You are here

Action is being taken against the provider of this service. Find out more

  • We have suspended the ratings for this service.

Inspection Summary

Overall summary & rating

Updated 25 August 2021

We have taken urgent enforcement action against the registered provider in relation to our concerns about this location. This included restricting new admissions into the service, without prior written approval of CQC (Care Quality Commission). However, we did not re-rate Cygnet Appletree following this focussed inspection. This is because the service type had changed since our previous comprehensive inspection in August 2019.

• Patients were not protected from abuse or poor care. Safeguarding issues were not always identified and reported to relevant agencies. This included reporting concerns to police, local authority and CQC.

• Patients were subjected to restrictive practices including restraint and the use of rapid tranquilisation. Staff did not always attempt to de-escalate incidents prior to using high level restrictions. Intra-muscular medications were used frequently without clear rationale to justify their use.

• Patients' privacy and dignity were not always protected when carrying out physical interventions, these were not used as a last resort and for the shortest possible time.

• Patients were not always protected from risks because the environmental risk assessment had not identified all risks. Seating in the courtyard had not been identified as a ligature risk.

• Observation records were not always accurate and did not reflect the level of observation patients needed to keep them safe as shown in risk assessments.

• Seclusion records and reviews of patients in seclusion were not completed in line with the Mental Health Act Code of Practice.

• Staff were not clear on what types of incidents should be reported. Staff did not always accurately record incidents. Systems in place to review incidents were not robust which meant that opportunities to learn from incidents were missed.

• Governance processes in the service were not effective. Managers had not identified all relevant issues as a result including environmental risks, use of restrictive interventions and safeguarding issues were not being addressed.


• The ward environment was clean, well maintained and well furnished

Inspection areas


Updated 25 August 2021


Updated 25 August 2021


Updated 25 August 2021


Updated 25 August 2021


Updated 25 August 2021

Checks on specific services

Acute wards for adults of working age and psychiatric intensive care units

Updated 25 August 2021