Cygnet Acer Clinic

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe- this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

People were not always protected from avoidable harm. People did not always receive safe, personalised care, care plans, risk assessments and crisis plans did not consistently provide staff with clear guidance to manage identified risks. People were not always cared for in a clean and safe environment. We identified significant concerns regarding cleanliness within patient bedrooms and en-suite facilities. Although leaders took immediate action following the inspection feedback and provided assurances regarding improvements, concerns identified on the day of inspection increased the risk of avoidable harm. Learning from incidents were not consistently translated into improvements in practice and governance systems had not identified or addressed concerns relating to risk management, care planning and environmental safety.

However, staff understood safeguarding processes and had completed safeguarding and Mental Capacity Act training. Staff completed mental and physical health assessments following patient admission, medicines were generally managed safely, staffing levels were usually maintained, and patients had access to multidisciplinary professionals and physical healthcare services when required.

The service was in breach of the legal regulations in relation to safe care and treatment (Regulation 12).

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed some shortfalls. The service did not always demonstrate an effective culture of learning from safety events. Whilst staff understood how to report incidents and raise concerns, leaders did not consistently demonstrate that learning from incidents was embedded into practice, monitored or evaluated to reduce future risk. Lessons were not always used effectively to drive and sustain improvements in patient safety.

Leaders did not ensure learning from incidents was effectively embedded into practice to reduce the risk of recurrence and improve patient safety. We reviewed incident data between 12 May 2026 and 26 May 2026 which recorded repeated incidents of self-harm, ligatures, cutting and head banging involving a cohort of patients. Staff continued to manage repeated incidents involving similar methods of self-harm and recurring risk behaviours. Leaders did not demonstrate that staff consistently implemented effective preventative measures to reduce recurrence or mitigate known risks. For example, records did not consistently evidence effective action to restrict access to items repeatedly used for self-harm or introduce alternative risk reduction strategies following incidents.

We reviewed the ward's lessons learned records between January 2026 and May 2026. Leaders recorded actions following incidents, however, records did not consistently identify the specific learning arising from incidents, how learning had been embedded into practice, or how leaders monitored and evaluated whether actions taken had been effective in reducing future risk. This limited leaders' ability to demonstrate that learning resulted in sustained improvements to patient safety.

However, the service promoted transparency in incident reporting. Staff knew how to report incidents and raise concerns and described receiving feedback following incidents and safety events. The service reported there was no serious incidents during the previous 12 months.

The evidence showed some shortfalls. The service did not always ensure that systems for monitoring and managing risks to people's safety were effective. Although staff worked with multidisciplinary teams, carers and partner agencies to support patient care and discharge planning, governance processes did not consistently identify, monitor or address concerns relating to risk management, care planning and learning from incidents.

Staff did not consistently feel able to influence admission decisions, and some staff raised concerns regarding the impact of recent admission processes on ward safety. Several staff and multidisciplinary team members told us they had limited influence over some admission decisions. Staff described recent changes to referral and admission processes and told us these could have resulted in a higher number of patients with similar diagnoses being admitted to the ward at the same time. Staff felt this increased the complexity of managing risks on the ward. Although leaders explained that the ward retained the ability to close to admissions when required, some staff did not feel this fully mitigated the challenges created by the current referral and admission process.

However, leaders assessed referrals and admissions, and staff worked effectively with patients, families and partner agencies to support safe discharge planning and continuity of care. Leaders assessed referrals before admission and could decline referrals where they could not safely meet a patient’s needs. Communication during admissions and transfers was generally effective and helped staff understand patients’ needs.

Staff demonstrated a collaborative approach to discharge planning. Multidisciplinary team members, patients, and family members contributed to discharge discussions and planning. Staff worked with relevant partner agencies to support continuity of care and reduce the risk of avoidable disruption when patients moved between services.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

Most staff had completed safeguarding training appropriate to their role. Staff knew how to make a safeguarding alert and did so appropriately when required. Staff were able to describe how they would recognise patients at risk of, or suffering, significant harm, and understood the importance of working in partnership with external agencies to ensure risks were escalated and managed effectively.

Staff gave examples of how they supported patients to be protected from harassment and discrimination, including those with protected characteristics under the Equality Act. They described promoting respectful care and taking action where discriminatory behaviour or vulnerability was identified.

Staff followed safe procedures for children visiting the service, with arrangements in place to ensure visits were appropriately risk assessed and supported in a way that maintained patient and visitor safety. Staff understood the importance of balancing family contact with safeguarding considerations.

Staff were aware of restraint and restrictive practice procedures and described the importance of least restrictive practice. They reported using de-escalation techniques as a first response and only using restraint when absolutely necessary to maintain safety. Blanket restrictions were identified and reviewed through governance processes to ensure they were proportionate and clinically justified.

However, most patients did not always feel safe on the ward. Patients described this in relation to ward acuity, the number of unwell patients on the ward at the same time, and the challenges this created in managing risk. Despite this, staff continued to respond to safeguarding concerns appropriately and escalate risks when required.

Mental Capacity Act

The provider had a Mental Capacity Act (MCA) policy in place, including arrangements relating to Deprivation of Liberty Safeguards (DoLS), which staff were aware of and could access. Staff compliance with MCA training exceeded 90%, which demonstrated good levels of training compliance across the service and supported staff to understand their responsibilities under the Act. Staff knew where to seek advice within the organisation when required and demonstrated a generally good understanding of the MCA, particularly the five statutory principles.

Staff took practical steps to support patients to make their own decisions and to maximise capacity wherever possible. Where patients may have lacked capacity, staff carried out decision-specific capacity assessments and recorded these appropriately.

Staff understood their responsibilities in relation to Deprivation of Liberty Safeguards (DoLS) and knew when an application would be required. During our assessment, there were no patients for whom a DoLS application was required.

The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not consistently ensure care planning and risk management documentation reflected patients' views, preferences and individual approaches to managing risk.

We reviewed five care records, risk assessments and risk management plans. Staff did not consistently record patient involvement within care planning and risk management documentation. Some care plans contained limited evidence of patient voice or co-production. Staff did not consistently develop crisis plans with sufficient detail that reflected patients' individual coping strategies, preferences or support needs during periods of deterioration. Several crisis plans contained generic information or referred to coping strategies that had not been documented. This reduced assurance that staff had fully considered patients' views, preferences and individual approaches to managing risk.

However, staff were involved patients in multidisciplinary team reviews, and we observed positive patient involvement during ward rounds. Records and observations demonstrated that patients contributed to discussions about their care and treatment, and staff involved family members where appropriate.

The evidence identified concerns regarding the service's ability to consistently detect and control potential risks in the care environment

Leaders did not ensure the ward environment was safe and did not effectively identify, assess or mitigate environmental risks. Leaders did not identify or address significant environmental cleanliness and infection prevention and control concerns through their own governance, audit and risk assessment processes. Staff did not effectively manage environmental risks within some patient bedrooms. Several bedrooms contained significant levels of clutter, which prevented staff from fully assessing, managing and mitigating environmental risks. Patients felt that staff did not always assess and manage bedroom environments and said these increased opportunities for self-harm. . The ward layout did not fully support effective observation. Visibility from the nursing station on the first floor of the service was restricted by tinted windows. Although these measures supported confidentiality, they reduced staff's ability to observe parts of the ward environment.

Following inspection feedback, leaders took immediate action to address the environmental concerns identified. Leaders implemented actions to reduce bedroom clutter and provided assurances regarding improvements to environmental oversight and risk management. Leaders submitted an action plan outlining the measures they intended to take to address the concerns identified during the inspection.

The evidence showed some shortfalls. The service did not always ensure staff had the appropriate experience, induction and support to undertake their roles effectively. However, leaders provided staff with supervision, development opportunities and support, and staff mostly worked well to provide care that met people's individual needs

Leaders generally maintained staffing levels that reflected planned establishment requirements. However, staff and patients did not always experience staffing arrangements to be sufficient to meet the changing acuity and needs of patients on the ward. Patients described delays and cancellations to escorted leave and changes to planned activities due to staffing pressures. Staff felt that although staffing numbers were generally maintained, the skill mix and experience of staff available on shift did not always reflect the complexity of the patients' needs. We observed one occasion where a patient was unable to readily access a qualified nurse because both qualified nurses were attending meetings away from the ward area. This reduced immediate access to nursing support at that time.

However, there were enough staff to undertake observations and respond to incidents. Leaders provided adequate medical cover during the day and night, with arrangements, in place for doctors to attend the ward in an emergency. Staff had completed mandatory training appropriate to their roles,

Leaders calculated the number and grade of the nursing and support staff required to safely operate the service, and planned staffing levels were met on shifts. Leaders maintained contingency arrangements to support staffing pressures, including access to bank and agency staff, regional support arrangements, an on-call management system and medical on-call cover. The service's staff turnover remained well below the provider's target of 25%. Sickness absences had increased in recent months but remained below the provider's group average. Staff were supported in their role through regular supervision, appraisals, and development opportunities.

The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Leaders did not ensure effective infection prevention and control arrangements or maintain a clean environment that protected patients from the risk of infection.

Staff did not consistently maintain clean ward environments. During the inspection, we identified significant cleanliness concerns within patient bedrooms and ensuite facilities. We found several unclean bedrooms, including blood within patient bedrooms and bathroom facilities following self-harm incidents. These findings did not demonstrate effective infection prevention and control practices and increased the risk of harm to patients and staff.

Leaders did not identify these concerns through their own governance, audit and monitoring processes before inspectors raised them during the onsite assessment. Cleaning records and existing oversight arrangements did not provide assurance that staff consistently maintained ward environments to an appropriate standard.

Patients told us their bedrooms and living environments were often unclean and said staff did not routinely support them to maintain clean bedroom environments. Housekeeping staffing levels were reduced at the time of inspection, which may have contributed to the cleanliness concerns identified on the ward. Following our feedback, leaders took immediate actions to address the cleanliness concerns.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences.

Staff did not consistently maintain clinic room records in line with expected standards. We found clinic room cleaning records had not been fully completed, including missing staff signatures to confirm if cleaning had taken place. This meant leaders could not always demonstrate that clinic room cleaning had been completed as required. Staff had not consistently applied clean equipment stickers to clinical equipment within the clinic room. This reduced assurance that equipment had been cleaned, checked and was ready for use. Staff did not always maintain medicines storage areas to an appropriate standard. We found excessive medicines stock held within the medicines room and identified damaged shelving within storage areas. This reduced assurance that medicines storage arrangements were effectively organised, monitored and maintained.

Staff did not always ensure medicines were administered in accordance with Mental Health Act requirements. We found one prescribed medicine requiring authorisation under a T2 certificate was not supported by a current and completed T2 form. A T2 form provided legal authorisation for the administration of medication for mental disorder where a detained patient has consented to treatment. This meant there was not always clear evidence that medication for mental disorder was being administered in accordance with the requirements of the Mental Health Act and increased the risk of non-compliance with legal and regulatory requirements.

These findings indicated that leaders had not consistently identified and addressed medicines management issues through governance and audit processes.

However, staff generally managed medicines safely and leaders had systems in place to support the safe ordering, storage, administration and disposal of medicines. Staff supported patients to be involved in decisions about their medicines and provided person-centred guidance to support the administration of when required medicines where appropriate. Staff maintained appropriate arrangements for the management of controlled drugs, and we did not identify concerns regarding the storage, recording, administration or disposal of controlled medicines. Staff were trained and assessed as competent to manage medicines safely and we found no evidence that medicines were used inappropriately to control patients' behaviour.