Cygnet Appletree

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question as good. At this assessment the rating has changed to requires improvement. This meant people were not always safe and were at risk of avoidable harm.

We identified a breach of Regulation 17 Good governance in relation to processes in relation to the governance and management oversight of the service being ineffective in providing assurances around the delivery of safe and high-quality care at the location. The service was also in breach of Regulation 12 Safe care and treatment in relation to:

• poor practice around medication, including high dose antipsychotic therapy medication
• the provider's referral and admission process failing to source basic, essential information about the patient to ensure the placement was safe.

Staff were not always classing serious incidents (including self-harm, threats to kill and all complaints involving alleged abuse) as safeguarding concerns, meaning they had not sent safeguarding referrals to the local authority.

Staff did not always ensure the cleaning records for the clinic room on Pippin ward were completed.

During our inspection, we came across a medication error which staff had not reported as an incident.

The service's referral and admission processes did not always ensure that all essential information about the patient was received to determine if the patient's needs could safely be met, such as their prescribed medication or physical health status.

Staff were not always including essential information in risk assessments about the patient such as their mobility, medication status or scarring to their person.

Staff used ineffective systems to record and store information relating to health and safety and maintenance relating to the hospital environment. Documentation was difficult to locate, incomplete or missing.

The quality of documentation in relation to medicines was poor. Forms used by staff were incomplete and difficult to read due to being photocopied numerous times. Staff were unsure who was responsible for the completion of documentation relating to the use of high dose antipsychotic therapeutic medication.

Staff turnover in the service was high. However, there were enough skilled, experienced and trained staff to safely meet the needs of patients using the service. Staff received lessons learned from investigating incidents, complaints and safeguarding concerns.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

In the last 12 months, there were 7 serious incidents within the service, all but 1 of which were on Bramley ward. 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.

Lessons learned from investigations into serious incidents were used to improve the service. These included the requirement of staff to always seek additional information from referring parties in relation to the risks associated with the patient; liaise with the patient’s current placement and home team and to take physical observations following a choking incident.

Another example was in relation to a patient who was found to have been illegally detained. Lessons learned from investigating this included:

• The requirement to request all Mental Health Act forms on acceptance of referral of a detained patient so that these can be scrutinised prior to patient arrival
• The scrutiny of forms to be completed for all detained patients and signed by 2 nurses on shift
• Ward managers to complete weekly spot checks of Mental Health Act paperwork
• A weekly update to be provided to responsible clinicians, including section expiry and treatment expiry dates.

All staff knew what incidents to report and how to report them. Staff reported most incidents appropriately, including self-harm, ligatures, violence and aggression and missed observations. However, during our inspection, we came across a medication error which staff had not reported as an incident. An incident report was completed soon after we raised this with managers within the service.

Staff understood the duty of candour. They were aware of the need to be open and transparent, and to give patients and families a full explanation if and when things went wrong.

Staff received feedback from the investigation of incidents, both internal and external to the service via handovers, lessons learned posters displayed on the wards and communications from the nurse in charge. The hospital director also sent emails to all staff if there were issues staff needed to be aware of such as items ordered online which contained concealed blades or other harmful properties.

Lessons learned from investigating incidents were discussed during team meetings and were part of standing agenda items.

Staff had made safety improvements within the service. Staff now had access to handheld transceiver radios and more personal alarms had been ordered for staff due to the increase in staff members needing to cover enhanced observations for patients with high risks.

Staff were debriefed and received support after a serious incident.

The service’s referral and admission processes did not always ensure that all essential information was received to determine if the patient’s needs could safely be met. One admission form did not contain the patient’s medication history, so staff were uncertain if the patient was meant to have a depot or not. Another admission form contained no information about the patient’s physical health or current weight. These issues were a breach of Regulation 12 Safe care and treatment.

Staff informed us that a central hub within the organisation was responsible for assessing admission forms and had only 1 hour to decide if an admission was appropriate for the service or not. Given the omissions of basic essential information we had found in the 2 admissions forms, we had concerns as to how the provider was assured around the safety and appropriateness of all patient admissions made to the service.

However, following our inspection, the provider accepted our findings and quickly devised an action plan which included processes to address these issues. These included:

• The requirement for the patient’s doctor and nurse to assume responsibility for ensuring that the record of admission is completed fully
• Any outstanding elements/actions to be recorded in the patient’s care record and shared at morning meetings
• Actions to be monitored during morning huddles for assurance
• An audit of the admission documentation to be conducted within 24 hours of its completion and the audit form to be saved to the hospital’s shared area
• For the ward manager or nurse in charge to complete a visual check on accepted referrals to ensure medication and physical health information has been completed.
• For any incomplete information to be requested from the referring party by the referral hub.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. There was a social worker within the service who liaised with external organisations such as community mental health teams, housing services and local authorities.

Staff were trained in safeguarding and knew how to make a safeguarding alert. At the time of our inspection, 94% of staff had completed their safeguarding training.

In the last 12 months, the service had sent 53 safeguarding referrals to the local authority. However, we were concerned that serious incidents on the wards were not always being classed as safeguarding concerns by staff within the service.

We looked at 6 incidents which included threats to kill and multiple instances of self-harm via ligaturing or inserting an item into an existing wound. None of these incidents were deemed to be safeguarding concerns by the managers investigating them and there was no evidence within the incident report that statutory notifications had been made to the Care Quality Commission.

We also looked at a complaint made by a patient in relation to allegations of an injury they sustained during an incident of restraint and abusive behaviour from staff members. Although the allegations were partially upheld and 1 allegation was deemed ‘inconclusive’, no safeguarding referral was made to the local authority, and no statutory notification was sent to the Care Quality Commission. We were concerned that the registered manager may have failed to notify the Commission of specific incidents relating to serious injuries and safeguarding. This may be a breach of Regulation 18 (notification of other incidents) of the Care Quality Commission (Registration) Regulations 2009. We will follow our processes to consider an appropriate response to this outside the inspection process.

However, following our inspection, the provider accepted our findings and quickly devised an action plan which included processes to address some of these issues. These included:

• Plans to roll out training to all staff who may undertake investigations of complaints
• Any complaints relating to safeguarding concerns to be reported to the local authority safeguarding team and Care Quality Commission prior to any investigation taking place.
• Reviews of complaints investigation reports to be carried out each week by a senior manager to ensure a comprehensive review of the complaint is being completed.

We asked for feedback from the local authority in relation to the service. The local authority reviewed 16 Referrals and enquiries between 27 August 2024 and 30 June 2025. Their findings were:

• Most referrals had been submitted within 24 hours with others being delayed due to further information being required
• All referrals were of good quality with all the relevant information included and they demonstrated immediate actions taken by the provider, the patients’ views and wishes, relevant Mental Capacity Act assessments carried out, advocacy and family involvement, and other professionals involved
• The referrals stated whether the Care Quality Commission had been informed.

The local authority also stated that staff within the service liaised well with the organisation in relation to whether a safeguarding referral needed to be submitted.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies such as the police and local authority safeguarding teams.

Staff followed safe procedures for children visiting the service.

We looked at 10 care records during our inspection to ascertain if staff assessed and managed patient risk appropriately. Staff sometimes confused risk with human behaviour. For example, shouting and crying were included as risks when in fact, these were potentially an indication the patient was experiencing distress or pain.

Not all risk assessments included essential information about the patient or were not clear in content. One patient was immobile at the time of our inspection, but this was not stated in their risk assessment. Another patient’s risk assessment contained their current information intermixed with that relating to their previous placement which made it confusing to read. Another patient we spoke with had visible scarring to their arms and thighs but there was no mention of how these had happened in their risk assessment. One patient’s risk assessment had not been updated in relation to their depot injection.

Risk assessments and risk management plans were not located in the same area of the provider’s care records system. Risk assessment and risk monitoring information was held in the PARA section whilst the risk management plan was under the patient’s care plan. This meant staff had to access 2 different areas in order to determine what the patient’s risks were and how to mitigate them.

There were reasonable blanket restrictions within the service due to the presence of ligatures and other risks such as the presence of cleaning chemicals and sharp implements in rooms and areas of the wards. This included restricted or supervised only access to the communal bathroom on Pippin ward, a gymnasium, cleaning cupboards, laundry areas, activity rooms and an activities of daily living kitchen.

Banned or restricted items on the wards were in-line with those expected for acute mental health wards and psychiatric intensive care units. These included access to sharps, solvents, alcohol and drugs, material inciting violence and/or hate crimes, flammable substances, laser pens, pornographic material of an illegal or extreme nature and equipment for the sole use of recording moving or still images such as cameras or webcams.

In the last 12 months, there were 333 incidences of rapid tranquilisation within the service. These were in relation to 103 patients. The highest outlier of rapid tranquilisation was Pippin ward which had 242 incidences in relation to 63 patients.

In the last 12 months, there were 754 incidences of restraint within the service, 23 of which were in the prone position (face down). The highest outlier of restraint was Pippin ward which had 692 incidences.

In the last 12 months, there were 27 incidences of seclusion within the service. These were in relation to 23 patients in total, most of whom were on Pippin ward.

We saw evidence in care records that staff involved patients in care planning and risk assessment and offered the patient a copy their care plan.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff enabled patients to give feedback on the service they received via surveys, the provider’s complaints process and community meetings on the wards. Staff ensured that patients could access advocacy.

Between the 10 and 12 June 2025, we were not asked for any proof of identity on our arrival at the hospital. We raised this with the hospital director and when we returned on 16 and 19 June, staff had been reminded to always ask for proof of identity and we were asked for this by the staff member on reception duty.

Staff did regular risk assessments of the care environment.

The design and layout of Pippin ward meant that there were areas accessible to patients that were out of sight of the nurse station. Staff mitigated this by using mirrors and patient observations levels.

There were potential ligature anchor points on the wards, but the associated risks were mitigated through the use mirrors and observations.

Staff had easy access to alarms and patients had easy access to nurse call systems.

The seclusion room contained anti-ligature bedding and clothing, two-way communication, toilet facilities and a clock within the room. Patients using the room had access to music, natural light and water.

We asked to see documentation relating to health and safety checks of the hospital premises. The information provided to us did not give assurances that the necessary actions identified were being carried out appropriately or that all health and safety processes were effective.

Documentation for the testing of emergency lighting did not specify how often these tests needed to be completed. Documentation for the testing of fire door checks were blank. A fire drill completed on 20 May 2025 identified some areas for improvement and how they would be addressed but there was no evidence to show the actions had been completed.

A health and safety inspection on 22 May 2024 had identified potholes and faded parking bay lines in the hospital car park that needed to be repaired. However, these issues were still evident at the time of our inspection, over a year later.

In relation to checks for water hygiene, a ‘Flush of little used outlets’ document stated, ‘all infrequent used outlets must be flushed twice a week including infrequently used toilets.’ However, there was no evidence within the health and safety files that checks were in place to ensure these flushes were taking place.

A resuscitation bag checklist showed that some issues had been identified but there was no action plan to state how the issues would be addressed. For example, documentation for two checks stated there was no thermometer for taking room temperatures so temperatures were not being recorded. There was no evidence to show how this was being addressed.

A ‘PPE register and checks’ form stated a telescopic ladder was unsafe. This was highlighted since January 2025 and remained broken in a further check in May. The form had nowhere to record if there was an action plan to address the issue, so we saw no evidence to confirm if the unsafe ladder had been reported or was still being used by staff.

Gas and electrical safety certificates dated 11 September 2024 stated an upright freezer required a new seal to be fitted but there was no evidence to confirm this had been done.

An engineer had recommended in a solid-state fire extinguisher service and delivery report dated 28 June 2024 to change the power supply unit located in a reception cupboard from 12.58 volts to 4 amps and to replace magnetic locks. There was no evidence to confirm it these recommendations had been acted upon.

When we identified gaps in health and safety information, we asked maintenance staff if the information was held elsewhere and they agreed to look into this. However, some information took 3 days to be provided to us, and some information was not provided at all. Processes for health and safety and the maintenance of the hospital was disorganised and that there was a risk to the safety of patients using the service and to staff.

However, following our inspection, the provider accepted our findings and quickly devised an action plan to address these issues. For example:

• All health and safety documentation had been updated since our inspection
• Health and safety information was now stored within 3 ring binders containing indexes in the maintenance office to make it more accessible
• There was now a requirement to audit health and safety documentation each month
• There was now a requirement for cleaning records to be checked by the ward managers and clinical managers
• Ward clerks were now required to save the cleaning records and checklists to the hospital’s shared area.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

There were enough staff to provide safe care and treatment to patients within the service. Staffing comprised:

• 21 whole-time equivalent nurses
• 50.5 whole-time equivalent support workers
• 2 whole-time equivalent occupational therapists
• 1 whole-time equivalent social worker
• 3 whole-time equivalent psychologists
• 4 whole-time equivalent psychiatrists
• 12.5 whole-time equivalent administration and management roles
• 11 whole-time equivalent maintenance and support services staff.

Vacancy rates within the service were low. There was only 1 whole time equivalent support worker vacancy at the time of our inspection.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

In the last 12 months, agency staff had been used to cover 2,300 shifts and bank staff had covered 405 shifts. The high usage was in relation to patient acuity and patients being on enhanced observations.

Staff turnover rates within the service were high. In the last year, the staff turnover rate was 43%. Staff turnover was reviewed in quarterly human resources meetings.

The provider had not identified any themes or trends of a negative manner in review of the staff turnover as a large portion of the voluntary leavers were due to personal reasons.

At the time of our inspection, 97% of staff had current Disclosure and Barring Service certificates in place. One staff member was on maternity leave, a second was on long-term sickness absence and a third was a new starter whose name had yet to be added to the provider’s human resources system, so their certificates were pending.

Managers had calculated the number and grade of nurses and healthcare assistants required. Managers used a staffing matrix to determine how many staff members were required to care for numbers of patients on the wards. These numbers could be increased to account for patients on enhanced observations and engagement.

A qualified nurse was always present in communal areas of the ward.

We spoke with 6 patients using the service. Three patients told us that they did not have regular 1 to 1 time with their named nurse.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

There were enough staff to carry out physical interventions such as observations, restraint and seclusion safely and staff had been trained to do so.

There was adequate medical cover day and night, a doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital.

Staff had received and were up to date with appropriate mandatory and statutory training. At the time of our inspection, the overall compliance rate with mandatory and statutory training was 91%. The training was appropriate for the patient group using the service and included:

• Awareness of self-harm and suicide
• Clinical risk management
• Health and safety
• Infection prevention control
• Ligature risk reduction
• Medication management
• Observation and engagement
• Physical healthcare
• Incident reporting
• Learning disability and autism
• Equality and diversity
• Basic and immediate life support

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

All ward areas were clean, had good furnishings and were well-maintained.

Staff did not always adhere to infection control principles. Cleaning records for the clinic room on Pippin ward had not been completed since 17 May 2025, and there were numerous dates missing prior to this.

However, following our inspection, the provider introduced a requirement for cleaning records to be checked by the ward managers and clinical managers and for the ward clerks to save the cleaning records and checklists to the hospital’s shared area.

Staff used handwashing facilities appropriately.

Staff within the service did not always follow good practice in medicines management. National Early Warning Scores 2 forms used for monitoring patients after they had received rapid tranquilisation medicines were poor due to the number of times the form templates had been photocopied. Forms were difficult to read and row headings had been cut off which posed a risk that some aspects of physical health monitoring could be missed.

High dose antipsychotic therapy (HDAT) monitoring forms used to monitor people prescribed with medicines exceeding the 100% British National Formulary maximum, were not being completed by medical staff or checked by nursing staff in line with the provider’s policy. This was a breach of Regulation 12 Safe care and treatment.

Failure to monitor the use of HDAT places patients at risk of adverse outcomes to their physical health and is not in line with the National Institute of Health and Care Excellence guidance.

We found 3 forms that were not completed in relation to 2 patients. The form in relation to 1 patient stated the HADT had been cancelled. However, the patient was currently receiving HDAT, and the only screening staff had carried out was on the 9 January 2025. We spoke with managers, nurses, a consultant and a medic about this, and all had different views on whose responsibility it was to complete the forms.

However, following our inspection, the provider quickly devised an action plan which included how it would address these issues. These included:

• A requirement for the medical team to conduct audits of HDAT records on a weekly basis
• For audit forms to be saved to the patient’s care record and the hospital’s shared area
• Actions from the audits to be recorded and monitored in morning meetings
• Learning from HDAT audits to be shared with staff in morning meetings.
• Physical health monitoring visual display boards on the wards being updated to ensure HDAT monitoring was recorded and reviewed within morning meetings
• Photocopies of National Early Warning Scores 2 forms being destroyed and the requirement for staff to use original copies on the wards.

We observed 2 morning meetings during our inspection and care staff discussed the medication each patient was currently receiving, the effects of the medication on their mental and physical health and whether the current dosage should be increased, decreased or maintained.

We looked at 6 patients’ prescription charts. Overall, they were completed in line with national guidance. However, 2 charts included an array of notes detailing medications that the patient had previously been prescribed and had since been stopped. Given this made the notes lengthier to read, it would have been more appropriate to start using fresh charts for ease of use.

The hospital director was the controlled drugs accountable officer and medication safety officer.

Medicines audits and stock control was undertaken by an external pharmacist service on a weekly basis.