Cygnet Hospital Woking

Updated 16 February 2026

We assessed Cygnet Hospital Woking form 10 to 11 December 2024.

We assessed the service following notifications we had received from the provider about increase in safety incidents across the wards. We were notified of incidents of patients swallowing and ingesting objects and staff not maintaining safe observations of patients. We were also notified about concerns regarding the inappropriate use of seclusion and the restraint of a patient using an unapproved restraint technique.

Cygnet Hospital Woking was registered with CQC in November 2010 to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of disease, disorder or injury. The service had a controlled drugs accountable officer and a Registered Manager.

We visited the following wards as part of the assessment:

Acorn ward 10 bedded adult female only psychiatric intensive care unit.

Kahlo Ward, 11 bedded adult female only acute ward for adults.

Picasso Ward, 12 bedded adult female only acute wards for adults.

Greenacre ward, 18 bedded adult forensic male only low secure inpatient ward. Oaktree ward, which is an 11 bedded adult forensic female only low secure inpatient ward.

At this assessment we identified breaches of regulations: 9 Person Centred Care, 12 Safe Care and Treatment, and 17 Good Governance.

At this assessment we assessed 2 assessment service groups; Acute wards for adults of working age and psychiatric intensive care units where we assessed 33 quality statements each for both the acute and psychiatric intensive care units and the forensic low secure wards.

We rated the service as requires improvement. In the acute wards for adults of working age and psychiatric intensive care units, we found 2 breaches of regulations in relation to: Staff were not always involving patients in planning their care and treatment, no restraint care plans in place, environmental concerns with the cleanliness and maintenance of the wards as well as environmental risks with unidentified blind spots which could present as a safety risk. The service was rostering staff to observe patients for four hours continuously without a break. Medicines were not always being managed in line with national guidance or legislation. Governance processes were not always effective in monitoring and mitigating risks and therefore action to address identified issues were not always taken in a timely manner. In the forensic low secure wards, we found 3 breaches of the regulations in relation to ensuring the care and treatment of patients was appropriate, met their needs and reflected their preferences, ensuring relatives and carers were involved in the care of the patients. Ensuring staff were not rostered to be on observation for more than 4hours without a break. Ensuring blind spots in patients’ bedrooms were sufficiently mitigated. Ensuring there was good record keeping of post-dose monitoring of Rapid Tranquilisation and ensuring there were enough staff deployed to work on the wards.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 17 November 2024

Date of assessment: 10 and 11 December 2024.

Cygnet Hospital Woking is an independent mental health hospital that provides specialist acute and psychiatric intensive care (PICU) services for women, across three wards and Forensic wards for males and females across two wards. We carried out an unannounced assessment of all 5 wards at the service.

• Acorn ward is a 10 bedded female only psychiatric intensive care unit.
• Kahlo ward is an 11 bedded acute service for women.
• Picasso ward is a 12 bedded acute service for women.
• Oaktree ward is an 11 bedded female only forensic inpatient / low secure ward.
• Greenacre ward is an 18 bedded male only forensic inpatient / low secure ward.

The inspection was triggered by an increase in notifications of incidents (sent by the provider to CQC) about patients swallowing and ingesting objects We were notified of a serious incident where it was found that staff were not fulfilling their duties in terms of enhanced observations due to staff members sleeping on duty. We were also notified about concerns about the inappropriate use of seclusion and the restraint of a patient using an unapproved restraint technique. This assessment was carried out following CQC’s new approach to assessment; Single Assessment Framework (SAF). We assessed all 33 quality statements across the safe, effective, caring, responsive and well-led key questions.

In January 2023, the service had a focussed inspection of the acute wards for adults of working age and psychiatric intensive care units which changed the overall rating for the service and was rated good overall, with requires improvement in effective and good in safe, caring, responsive and well-led.

Following this inspection, we rated the service as Good overall. We rated safe as requires improvement and effective, caring, responsive and well-led as good. We identified areas of improvement that were required in relation to staff not always involving patients in planning their care and treatment, environmental concerns with the cleanliness and maintenance of the wards as well as environmental risks with unidentified blind spots which could present as a safety risk, medicines were not always managed in line with national guidance or legislation and governance processes were not always effective in monitoring and mitigating risks and therefore action to address identified issues was not always taken in a timely manner. We found the service to be in breach of Regulation 12, Safe care and treatment and Regulation 17, Good Governance.

However:

Staff knew what incidents to report, and how to report them. All records had risk assessments that were regularly updated and contained all relevant risk information. Staff told us they avoided using restraint by using de-escalation techniques, and we saw this in practice. There were enough staff to ensure people’s safety and meet their needs. Staff completed key mandatory training, monthly supervision and yearly appraisals. Patients could access a range of interventions and activities in line with national guidance. Ward activities helped promote a healthy lifestyle for patients. Patients told us staff were kind and treated them well. They told us staff were available on the ward to support them when needed. Patients were supported to have choice and control and could give feedback on their care. All staff told us they felt respected, supported and valued by their colleagues and managers.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 17 November 2024

Our view of the service

We completed an assessment and inspection of Cygnet Hospital Woking on 10 and 11 December 2024 with additional offsite interviews with carers on 6 and 7 January 2025.

Cygnet Hospital Woking is an independent mental health hospital run by Cygnet Surrey Limited. The hospital offers a range of mental health services for men and women across 5 wards.

Cygnet Hospital Woking delivers acute/psychiatric intensive care wards (PICU) and forensic care across 5 wards. Acorn ward is a 10 bedded female only psychiatric intensive care unit, Kahlo ward is an 11 bedded acute service for women, Picasso ward is a 12 bedded acute service for women, Oaktree ward is an 11 bedded female only forensic inpatient/low secure ward and Greenacre ward is an 18 bedded male only forensic inpatient/low secure ward.

We carried out an unannounced assessment of all 5 wards at the service.

The inspection was triggered by an increase in notification of incidents about patients swallowing and ingesting objects. We were notified of a serious incident where it was found that staff were not fulfilling their duties in terms of enhanced observations due to staff members sleeping on duty. We were also notified about concerns about the inappropriate use of seclusion and the restraint of a patient using an unapproved restraint technique. This assessment was carried out following CQC’s new approach to assessment; Single Assessment Framework (SAF). We assessed all 33 quality statements across the safe, effective, caring, responsive and well-led key questions. The service had previously been inspected in April 2022, and we rated it as Good overall. We rated the safe domain as requires improvement because staff were not calibrating medical equipment, did not keep the right room temperature for safe storage of medicines and staff did not monitor the effects of clozapine on patients. The service was rated good in effective, caring, responsive and well led.

At the time of our December 2024 inspection, we found that actions from the previous inspection had been addressed. Staff routinely calibrated medical equipment for measuring blood glucose levels, the provider took action to safeguard medicines supplies when the temperature of medicines storage areas fell outside of the recommended limits, and staff monitored and reviewed the effects of patients’ medication on their physical health, particularly patients prescribed Clozapine.

However, this inspection identified some areas for improvement. Overall, we rated the service as requires improvement because we identified breaches of regulatory standards. Staff did not always involve patients in the planning of their care and treatment, the provider required staff to observe patients for 4 hours without a break and managers of the service did not always use governance processes to effectively monitor, manage and take action to address identified issues in a timely manner.

During this assessment the provider did not always:

• Ensure the care and treatment of patients was appropriate, met their needs and reflected their preferences.
• Ensure relatives and carers were involved in their loved one’s care where this was appropriate.
• Ensure staff were not rostered to be on observation for more than 4 hours without a break.
• The service did not always record which rapid tranquilisation medicine was first line when multiple medicines were prescribed.
• Ensure there were enough staff deployed to work on the wards.