Cygnet Acer Clinic

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led- this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Governance systems were not always effective in identifying, assessing and mitigating risks to patients. We found concerns relating to risk management, care planning, incident learning, patient feedback and environmental cleanliness had not been identified or effectively addressed through governance processes. Although audits and monitoring systems were in place, these had not resulted in sustained improvements in practice or reduced risks to patients.

Leaders did not consistently demonstrate that learning from incidents was translated into meaningful service improvements. Patients continued to engage in repeated self-harm using similar methods and materials over an extended period, and records of lessons learned did not demonstrate robust action planning, monitoring or evaluation of effectiveness.

However, staff generally felt supported by local leaders and described a positive team culture. Leaders were open and transparent throughout the inspection process and responded promptly to concerns raised during the inspection. The service demonstrated a commitment to improvement through participation in quality improvement initiatives. Staff had opportunities to contribute to service development and leaders promoted equality, diversity and inclusion within the workforce.

The service was in breach of regulation for governance at the service (Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).

We have not awarded this service a score for Well-led.

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

The evidence showed some shortfalls. The service had a clear shared vision, strategy, and culture based on transparency, equity, equality, human rights, diversity and inclusion, and engagement. However, this was not always consistently reflected in practice, and patients did not always experience care in a way that demonstrated full understanding of their needs or the challenges faced by their communities.

The provider set out a clear vision, strategy, and set of values focused on delivering high quality, safe, and compassionate care, underpinned by openness, honesty, inclusivity, equity, and human rights. The service described its vision as ensuring people feel safe and supported, staff feel proud to work for the organisation, and stakeholders trust the service. The mission emphasised working in a culture of openness and inclusivity to deliver safe, compassionate care, and the values promoted respect, trust, empowerment, and integrity.

However, this vision and values were not consistently reflected in the experience of patients in practice. Some patients reported that they did not always feel listened to or fully involved in decisions about their care. Feedback indicated that patients did not always feel the service acted on their views or consistently demonstrated that their experiences shaped service delivery. Staff understood the organisational vision and values and were expected to work in line with them. However, there was variability in how consistently these were demonstrated in day-to-day practice, particularly in relation to compassionate care, engagement with patients, and ensuring people felt fully involved and respected.

The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation.

Leaders demonstrated experience and a commitment to openness, transparency and engagement with patients, staff and external stakeholders. However, leadership arrangements had not always been effective in ensuring that identified concerns were fully addressed, monitored and sustained improvements were achieved. Further assurance was needed that governance processes, learning and improvement actions were consistently driving positive outcomes for patients

Leaders were not always fully aware of the concerns identified during the inspection, including issues relating to infection prevention control, safety of the environment, risk management and efficient crisis planning. As a result, they did not always act quickly to address emerging concerns about culture and the impact this had on the quality of care. This limited their ability to fully assure themselves that improvements were being consistently embedded across the service.

The service had a recent change in registered manager, who had been in post since March 2026. Leaders were visible within the service, including the registered manager and ward manager, and were accessible to both staff and patients.

Staff reported that leaders were approachable, led by example, and were visible within the service. Staff also reported feeling supported by leaders and having access to appropriate leadership support and development opportunities. Leaders themselves also reported access to support and development from the provider and senior organisational structures.

Leadership development opportunities were available within the service, supporting staff progression into leadership roles and strengthening succession planning.

The evidence showed some shortfalls. People did not always feel they could speak up and that their voices would be heard.

Patients and staff had opportunities to give feedback on the service in ways that reflected their individual needs. Patients felt able to speak up and raise concerns. However, they did not always feel that issues were consistently resolved or followed through. Managers and staff had access to feedback from patients, carers, and staff. However, this feedback was not always consistently used to drive improvement or demonstrate clear changes in practice. The provider had policies and processes to support involvement in service development. However, we found that patients were not consistently involved in decision-making about changes to the service based on the feedback reviewed during the assessment. Patients and staff had opportunities to meet with leaders through community meetings, which provided a forum to share views and raise concerns. Leaders promoted a culture were speaking up was encouraged, particularly among staff.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders promoted equality, diversity and inclusion within the service and took steps to create a culture where staff felt respected, valued and supported.

Leaders demonstrated a commitment to improving equality, diversity and inclusion and undertook initiatives to celebrate and recognise diversity within the workforce. For example, the service participated in awareness events, including LGBTQ+ celebrations, to promote inclusion and understanding among staff and patients.

Staff could request flexible working arrangements to support personal circumstances, including caring responsibilities and health needs. Leaders described how reasonable adjustments could be implemented to support staff to carry out their roles effectively where required. For example, leaders supported staff who required reasonable adjustments due to living with autism by providing access to a quieter workspace for administrative tasks, report writing, and documentation, noise-reducing headphones when undertaking non-patient-facing work and considered sensory factors such as lighting, noise levels, and workspace location. Staff told us leaders were supportive when they experienced discrimination, including incidents of racist behaviour from patients. Staff described receiving support from colleagues and leaders following such incidents and felt concerns would be taken seriously. Leaders monitored workforce equality and diversity and reviewed policies and procedures to promote fair and inclusive working practices. Staff told us they felt able to raise concerns and contribute ideas for service improvement without fear of negative consequences. Leaders took action to promote an inclusive culture and sought opportunities to engage with staff from a range of backgrounds and experiences. Staff generally felt respected, supported and valued within their teams.

The evidence showed significant shortfalls. The service did not have clear responsibilities, systems of accountability, or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were not consistently effective in identifying, assessing, responding to and mitigating known risks. Although governance processes, audits and monitoring systems were in place, leaders did not always ensure that learning from incidents was effectively embedded into practice or that actions taken resulted in sustained improvements.

We reviewed incident data which recorded a high number of incidents involving repeated self-harm, ligatures, cutting and head banging. Despite incidents being reviewed through governance processes, patients continued to engage in repeated self-harm using similar methods and materials. Leaders could not consistently demonstrate that effective actions had been implemented, monitored and evaluated to reduce recurrence or mitigate known risks.

Leaders did not always ensure that learning from incidents resulted in measurable improvements. Records of lessons learned primarily identified actions relating to communication with staff through meetings and emails, with limited evidence of further action, monitoring, audit or evaluation of effectiveness. Actions were not always specific, measurable or clearly linked to risk reduction.

Leaders did not always ensure records were accurate, complete and reflective of patients’ current needs and risks. Care plans, risk assessments and crisis plans contained generic information, lacked sufficient individualised guidance and did not consistently demonstrate how risks were being monitored or reduced. Governance processes had not always identified or addressed these concerns.

Leaders did not consistently use feedback from patients to improve the service. Patients we spoke with provided negative feedback regarding their care and treatment, including concerns about safety, therapeutic engagement and whether their individual needs were met. Leaders could not demonstrate that themes identified through patient feedback had been effectively addressed.

Leaders did not always ensure effective oversight of staff practice and ward culture. During the inspection, we observed limited therapeutic engagement between staff and patients, task-focused interactions and missed opportunities to provide emotional support. Governance systems had not identified or responded to these concerns.

Leaders did not always ensure effective oversight of environmental safety and infection prevention and control. We identified concerns relating to cleanliness, cluttered patient bedrooms and the management of environmental risks which had not been effectively identified or addressed through governance processes.

As a result, governance systems had not consistently demonstrated that risks were being effectively identified, assessed, mitigated and reduced to ensure safe care for patients.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership. They share information and learning with partners and collaborate for improvement.

Staff and leaders understood the importance of working in partnership with external agencies and services to support patients throughout their care journey. We saw evidence of effective multidisciplinary working and collaboration with commissioners, community teams, healthcare professionals and family members to support care planning and discharge arrangements.

Leaders were open and transparent with external stakeholders and demonstrated a willingness to work collaboratively to improve the service. For example, following feedback provided during the inspection, leaders responded promptly, developed action plans, and implemented immediate measures to address concerns identified during the inspection process.

The service achieved the stage 1 Triangle of Care accreditation, reflecting its commitment to strengthening collaboration between carers, patients and healthcare professionals. This supported greater involvement of families and carers in care planning and treatment decisions.

Staff shared information appropriately with partner agencies to support continuity of care and ensure patients received coordinated support. Feedback from multidisciplinary team members was generally positive regarding joint working and communication between services.

The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation, and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Leaders did not consistently ensure learning from incidents, patient feedback and governance processes resulted in effective improvements in practice. Despite a range of improvement initiatives, we found repeated themes relating to self-harm, risk management, therapeutic engagement and patient experience which had not been effectively addressed. Incident reviews and lessons learned records did not consistently demonstrate how learning was monitored, evaluated or embedded into practice. Leaders could not consistently demonstrate that actions taken following incidents and feedback had resulted in measurable improvements or reduced risks to patients.

Leaders did not always ensure opportunities for learning were translated into sustainable changes in practice. Whilst learning was shared through meetings and communication with staff, there was limited evidence of robust monitoring, audit or evaluation to assess the effectiveness of actions taken.

However, leaders and staff demonstrated a commitment to learning, improvement and innovation. Staff were encouraged to contribute to service improvement initiatives and leaders supported opportunities to develop and test new approaches to care delivery and risk management.

The service participated in a number of improvement projects. For example, the service had commenced work on Project Beacon in May 2026 as part of a wider organisational programme to review non-fixed ligature risks and associated mitigations across Cygnet services. The project aimed to reduce non-fixed ligature risks through enhanced risk assessment, environmental review and strengthened risk reduction measures. At the time of our inspection the project remained in the data contextualisation and early delivery phase, and it was too early to evaluate its impact on patient safety outcomes.