Updated 30 April 2025
Cygnet Sedgley House and Cygnet Sedgley Lodge is a 34 bedded high support inpatient mental health rehabilitation service for men aged 18 and over with complex needs. It is split into 2 wards, the House and the Lodge. The House has 20 beds and is a locked door rehabilitation ward for men with a diagnosis of mental illness and who have had at least 1 admission to an acute or forensic ward. The Lodge has 14 beds. It is not locked and is a step down ward following assessment at the House. Most patients were detained under the Mental Health Act 1983 but not all. The service is part of Cygnet Behavioural Health Limited.
We last inspected the service in June 2018 and rated it as Good overall. At this assessment we reviewed all the quality statements.
We carried out an onsite assessment on the 3 and 4 December 2024 and asked for, and reviewed data related to the assessment.
During this assessment we piloted an approach to identifying and improving service culture using extended observations.
Staff assessed risks to people's health and safety and mitigated those risks. People had care plans to guide safe practice. Patients felt safe and said they were cared for well. There was a good range of activities and therapy to support patients rehabilitation. Managers understood the service and staff were suitably trained.
However, we found a breach of the legal regulation in relation to good governance. Not all staff felt supported by managers and some said they did not get formalised supervision on a regular basis. Some staff felt their morale was low and there was a poor culture. Most staff said they did not think there were enough staff.
We have asked the provider for an action plan in response to the concerns found at this assessment.
Mental Health Act and Mental Capacity Act Compliance
Mental Health Act
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Managers made sure that staff could explain patients’ rights to them.
Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice.
Staff knew who their Mental Health Act administrators were and when to ask them for support.
The service had clear, accessible, relevant and up-to-date policies and procedures that reflected all relevant legislation and the Mental Health Act Code of Practice.
Patients had easy access to information about independent mental health advocacy.
Staff explained to each patient their rights under the Mental Health Act in a way that they could understand, repeated as necessary and recorded it clearly in the patient’s notes each time.
Staff made sure patients could take section 17 leave (permission to leave the hospital) when this was agreed with the Responsible Clinician and/or with the Ministry of Justice.
Staff requested an opinion from a Second Opinion Appointed Doctor (SOAD) when they needed to.
Staff stored copies of patients’ detention papers and associated records correctly and staff could access them when needed.
Informal patients knew that they could leave the ward freely and the service displayed posters to tell them this.
Managers and staff made sure the service applied the Mental Health Act correctly by completing audits and discussing the findings.
Mental Capacity Act
Staff supported patients to make decisions on their care for themselves. They understood the trust policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.
Staff gave patients all possible support to make specific decisions for themselves before deciding a patient did not have the capacity to do so.
Staff assessed and recorded capacity to consent clearly each time a patient needed to make an important decision.
When staff assessed patients as not having capacity, they made decisions in the best interest of patients and considered the patient’s wishes, feelings, culture and history.