Cygnet Acer Clinic

Updated 21 July 2026

We assessed Cygnet Acer Clinic on 26 May 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 visited the following wards as part of the assessment:

Acer Upper – Acute Service for women of working age with 14 beds.

At this assessment, we identified breaches of Regulations 10 (Dignity and Respect), 12 (Safe Care and Treatment), and 17 (Good Governance

At this assessment we assessed 1 assessment service groups; Acute wards for adults of working age and psychiatric intensive care units where we assessed 33 quality statements.

We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

We rated the service as requires improvement. In the acute wards for adults of working age, we found 3 breaches of regulations in relation to dignity and respect, safe care and treatment, and good governance. Concerns included the management of risks associated with repeated self-harm, the quality and effectiveness of care planning and crisis planning, the cleanliness and maintenance of patient environments, patients' cultural and religious needs not being consistently recognised and/or respected, and the effectiveness of governance systems to identify, monitor and address risks and drive improvements in care.

We are taking regulatory action in response to the concerns identified during this assessment. Details of this action will be published once the regulatory process has concluded.

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.

Updated 31 July 2024

Cygnet Acer Clinic is an independent hospital based in North East Derbyshire. It is made of two wards. Lower house is a 14 bed Long Stay Rehabilitation mental health ward for adult female patients with complex mental health needs. Upper House is a 14 bed acute ward for female patients with new or emerging complex mental health needs who are in mental health crisis. The Cygnet Acer Clinic was last rated as Good in June 2022. The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our onsite assessment at Lower House only on 7 August 2024. The assessment took place following a serious incident in May 2024 to assess that make sure that the provided safe care, suitable risk management procedures and the environment was safe for people who used the services. We looked three quality statements in the safe key question.

During this assessment we found that leaders ensure 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.