- Independent mental health service
Cygnet Appletree
Assessment report published 8 August 2025
Contents
Ratings
Our view of the service
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or addressing areas for improvement such as poor-quality documentation and health and safety information being out-of-date or inaccessible.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.