You are here

Archived: Cygnet Yew Trees Inadequate

The provider of this service changed - see old profile

We are carrying out a review of quality at Cygnet Yew Trees. We will publish a report when our review is complete. Find out more about our inspection reports.


Inspection carried out on 24 and 30 July and 04 August 2020

During an inspection looking at part of the service

We completed this focused inspection based on concerning information received about the alleged abuse of patients. We specifically focused on our safe, caring and well led domains.

We did not rate this inspection.

We identified the following areas of concern:

  • Some staff did not protect patients from abuse and improper treatment. We reviewed close circuit television (CCTV) footage which showed staff physically and emotionally abusing a patient. Staff who witnessed the incident did not raise or report their concerns to anyone at the hospital. We reviewed 20 further episodes of CCTV footage, saved between May 2020 and July 2020, which we requested from the hospital. Out of these 20 episodes, we identified in 8 (40%) examples of inappropriate staff behaviour, including physical and emotional abuse. No staff reported or raised concerns about this practice. Staff did not recognise when an incident of seclusion occurred and therefore, the patient did not have access to the appropriate reviews and safeguards outlined in the mental health code of practice.
  • Staff did not record incidents accurately. We reviewed all incident records relating to the 20 episodes of CCTV we requested. Forty five percent of the reports did not align with the CCTV footage. Staff did not accurately record the descriptions of the incidents and staff did not record the time of incidents accurately. None of the incident forms recorded inappropriate staff behaviour.
  • Managers failed to assess, monitor and mitigate risks relating to the health, safety and wellbeing of patients at the hospital and failed to improve the service. We continued to identify breaches of regulations that we raised at previous inspections. The service remained in special measures and had conditions placed on its registration. Managers did not always act on audit outcomes and did not respond to prompts sent about key performance items such as completing supervision.
  • Managers had not ensured they took every step to ensure they recruited and continually assessed people with the right skills, experience and values to work with a vulnerable patient group. Managers did not offer regular and robust supervision. They did not review specific agenda areas such as safeguarding and whistleblowing. Staff responsible for recruiting new staff did not always ask all questions at interview, including questions about when to raise concerns. Scores were not always recorded to demonstrate candidates met the recruitment thresholds.
  • Staff contributed to poor culture in the hospital that increased the risk of harm to patients. This included abuse and human rights breaches. Staff did not always report when they witnessed inappropriate behaviour of other staff. When staff did raise concerns, managers did not act on them and take steps to safeguard patients. In one example, where staff raised concerns about practice there was a delay of 509 days before a safeguarding notification was sent to CQC and action was taken to investigate the concerns. Staff described issues with team dynamics, relationships and support from managers. Staff used nicknames for each other that gave weight to a poor culture.


  • The hospital acted to suspend staff involved in one incident of abuse and inappropriate behaviour. Managers made appropriate referrals to Police, the Nursing and Midwifery Council and the Disclosure and Barring service. Managers continued to review CCTV footage, after the inspection, to assess additional staff and their treatment of patients. Managers had taken appropriate steps to support patients who were victims, this included offering psychological support. Managers informed families and carers of the incidents.

Inspection carried out on 13, 22, and 29 January 2020

During a routine inspection

Cygnet Yew Trees is a 10-bed hospital, which provides care and treatment for women aged 18 years and above who have a learning disability.

We rated Cygnet Yew Trees as inadequate because:

  • The provider did not ensure that there was adequate leadership and oversight of the safety and quality of the service. It had not made the required improvements that we told them were needed at previous inspections in relation to a section 29 warning notice.
  • The provider did not address concerns related to staff ensuring the safe observation of patients and completion of accurate records.
  • The provider did not ensure adequate governance structures, processes and systems of accountability for the performance of the service. We identified risks with the provider’s systems for assessing and monitoring of staff appraisal and supervision, response to complaints, the workforce race equality standards, and the accessible information standards.
  • Despite being a hospital for women, from November 2019 to January 2020, only 40% of staff were female. This meant that there were often insufficient female staff to support patients with personal care needs.

At this inspection we also found:

  • The provider did not have systems in place to ensure the effective sharing and implementation of policies such as physical health policy, epilepsy care pathway and their ‘engagement and observation policy’ to ensure all staff knew how to respond should a patient experience a seizure. Staff were not ensuring relevant patients’ care plans detailed how to keep patients who might experience a seizure safe in line with The National Institute for Health and Care Excellence ‘Epilepsy in adults Quality standard [QS26]’.
  • We identified further risks as staff did not fully follow the provider’s systems for responding to complaints.
  • The provider did not ensure that staff had easy access to essential information. We received conflicting information from staff about where the up to date care plans and risks assessments were for patients, therefore not all staff on duty knew where to locate information.
  • The hospital had insufficient space for the number of complex patients with challenging behaviour. The staffing levels required to undertake patient observations made the environment crowded. There was limited quiet space for patients or staff to use for de-escalation. There were a number of incidents where patients were violent and aggressive towards staff or other patients, affected by the lack of space.
  • The provider could not demonstrate that (where relevant) staff had supported, informed and involved families or carers in patients’ care and treatment. Carers told us that staff did not always effectively communicate with them and they were not involved as much as they would like in patients' care.
  • The provider currently had eight of 10 patients with delayed discharges. Staff spoke with us about the challenges of working with commissioners to find and fund suitable placements outside of the hospital. The average length of stay at the hospital was three years. This is an increase since our April 2019 inspection (782 days) and above the national average (554 days source: Learning Disability Census Further Analysis: England 2015).


  • The provider was bringing the hospital and other local hospitals in the Cygnet group under one-line management ‘healthcare’ structure and one operations director) to help improve line management structure and oversight.
  • Managers had made some improvements to their governance system for their oversight of restraints and safeguarding adults’ procedures. Staff had improved their recording of incidents. The provider had made some improvements to ensure staff received feedback from investigation of incidents.
  • Staff regularly reviewed the effects of medications on each patient’s physical health. They knew about and worked towards achieving the aims of stopping over-medication of people with a learning disability, autism or both (STOMP).
  • Staff completed assessments of patients either on admission or soon after. Care plans were personalised. Positive behaviour support plans were present and supported by a comprehensive assessment.
  • Staff were discreet, respectful, and responsive when caring for patients. Staff used appropriate communication methods to support patients to understand and manage their own care treatment or condition.
  • Most staff felt respected, supported and valued. They were positive about the management changes since our April 2019 inspection.

Inspection carried out on 28 to 29 October 2019

During an inspection looking at part of the service

We rated Cygnet Yew Trees as Inadequate because:

  • The provider had not ensured consistent robust leadership and governance at the hospital since our last inspection. We identified risks for the service regarding incident reporting, incident investigation and learning and staff management of patient risks.
  • Staff did not always know what incidents to report or when to report them. We reviewed 15 incidents documented in the daily case notes of three patients. We found four incidents that staff had not reported on the incident reporting system. Staff were not always aware of how to deal with specific risk issues such as choking. We found evidence of a patient twice choking on the same day despite their risk assessment highlighting a choking risk.
  • Staff did not always follow the provider’s policy for observing patients. Staff did not always respond to changes in patient’s risk levels. We found evidence of staff not responding to a patient’s changing risk following an incident of using a ligature. Staff did not follow the patient’s observation plan after the incident and left the patient’s door closed at night despite the patient being on continuous staff observation within eyesight. The provider identified another occasion when staff were sitting outside the patient’s bedroom with the door shut and were not observing them as prescribed. Staff also left the patient unobserved whilst they responded to an emergency. We reviewed the observation records for three patients and found incidences where staff had remained on continuous observations for more than two hours. This was not in accordance with the provider’s policy or protocol for enhanced observations of patients.
  • Two patients told us they were not always directly involved in their care. One patient told us staff wrote the care plans and they would then tell the staff whether they agreed or not.
  • There was not a clear framework of what staff must discuss at a ward or team meetings to ensure senior staff shared essential information. We reviewed the minutes for three team meetings. We could not see any evidence that staff had discussed incidents or complaints.
  • Staff did not always make notifications to external bodies. We found evidence where four notifiable incidents had occurred, however staff had not made the necessary notifications to the Care Quality Commission. We also found evidence where staff had not informed the local authority regarding two safeguarding incidents, where patients had been the victim of assault by other patients.
  • The environment was not purpose built and there was insufficient space to meet the individual needs of current patients. There was a high number of staff to meet the levels of observations required to manage the current patient group which made the environment crowded. 


  • The provider had appointed a new hospital manager, deputy manager and regional manager. Managers were aware of areas for improvement and had implemented plans to make these necessary improvements.
  • Staff felt respected and valued by the senior staff. Staff we spoke to told us the morale within the hospital had improved over recent months and they spoke positively about the recent changes of leadership.

Inspection carried out on 30 April 2019

During a routine inspection

Our rating overall went down. We rated Cygnet Yew Trees as 'requires improvement' because:

  • The provider’s governance systems did not always sufficiently assess, manage and mitigate risks for the hospital. Improvements were needed to safeguard patients. For example, the provider had not made thorough checks to ensure agency staff were suitable to work with patients. The provider had not clearly identified protection plans to detail the actions staff needed to take to ensure vulnerable adults were safe following incidents. The provider’s policy did not give clear information to staff about these areas. The provider’s governance systems did not show how they were monitoring and assessing the use of staff restraint with patients and taking action to reduce them.
  • The provider had not always ensured that staff were completing accurate records of their observations of patients which posed a risk to patients’ safety.
  • The provider’s staff recruitment and retention processes were not fully effective as there were 11 nursing vacancies and there was 27% staff turnover. There were 33 occasions (39%) over a six-week period when there was less than 50% female staffing to support patients' needs.
  • The provider had not ensured that the manager had sufficient training for their role as a leader. The provider had not ensured staff always received regularly supervision as per their standard.
  • The provider's discharge processes were not fully effective. Patients stayed longer at the service 782 days, an increase since our last inspection in June 2017 (408 days) and above the national average (554 days). There were five patients with delayed discharges when we visited.
  • The provider had not completed a specific assessment of how they were meeting the accessible information standards- in line with section 250 of the Health and Social Care Act 2012.
  • The provider was unable to show their compliance with reporting requirements for the Workforce Race Equality Standard.


  • Staff were creative and had developed a variety of ways to help patients non-verbally communicate their needs and choices and express how they were feeling. This had empowered patients and helped them not to be reliant on staff. 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 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 ward for people with a learning disability (and/or autism) and in line with national guidance about best practice. Staff involved patients in care planning and risk assessment and actively sought their feedback on the service provided.
  • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s physical health. They knew about and worked towards achieving the aims of the STOMP programme (stop over-medicating people with a learning disability.
  • The ward teams included or had access to a range of staff required to meet the needs of patients on the wards. Managers ensured that these staff received training 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 we spoke with felt respected, supported and valued.

Inspection carried out on 6 June 2017

During a routine inspection

We rated Yew Trees good because:

  • The ward environment was clean, tidy, and well maintained. Cleaning records were up to date and demonstrated that staff regularly cleaned the ward environment.
  • The provider maintained safe staffing levels. We reviewed eight weeks of duty rotas which showed that the provider had covered all shifts with sufficient numbers of staff.
  • Staff had received, and were up to date with mandatory training. Mandatory training compliance was 99%.
  • Staff completed a comprehensive assessment of patients’ needs following admission. Staff used the information gained during these assessments to create care plans and risk assessments.
  • Staff received regular supervision and annual appraisals. We reviewed supervision and appraisal records which showed staff were compliant with the provider's policy for supervisions per year.
  • Patients were involved in the planning of their care. We reviewed four care records that showed staff had documented patients’ views on their care plan.
  • Staff provided activities seven days a week. Occupational therapist and activities coordinator managed activities during weekdays and care staff would provide activities at weekends.
  • The provider had systems in place to monitor staff training, supervision, and appraisals. The manager maintained spreadsheets which they updated and monitored regularly.
  • Staff followed the providers safeguarding procedures. Staff made safeguarding referrals when appropriate contact the local authority for updates.


  • The provider did not always share lessons learnt from incidents and complaints with staff. We reviewed four team-meeting minutes. Only one of these minutes contained evidence that staff had discussed lessons learnt from incidents and two contained evidence of discussion of complaints.
  • The provider had a high rate of agency staff use. This was due to high staff turnover and difficulty with recruitment. 

Inspection carried out on 05 May 2016

During a routine inspection

We rated Yew Trees as good because:

  • Clinical areas were clean with appropriate equipment to ensure safety. Cleaning records were up to date and staff followed infection control principles. Staff completed health and safety risk assessments of the environment and carried personal alarms, which were tested regularly.
  • Staffing levels were safe. The provider used regular bank and agency staff who were familiar with the hospital. The manager adjusted staffing levels according to the needs of the patients and staffing ratios were one staff to three patients.
  • Staff analysed incident data and used this to review and update individual risk assessments and behaviour support plans. Staff held twice daily de-briefs to review the day and incidents. The hospital responded to incidents, complaints, patient, and relative feedback and shared lessons learnt.
  • Staff read patients their legal rights and assessed patients’ capacity to make individual decisions. Staff made best interest decisions for patients who did not have capacity to do so.
  • The provider had good medicines management practices with safe prescribing and administration. Staff completed consent to treatment and capacity requirements and staff attached forms to medication charts.
  • Staff recorded patient and staff contact with relatives in a communication book and patients used skype to contact families. Staff invited families to a yearly family forum and patients attended local and regional service user forums. The hospital were visited by patients from other hospitals within the Danshell group as ‘experts by experience’, to provide feedback about Yew Trees.
  • All staff were up to date with training in the Mental Health Act 1983 (MHA), the Mental Capacity Act 2005 (MCA), safeguarding, physical restraint and other mandatory training. Staff had regular clinical supervision, team meetings, annual appraisals and had opportunities for professional development.
  • Staff completed holistic nursing assessments, annual and on-going physical health monitoring. Staff created person centred care plans, completed and signed by all patients. These were all in easy read versions. Staff followed the framework of the care programme approach (CPA) and invited community teams and families to attend and provide input. The hospital discussed discharge planning and had comprehensive discharge care plans, which involved patients.
  • Staff had recently built a practice kitchen to enable patients to develop their cooking skills. Patients had access to hot drinks, snacks on request, pictorial menus, private telephone calls and could access fresh air in the garden when they wanted to. Patients could personalise their rooms and some patients had keys to their bedrooms.


  • The hospital building was a house across two floors that had blind spots where staff could not observe all areas of the environment. Staff managed this by carrying out regular observations of patients and used mirrors in corridors.
  • The hospital’s ligature risk assessment was out of date. Staff did not identify some ligature points (anything that can be used to self-harm with) in bedrooms, the disabled toilet, in the administration corridor and the garden on their ligature risk assessment. Staff mitigated this risk with increased observations for all patients or supervising high-risk patients in areas with ligature points. We observed items on the ligature risk assessment that were no longer on site. We raised these issues with the provider who acknowledged that the assessment was inaccurate and they would address this.
  • The provider observed all patients at least every 15 minutes. Observation levels were not necessarily linked to individual risk assessments and were, therefore restrictive.
  • There were no nurse call alarms in patient bedrooms or in corridors. Staff mitigated this risk by regularly observing patients.
  • The lift had been broken for over a year although this did not currently affect any patients. Staff told us they were waiting for this to be repaired.
  • Staff kept resuscitation equipment and ligature cutters in a locked cupboard in the nursing office, which could cause a delay accessing these in an emergency. Staff addressed this when we raised it with them by moving the equipment in to the nursing office.

Inspection carried out on 10 July 2013

During a routine inspection

We used a number of different methods to help us understand the experiences of people who used the service. This was because the people who used the service had complex needs which meant that they did not all feel able to tell us their experiences. We spoke to most people who lived at the service and were able to observe staff supporting people.

We saw that people were supported and encouraged to exercise choice in their day to day lives. Independence was also promoted and staff worked with people to achieve this. People received the care, support and treatment they needed and this was provided in an individual way.

During the course of our inspection we saw that people were supported to express their views and choices by whatever means they were able to and staff clearly understood each person�s behaviours and their way of communicating their needs.

Staff looked after people's healthcare needs in a proactive way. The staff team were well trained and supported to carry out their role.

None of the people we spoke with expressed any concerns about their safety. One person said: �They look after you here it is difficult sometimes but at least they keep you safe."

The provider had effective systems in place to monitor the quality and safety of the service that people received.