- Independent mental health service
Cygnet Acer Clinic
Assessment report published 21 October 2026
Contents
Ratings - Long stay or rehabilitation mental health wards for working age adults
Our view of the service
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.
People's experience of this service
Patients gave mixed feedback about their experiences of care and treatment. Many patients spoke positively about permanent members of staff and described staff as caring, supportive and respectful. Patients were involved in discussions about their care and treatment and had opportunities to contribute to decisions about their rehabilitation goals, community access and future plans. Patients had access to independent advocacy services and could raise concerns through a range of mechanisms, including community meetings, care reviews and direct discussions with staff. We reviewed community meeting minutes which demonstrated that patients regularly shared their views, concerns and suggestions regarding the service and received updates about actions taken in response.
However, patients also raised concerns about staffing levels and the use of agency and bank staff. Several patients told us that unfamiliar staff did not always know their individual triggers, warning signs or preferred approaches to support. Some patients reported feeling less supported and less understood when temporary staff were working on the ward, particularly during periods of heightened distress or increased risk. Similar concerns were raised by advocacy services and commissioners, who reported that continuity of care could be affected when staff were unfamiliar with individual patients' needs.
Patients had access to activities, therapies and opportunities designed to support their recovery and independence. Patient's feedback demonstrated that they were supported to work towards individual goals relating to community access, increased independence and future discharge from hospital. Patients also had access to physical healthcare, occupational therapy, psychological support and community-based rehabilitation opportunities.
Feedback from advocacy services indicated that staff generally listened to patients' needs and requests when concerns were raised on their behalf. Advocacy services reported that the multidisciplinary team were responsive and that leaders were open to feedback.
Patients had access to independent advocacy, interpreter services and translation technology where required.