- Independent mental health service
Cygnet Acer Clinic
Assessment report published 21 July 2026
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
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.
People's experience of this service
We spoke with five patients and two family members during the inspection.
The patients we spoke with consistently provided negative feedback about their experiences of care and treatment. All five patients described concerns regarding their experiences of care and treatment and did not feel the service consistently met their needs.
Patients told us the ward environment was often not clean and that staff did not always provide sufficient support to help them maintain their bedrooms and en-suite facilities. Three patients showed us blood staining within their bedrooms and bathrooms following self-harm incidents and told us this had remained unclean for several days. Patients felt this affected their dignity and wellbeing.
All five patients we spoke with told us there was limited meaningful engagement from staff. They described staff as often being task-focused and said they did not always feel listened to or emotionally supported when distressed. This was consistent with our observations during the inspection, where we saw patients spending prolonged periods in communal areas with little meaningful activity or therapeutic engagement taking place.
Most patients we spoke with told us that activities advertised on the ward timetable were often cancelled, which contributed to their view that there was little meaningful activity available on the ward. As a result, some patients described feeling bored.
One patient told us they did not feel their cultural and religious needs were consistently recognised or respected. This was supported by our discussions with staff, where one member of staff incorrectly advised there were no patients on the ward with specific cultural or religious needs.
Patients also raised concerns regarding risk management within the service. Some patients told us they remained able to access items they considered unsafe and did not always feel risks were managed effectively. One family member shared similar concerns and felt opportunities to reduce known risks had been missed.
Patients told us they were aware of how to raise concerns and provide feedback. They knew about community meetings, advocacy services, and other opportunities to share their views. However, several patients did not feel their concerns resulted in meaningful change and expressed limited confidence that issues raised would be addressed.
Family members were generally positive about communication from the service and told us staff kept them informed about important developments regarding their relatives' care and treatment. They spoke positively about involvement in care planning and discharge discussions.
Despite the concerns identified, patients confirmed they had access to physical healthcare, advocacy services, and support from members of the multidisciplinary team. Patients also told us staff supported them to maintain contact with family and those important to them during their admission.