The Care Quality Commission
  • Mental Health
  • Independent mental health service

Cygnet Appletree

Overall: Requires improvement read more about inspection ratings

Frederick Street North, Meadowfield, Durham, DH7 8NT (0191) 378 2747

Provided and run by:
Cygnet Behavioural Health Limited

All Inspections

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

Cygnet Appletree is a mental health hospital for female patients in Durham. The hospital comprises 2 wards. Bramley ward is a 15-bed acute mental health ward for patients experiencing an acute episode of mental illness and who require an emergency admission. Pippin ward is a psychiatric intensive care unit for emergency and crisis admissions.

The hospital director was the registered manager and controlled drugs accountable officer. Controlled drugs accountable officers are responsible for all aspects of controlled drugs management within their organisation.

Cygnet Appletree is registered to carry out the following regulated activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983
  • Treatment of disease, disorder, or injury

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by the Care Quality Commission as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.

However, the information shared with Care Quality Commission about the incident indicated potential concerns about the management of risk in relation to medicines management and patients having access to medication without staff being aware of this. This inspection examined those risks.

We also received anonymous whistleblowing concerns about a lack of management oversight and governance within the service and patients being illegally detained because the date of their detention period under the Mental Health Act had expired.

The dates of our inspection were 10, 11, 12, 16 and 19 June 2025. We originally planned to inspect on 10, 11 and 12 June but due to the number of significant issues we identified in relation to the lack of effective systems and processes to ensure good governance and management oversight, our inspection was extended, including a medicines management review of the service on 16 June. The inspection team comprised 2 Care Quality Commission inspectors, a Care Quality Commission medicines inspector, an expert-by-experience with experience of mental health services and a psychiatric nurse acting as a specialist advisor to the Care Quality Commission.

We rated the service as requires improvement because we found a breach of the legal regulations in relation to the governance and management oversight of the wards and in relation to the use of high dose anti-psychotics medicine and the process for patient admissions.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

At the time of our inspection, 98% of staff had completed their mandatory Mental Health Act awareness training. Staff had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who the Mental Health Act administrator was within the service.

The provider had relevant policies and procedures that reflected the most recent guidance.

Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had easy access to information about independent mental health advocacy.

Staff did not always record whether they had explained to patients their rights under the Mental Health Act. We looked at 10 care records and 3 did not contain evidence that staff were routinely reminding the patient of their rights under the Act.

We saw evidence in care records that staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted. We also attended two morning meetings, during which, the multidisciplinary team reviewed patients access to Section 17 leave and if any changes should be made such as moving from escorted to unescorted.

Staff sought the opinion of a second opinion appointed doctor when necessary.

We found difficulty in locating detention documentation and when we asked the hospital director and one of the clinical managers where we could find it, they said they did not know where it was, and they would need to ask the Mental Health Act administrator. This led to our having concerns about the management oversight of the quality of detention paperwork.

The service had arrangements to monitor adherence to the Mental Health Act. The Mental Health Act administrator within the service checked associated documentation to ensure staff followed the Act correctly.

The service displayed a notice to tell informal patients that they could leave the ward freely.

Staff did audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

Mental Capacity Act

At the time of our inspection, 99% of staff had had training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

In the last 12 months, no deprivation of liberty safeguards applications had been made to the local authority.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice regarding the Mental Capacity Act, including deprivation of liberty safeguards. Staff could seek advice and guidance from the Mental Health Act administrator within the service.

Staff took all practical steps to enable patients to make their own decisions.

Staff assessed and recorded capacity to consent appropriately when there were concerns about a patient's mental capacity. They did this on a decision-specific basis with regard to significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person's wishes, feelings, culture and history.

The service had arrangements to monitor adherence to the Mental Capacity Act. This role was undertaken by the Mental Health Act administrator within the service who checked associated documentation to ensure staff followed the Act correctly.

During an assessment of the hospital overall

We rated the service as requires improvement because we found a breach of the legal regulations in relation to the governance and management oversight of the wards for which we served a warning notice on the provider.

Governance systems and audits were not effective in identifying or addressing areas for improvement such as poor-quality documentation and health and safety information being out-of-date or inaccessible. Staff did not consistently report serious incidents including self-harm, threats to kill, an allegation of improper treatment and an injury sustained during restraint to the local authority.

We identified poor practice in relation to the use of rapid tranquilisation and high dose antipsychotic medication within the service. Three patients using the service said they did not have regular 1 to 1 time with their named nurse.

However, there were enough skilled and experienced staff to ensure people's safety and that their needs were met. Managers shared lessons learned from investigating incidents, complaints and safeguarding concerns with staff.

Staff were kind, caring and supportive. People were supported to have choice and control and could give feedback on their care.

The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team.

19 and 20 October 2022

During a routine inspection

Our rating of this service improved. We rated it as good because:

  • The service provided safe care and the ward environments were clean and well maintained. The wards usually had enough staff who assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service managed beds well so that a bed was always available to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
  • The service was well led, and the governance processes ensured that ward procedures ran smoothly.

However:

  • The design and layout of Pippin ward meant that there were areas accessible to patients that were out of sight of the nurse’s station.
  • The hospital had some nurse vacancies which meant that not all shifts on Pippin had the required 2 qualified nurses.
  • Care plans were repetitive and sometimes difficult to follow due to the amount of information in them.
  • One patient did not have clear care plans outlining the use of pro-re-nata (PRN) medication and use of intra-muscular administration of medications or rapid tranquilisation. PRN medications are medicines that are used when needed.

21, 27 April and 14 May 2021

During an inspection looking at part of the service

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.

However:

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

5 - 6 August 2020

During an inspection looking at part of the service

We have taken enforcement action against the registered provider in relation to our concerns about this location. However, we did not re-rate Cygnet Appletree following this focused inspection. This is because the service type had changed since our previous inspection in August 2019.

We found the following issues that the provider needs to improve:

  • The service did not have effective systems in place to ensure patient safety on the ward. There was no comprehensive environmental risk assessment in place to identify all ligature risks and blind spots on the ward, and staff did not have a full understanding of how to mitigate such risks. Staff did not follow the hospital processes and policies in recording patient risk, resulting in patients being exposed to harm.
  • The service did not have robust systems in place to ensure that staff were adhering to safe practice. Ongoing physical health monitoring was not consistent for all patients or in line with Cygnet processes. Monitoring of patients following the use of rapid tranquilisation was not in line with The National Institute for Health and Care Excellence guidance. All clinical staff had not completed training in intermediate life support as recommended by The Resuscitation Council (UK) and staff were not following the guiding principles of the Mental Health Act Code of Practice in relation to the seclusion and segregation of patients.
  • Staff did not follow Public Health England guidance in the use of personal protective equipment related to COVID-19. Nor did the service have their own systems for ensuring COVID-19 safety that were equal to, or better than the guidance from Public Health England.
  • Staff did not have adequate training to ensure that all incidents were reported accurately and in full. Incidents were not investigated by management and there were no systems in place to identify learning from incidents or share learning with staff.
  • Staff had not received supervision and appraisal in line with Cygnet policy.
  • Managers failed to provide assurance that they had oversight of the service they managed. They did not thoroughly investigate all concerns raised with them. Staff reported feeling disrespected by other members of the team. The service did not follow company policy in relation to family members working together and being line managed by one another.

07/08/2019

During a routine inspection

We rated Cygnet Appletree as good because:’

  • The service provided safe care. The hospital environment was safe and clean. The hospital had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The team included a full range of specialists required to meet the needs of patients. Managers ensured that these staff received training, supervision and appraisal. The hospital staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The service worked to a recognised model of mental health rehabilitation. It was well led, and the governance processes ensured that ward procedures ran smoothly.

However,

  • Although staff were booked to attend safeguarding level 3 courses the provider was not compliant at the time of the inspection.

26 - 27 June 2018

During an inspection looking at part of the service

We carried out a comprehensive inspection of Cygnet Appletree on 8th and 9th May 2018. At that time, we identified concerns with the safety of the hospital. In June 2018, we received three whistle-blowing's from staff raising serious concerns about the safety of patients and staff, staffing levels and staff training, the attitudes and behaviours of staff at all levels, and the management of the service. The whistle-blowers also stated that staff had felt unable to speak truthfully at the time of the comprehensive inspection, therefore we could not trust all of the evidence gathered at that time. We returned on 27th and 28th June 2018 to look at these specific concerns. As this was a focused inspection, we have insufficient evidence to rate this hospital. However, due to the seriousness of the issues found at this inspection, we have taken action against this provider in line with our enforcement powers.

  • The service was not safe. Patients did not feel safe due to the high numbers of incidents of violence and aggression. Staff and patients were experiencing aggressive behaviours on a regular basis. The service did not have enough staff to provide safe care and treatment.
  • The service was not effective. Staff did not provide care that met the needs of one patient with a learning disability and did not have the required skills and knowledge to support this patient group. Staff were not monitoring the effects of high dose anti-psychotic medication on one patient’s physical health.
  • The service was not responsive. Staff were not meeting the needs of all patients being admitted to a rehabilitation environment. Staff did not manage complaints in line with the provider’s policies or support patients to raise concerns.
  • The service was not well-led. Systems that were in place to ensure good governance of the service were not being operated effectively. Managers did not notify CQC of all incidents as required. Staff raised concerns about poor leadership, a bullying culture and low staff morale. There was a lack of visible clinical leadership and effective team working.
  • Staff were not always caring. Staff did not always treat patients with dignity and respect. Staff and patients raised concerns about the attitudes and behaviours of staff towards patients.

8 - 9 May 2018

During a routine inspection

We rated Cygnet Appletree as good because

  • Patients and carers spoke positively about the way staff treated them. Interactions between patients and staff were kind, caring and respectful.
  • Staff completed and regularly reviewed detailed assessments of each patient’s needs, risk and treatment goals. Care plans were individualised and holistic.
  • Staff offered patients treatment that was based on best practice and National Institute for Health and Care Excellence guidance. Staff monitored outcomes using recognised rating scales. Patients had access to individual and group therapy and a range of activities to aid their recovery.
  • Cygnet Appletree had effective systems in place to ensure good governance. Staff undertook regular audits and developed action plans to improve patient care and treatment. The majority of staff felt managers were approachable, visible and supportive.

However:

  • Patients reported they did not feel safe at Cygnet Appletree. There had been a recent increase in incidents of violence and aggression from patients.
  • Staff were not trained in immediate life support which is recommended training by the National Institute for Clinical Excellence and the UK Resuscitation Council for staff who are involved in restraint and rapid tranquilisation.
  • Medicines stock did not always match medicines administration records. Patients individual plans for ‘when required’ medicines did not always reflect the medicines they were prescribed.

18 July and 24 July 2017

During an inspection looking at part of the service

This was a focused inspection in relation to concerns raised about Appletree. Ratings have not been given for this inspection.

We found the following issues that the provider needs to improve:

  • Staff did not always carry out the necessary screening and monitoring of patients following the administration of rapid tranquilisation, or those receiving high risk medications.
  • Staff did not always complete documentation on patients’ physical healthcare accurately or in full.
  • There were discrepancies in the management of medicines that had not been identified by Appletree’s audit processes.
  • Staff placed restrictions on patients that were not proportionate to the risk of harm.

However, we also found the following areas of good practice:

  • Compliance with staff training was high and newly recruited staff underwent a series of employment checks, an induction and a probationary period.
  • Staff reported safeguarding concerns as required and worked closely with the local safeguarding authority.
  • Staff worked closely with community teams and the patients’ families to plan for their discharge.

24 May 2016

During an inspection looking at part of the service

We rated Cambian Appletree as good because:

  • Cambian Appletree was staffed to safe levels. Staff were suitably trained and compliance with mandatory training was at 100%.
  • Medicines management practice, including storage, dispensation, and administration was in line with the relevant guidelines. Staff regularly reviewed patients’ medication needs and undertook regular audits of medicines management practice.
  • Cambian Appletree had a full range of rooms and equipment to support patients’ care and treatment. A range of activities were available throughout the week and staff took into account patients’ views in planning their day.
  • Staff completed a comprehensive assessment of patients’ risk and need on a regular basis using standardised tools. Patients’ care plans were individual and holistic.
  • Staff had received training in the revised Mental Health Act code of practice. Patients understood their rights and which section of the Act they were detained under. Staff were supported by a Mental Health Act administrator who completed audits and scrutinised documentation.
  • Staff worked well together as a team and held daily multi-disciplinary meetings. Patients felt supported by staff and we observed staff treating patients with kindness, dignity and respect.

However:

  • Cambian Healthcare Limited had not fully updated its policies to reflect the changes in the Mental Health Act revised code of practice.
  • Staff understanding of their responsibilities under the Mental Capacity Act varied. Staff did not always reflect decisions made about patients’ capacity in their care plan.

19 and 20 January 2016

During a routine inspection

We rated Cambian Appletree Hospital as requires improvement because:

  • Staff did not always prescribe medication in accordance with Cambian policy or recognised best practice. Where prescribing was outside of recommended limits, staff did not detail the reason for prescribing such medication.
  • Staff did not search patients in line with hospital policy. Staff searched every patient on return from leave without an individual assessment of risk and need.
  • Appletree Hospital did not have an implementation plan in place for the revised Mental Health Act Code of Practice.
  • Staff had not updated policies and procedures to reflect changes in the revised Code of Practice. Only 29% of staff had been trained in the revised code of practice.
  • Staff did not clearly document how they shared lessons learnt from incidents with other staff and how this resulted in changes within the hospital.

However:

  • Appletree Hospital had no staff vacancies and there was a sufficient skill mix to meet patients’ needs. Compliance with mandatory training was high. Staff felt supported by the manager and morale was high.
  • The hospital had a full range of rooms and equipment to support patients’ care and treatment. A range of activities were available throughout the week, and staff took into account patients’ views in planning their day.
  • Staff completed a comprehensive assessment of patients’ risk and need on a regular basis using standardised tools. Patients’ care plans were individual and holistic.
  • Staff treated patients with kindness and respect. Families and carers were involved in patients’ care and there were good working relationships with other organisations.

14 August 2013

During a routine inspection

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

Patients were given the opportunity to influence how the service was run. Patients had contributed to their care planning and assessments and these were written in the first person. The provider had a contract in place with a local advocacy service which included the provision of Independent Mental Health Advocates (IMHA) for qualifying patients.

We saw meetings with patients were held on a regular basis. This included daily activities planning meetings, weekly community meetings and monthly meetings chaired by the advocate.

Patients' needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We looked at the records held for three patients. We found each patient's assessment included detailed information about their needs and personal history. They also included information from other professionals who had been involved in the care and treatment of the patient.

The provider made every effort to maintain the safety and dignity of patients when any form of restraint was used. Patients told us they had been restrained by staff when it had been necessary for them to do so. They told us any restraint used had been appropriate, reasonable, proportionate and justifiable to them.

Patients were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. This included through the provision of training and supervision from line managers.

The provider had an effective system to regularly assess and monitor the quality of service that patients received.