patients directly, supporting the appointment of staff whose values aligned with the needs of people using the service.

Managers had calculated the number and grade of nurses and healthcare assistants required. The hospital manager could adjust staffing levels daily to take account of patients’ individual needs.

The average staff sickness rate in the last 12 months was 1.75%.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, they received an induction to the service. Agency use was reported as minimal (0–1%), indicating strong staff continuity and stability despite short‑term staffing pressures. While potential future impacts of overseas sponsorship changes were acknowledged, this affected a small number of staff only, and the provider had active recruitment plans in place to mitigate any risk to staffing levels.

The average staff turnover over the last 12 months was 10%. However, staff surveys had showed an increase in positive responses about working for the provider since the previous year. Reasons for staff leaving the service included promotion opportunities, finding a place of employment nearer to the staff member’s home and better career prospects.

Staffing levels allowed patients to have regular one-to-one time with their named nurse. Managers conducted audits of patients’ care records to ensure one-to-ones were taking place.

Escorted leave or ward activities had not been cancelled due to staffing issues within the last 12 months.

There were enough staff to carry out physical interventions and observations safely and staff had been trained to do so.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. This included a doctor, a consultant, nurses and an on-call doctor on the night.

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 within the service was 96%. The training was appropriate for the patient group using the service and included:

• basic life support
• immediate life support
• dealing with concerns at work
• equality and diversity
• food safety
• infection prevention and control
• information governance awareness
• protecting our health & safety
• responding to emergencies
• safeguarding individuals at risk
• safety intervention.

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. One patient told us the hoist used by staff to move them was not working. However, no reports of a broken hoist had been reported or sent to repair and the service had multiple hoists in situ to ensure patients could always be moved when required.

All ward areas were clean, had good furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing.

Following a diarrhoea and vomiting outbreak on 13 October 2025, an infection prevention and control after action review was undertaken to ensure risks to people using the service and staff were identified, managed, and reduced. The review identified necessary improvements in relation to managing such outbreaks. An action plan with clear responsibilities and timeframes was agreed and overseen by the IPC lead and management team.

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 9 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, 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 4 patients’ care records during our inspection. All 4 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.