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CQC inspect services at Cygnet Hospital

30 October 2017
Cygnet Hospital Godden Green
  • Media,
  • Hospitals,
  • Mental health hospital services

The Care Quality Commission has today published a report on Cygnet Hospital Godden Green in Sevenoaks, Kent.

CQC undertook a series of unannounced and announced, focused inspections, throughout July, August and September following concerns raised about the safe care and treatment of young people on Knole ward.

A full report has been published on our website.

Natasha Sloman, Head of Hospital Inspection (mental health) said:

“This is a disappointing report and I was concerned to read about the hospitals systems for checking risk, on-going assessment of health care needs, restraint, rapid tranquilisation and prescribing medicines. We took enforcement action against the provider and put a restriction on admissions to Knole ward to make certain young people were not exposed to the risk of harm."

"During our inspection in September, we were able to see the provider had put systems in place to reduce the risks to young people and we lifted a previously imposed restriction on admissions to Knole ward. We did however, take further enforcement action and issued a warning notice in relation to seclusion and segregation, which we were concerned was used to control and contain young people in the absence of other approaches. We will follow this outstanding issue up at a future inspection."

“While leadership have provided assurances to us that it now has oversight of the issues and are making the improvements necessary, we will continue to monitor and inspect the hospital to ensure the changes put in place are further embedded."

Inspectors found the following issues that still required further improvement:

  • The hospital did not comply with the Department of Health guidance on same-sex accommodation on Knole ward. Although young people’s bedrooms had en-suite toilet and shower facilities, the ward did not have separated sleeping arrangements in place for males and females and lacked a female only lounge.
  • Young people’s medicines were changed without an individual assessment carried out and decisions to change medicines were not based on clinical need. Inspectors judged this to be restrictive practice, to suit the needs of the service.
  • Medicines were not always available for young people at all times. Where specific medicines were not available, appropriate action was not taken by staff to prevent the risks associated with not taking the medicine prescribed.
  • Staff did not always operate within the service provider’s policy and Mental Health Act Code of Practice to ensure young people were appropriately safeguarded when placed in seclusion or long-term segregation.


For further information, please contact John Scott, Regional Engagement Manager on 077898 75809.

Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here.

Please note: the press office is unable to advise members of the public on health or social care matters. For general enquiries, please call 03000 61 61 61.

Last updated:
30 October 2017

Notes to editors

Whenever CQC inspects it will always ask the following five questions of every service:
  • Are they safe?
  • Are they effective?
  • Are they caring?
  • Are they responsive to people’s needs?
  • Are they well-led?
Since 1 April, registered providers of health and social care services have been required to display their ratings on their premises and on their websites so that the public can see their rating quickly and easily.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.