Cygnet Acer Clinic

Updated 21 October 2026

We assessed Cygnet Acer Clinic from the 7 to the 14 September 2026. 

We undertook the assessment in response to concerns received regarding the safety and quality of care provided within the service. 

Cygnet Acer Clinic was registered with CQC in May 2016 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 have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed patients with a learning disability and autistic patients respect, equality, dignity, choices, independence and good access to local communities that most patients take for granted. 

At this assessment we assessed 1 assessment service group; long stay or rehabilitation mental health wards for working age adults we assessed all 33 quality statements. 

We rated the service as good. The rating from this assessment has been combined with ratings of the other service from the last inspection. See our previous reports to get a full overview of all other services at Cygnet Acer Clinic. The overall rating of Cygnet Acer Clinic has remained requires improvement.

Updated 21 August 2026

This assessment of Cygnet Acer Clinic – Acer Lower Ward took place from the 7 to the 14 September. We completed an onsite visit on the 7 September 2026.  Acer Lower was Cygnet Acer Clinic’s 14 bed service providing assessment, treatment and rehabilitation for women with personality disorder and complex needs. The aim of the treatment being, rehabilitation and re-socialisation programme is to prepare the individuals for either for transfer to a less secure environment, or for a life in the community. 

The service was registered to support patients with mental health needs, including autistic people. We assessed the service against the principles of Right Support, Right Care, Right Culture to help us determine whether autistic patients and patients with a learning disability experienced care that promoted respect, equality, dignity, choice, independence and inclusion. 

We undertook the assessment in response to concerns received regarding the safety and quality of care provided within the service. We carried out an unannounced, comprehensive inspection of this service, looking at all five key questions to assess if services were safe, effective, caring, responsive and well led. 

The rating from this assessment has been combined with ratings from other services at the location from previous inspections. See our previous inspection reports for a full overview of all services provided at Cygnet Acer Clinic. We rated long stay or rehabilitation mental health wards for working age adults Good.  

Staff maintained a safe care environment and had systems to identify and respond to risks. Staff used daily safety summaries, handovers, Positive Behaviour Support plans, incident reviews and risk management processes to monitor patients' safety and respond to changes in presentation. Patients had access to physical healthcare, medicines management systems, environmental safety measures and staff were trained to support patients with complex mental health needs. 

Staff completed mental and physical health assessments following admission and delivered treatment and support within a multidisciplinary rehabilitation model of care. Patients had access to a range of evidence-based interventions, including psychological therapies, occupational therapy, sensory modulation approaches and community-based rehabilitation opportunities. Staff worked collaboratively with a wide range of healthcare professionals, commissioners, safeguarding teams and community services to support patients' care and future discharge planning. 

Patients were involved in discussions about their care, treatment and rehabilitation goals and had access to advocacy services and communication support where required. The service provided opportunities for patients to give feedback through community meetings, advocacy services and individual discussions with staff. Patients were supported to develop skills for greater independence and worked towards individual goals relating to recovery, community access and future discharge. 

Leaders demonstrated a good understanding of the service and its challenges. Governance systems included audits, outcome measures, incident reviews, multidisciplinary discussions and service development plans. Leaders reviewed incidents to identify patterns and trends and described how this information was used to inform care planning and risk management. Staff received regular training, supervision and appraisals, and leaders had implemented improvement initiatives in response to staff and patient feedback. 

However, patients, staff and external stakeholders consistently raised concerns regarding staffing pressures and the use of temporary staff. Some patients reported feeling less supported and less understood when unfamiliar staff were working on the ward. 

We also identified some shortfalls in care planning documentation. Although staff assessed and reviewed patients' needs, records did not always provide sufficiently detailed guidance regarding the management of specific physical healthcare risks. This meant staff did not always have clear information about the signs and symptoms they should monitor for or the actions they should take if concerns arose.

Updated 20 April 2026

This assessment of Cygnet Acer Clinic – Acer Upper Ward took place on 26 May 2026. Acer Upper Ward is a 14-bed acute mental health service for women. The service provided support for individuals experiencing an acute episode of mental illness who required an emergency admission.

The service was registered to support people with mental health needs, including autistic people, and we assessed the service against the principles of Right Support, Right Care, Right Culture to help us determine whether autistic people and people with a learning disability experienced care that promoted respect, equality, dignity, choice, independence and inclusion.

We undertook the assessment in response to concerns received regarding the safety and quality of care provided within the service. We undertook an unannounced, comprehensive inspection of this service, looking at all five key questions to assess if services are safe, effective, caring, responsive and well led.

The rating from this assessment has been combined with ratings from other services at the location from previous inspections. See our previous inspection reports for a full picture of all services provided at Cygnet Acer Clinic. We rated this service as Requires Improvement. We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to dignity and respect, safe care and treatment, and good governance.

Staff did not consistently treat people with dignity and respect. All five patients we spoke with described poor experiences of care and treatment and told us they did not always feel listened to, supported or meaningfully engaged by staff. This was consistent with our observations, which identified limited therapeutic engagement between staff and patients and missed opportunities for staff to provide emotional support and meaningful interaction.

Staff did not always assess, monitor and mitigate risks to people's health and safety effectively. We identified repeated incidents of self-harm involving a cohort of patients and found that risk management arrangements were not always effective in reducing known risks. Care plans, crisis plans and risk assessments did not consistently provide staff with clear, personalised guidance to support safe care and treatment.

Leaders did not operate effective governance systems to assess, monitor and improve the quality and safety of the service. Governance processes had not identified or addressed concerns relating to risk management, care planning, patient experience, staff practice and environmental safety. Learning from incidents and patient feedback was not consistently translated into improvements in practice.

However, leaders and staff worked effectively with multidisciplinary teams, carers and partner agencies to support patient care and discharge planning. Staff completed mental and physical health assessments following admission and patients had access to a range of evidence-based interventions, physical healthcare services and specialist professionals. Staff supported patients to access advocacy services, interpreter support and information in formats that met their communication needs. Staff received regular training, supervision and appraisals, and leaders demonstrated a commitment to service improvement through a number of quality improvement initiatives and accreditation programmes.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

Staff had completed mandatory Mental Health Act awareness training with 91% compliance across the hospital. Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff were aware of their designated Mental Health Act administrators, and the necessary policies and procedures that were in place.

Patients had access to independent mental health advocacy. Care plans recorded that patients had their rights under the Mental Health Act explained in an accessible way, with support from other professionals when required.

Staff stored copies of patient's detention papers appropriately, ensuring they were accessible to all staff who required them. Staff ensured that patients were able to take Section 17 leave (permission to leave the hospital) when it had been authorised. We saw that staff documented this authorisation clearly.

Mental Capacity Act

Staff had completed mandatory Mental Capacity Act (MCA) awareness training with 91% compliance across the hospital. Staff had a good understanding of the MCA, particularly the five statutory principles. Staff knew where to get advice from regarding the MCA, including deprivation of liberty safeguards. The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act.

Staff took all practical steps to enable patients to make their own decisions. Capacity assessments were completed in line with the Mental Capacity Act, which were time and decision specific. Assessments were only undertaken when staff had reason to believe that someone lacked capacity.

No applications for Deprivation of Liberty Safeguards had been submitted within the previous 12 months. Such applications are required when a person lacks the mental capacity to make decisions about their care and may need legal safeguards to ensure their rights are protected. The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were familiar with this policy and knew how to access it.