Cygnet Acer Clinic

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

Leaders ensured that there was a positive culture of safety where safety events were reported and investigated. Staff and leaders ensured that the environment was safe for people who used the service. Staff worked in partnership with people to manage their risks based on the individual person’s needs.

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.

Leaders ensured that people had time to discuss any learning from incidents and any to take any actions that were required to reduce the risk of repeated incidents occurring.

Leaders explained that lessons learnt were shared in every morning meeting, and reflective practice groups.

Leaders had a clear process in place to ensure that safety events were reported, investigated, and any lessons learnt were shared not just across the service but across the providers other services.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We observed that people were involved in managing their individual risk behaviours. People worked with staff to identify property or times of the day their risks were increased and planned for this. For example, locking certain types of property in lockable cupboards in their bedroom to minimise their risk.

We observed that staff worked with people to understand and manage risks. Risk assessments clearly identified individual peoples triggers for potential of increasing their own risks. In addition, the risk assessments highlighted coping strategies that people found useful that they could use to reduce their risk and staff supported them with this. We heard of examples of people talking to staff about their concerns and staff supporting them to manage their anxieties. For example, increasing escorts to support access the community or using sensory equipment. It was evident in the daily morning meeting that staff and leaders were fully aware of peoples risks and how to manage and support them.

Every morning the multi-disciplinary team met to review each person’s risk. They looked at the risk profile of each individual for the previous 24 hours and determined if their level of risk and nursing observations needed to be increased. We heard discussion about fluctuations in mood, concordance with medicines and risk incidents. Each person’s risk assessment was updated in the meeting. At times people did need to either restrictions placed on access to their property or extra staff support to carry out activities, to maintain their safety, but this was carried on a patient by patient basis.

Although people did not want to talk to us during this assessment, we observed people being relaxed in the hospital environment. It was evident in peoples care records that they had been supported by staff to maintain their safety when they voiced concerns or used maladaptive coping strategies to manage their distress.

Staff and leaders reported any environmental issues or concerns in the morning risk meeting. These task were given to the estates team who would take action to remedy the concerns.

Staff were observed completing observations in both the communal lounge area and bedspace corridor depending on the location and observation level of patients. We reviewed governance data in relation to incidents of ligatures and acts of deliberate self-harm. We found there had been a significant reduction for both. On average between January 2024 to April 2024 there had been a total of 85 ligature incidents. In May 2024 there was a total of 34 incidents. Between January and April 2024, the average number of incidents of deliberate self-harm was 186. In May there were 84 of this type of incident reported.

Managers had completed and regularly reviewed ligature risk assessments. The last one had been completed in May 2024. It clearly highlighted areas of risk and all the potential ligature points, clinical and environmental actions that are required to mitigate the risk. The audit identified if there are any blind spots in the specific area and how it was mitigated. For example, in peoples bedrooms there were blind spots behind the separator wall and ensuite. The audit highlighted that the clinical action to mitigate the risk was for staff to enter room to observe fully environment action. Convex mirrors were also in place as further mitigation. Leaders had produced a ligature hot spot pictorial guidance booklet for staff. It had pictures of potential suspended ligature points. This booklet clearly highlighted to staff what and where to observe for potential ligature incidents. In addition, we noted that the ligature audit clearly noted where there were door handles and window restrictors in place and that these need to be audited on a monthly basis. We reviewed these documents and found that they had been completed in line with the audit.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.