Cygnet Maple House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This is the first assessment for this service. This key question has been rated Good.

Staff assessed the physical and mental health of all patients on admission. They did not always develop individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

We reviewed 5 patients’ care plans during the assessment. We found that staff completed comprehensive mental health assessments in a timely manner at, or shortly after, admission.

Staff developed care plans that reflected the needs identified during assessment. Leaders and staff explained and demonstrated the admission process, including the level of detail gathered before a patient was admitted to the service. This also included timely assessments of patients’ physical health needs after admission.

Care plans were not always personalised, holistic, or recovery‑oriented. In one care plan, staff used incorrect pronouns for the patient. In another, we found no physical health care plan addressing the patient’s specific health condition.

During our review, we found that care plans did not include information about patients’ likes and dislikes. While the records contained information about patient history, presenting risks, and goals for their admission, they did not describe who the patient was as a person. This type of information would support staff to build a more personalised understanding of the patient. However, we acknowledge that staff knew their patients well, as they were able to describe them clearly and demonstrated understanding that was not reflected in the written records.

Although staff sometimes updated care plans when necessary and made changes when a patient’s risk level changed, this was not consistent across the patient group and therefore we were not assured of patient safety.

The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well

Staff provided a range of care and treatment interventions suitable for the patient group. They delivered interventions recommended by the National Institute for Health and Care Excellence, including Dialectical Behaviour Therapy (DBT), Cognitive Behavioural Therapy (CBT), Compassion Focused Therapy (CFT), Eye Movement Desensitisation and Reprocessing (EMDR), and Schema Focused Therapy (SFT). As the service was a rehabilitation ward, staff also offered activities, training, and work opportunities designed to help patients develop daily living skills.

Staff ensured that patients had good access to physical healthcare, including specialist support when needed. The service had arranged with a local dental practice to reserve 16 rolling appointments so that every patient could access dental care when required. Leaders told us they had a strong relationship with the local GP practice.

The team included, or had access to, the full range of specialists needed to meet patients’ needs. At the time of our assessment, the MDT was fully recruited and included doctors, nurses, an occupational therapist, a forensic psychologist, a psychiatrist, and two assistant forensic psychologists. As part of a regional network, the service also had access to speech and language therapists and dietitians when required.

Staff were experienced, qualified, and had the necessary skills and knowledge to meet the needs of the patient group. Before the service opened in September 2023, staff received training specific to the patient group, and new staff recruited afterwards were also trained accordingly.

Leaders provided staff with supervision which covered case management, reflective practice, personal support, and professional development—as well as regular appraisals. Supervision compliance was 100%. Staff we spoke with confirmed that they had regular access to supervision and team meetings.

Managers identified staff learning needs and provided opportunities for them to develop their skills and knowledge. Managers also ensured that staff received the specialist training necessary for their roles.

Managers addressed poor staff performance promptly and effectively.

In October 2025, the service was assessed under the Royal College of Psychiatrists’ ‘Enabling Environments’ programme. Documents provided by the service explained that: “The Enabling Environment Award is a mark of quality that shows a service has met the standards and is an Enabling Environment. The framework is designed as a quality improvement mechanism to support services to achieve excellence in how relationships function within their environment.” The assessment required the service to evidence how they met the standards to gain accreditation. We saw evidence within this documentation that the service met the standards set by the Royal College of Psychiatrists.

Mental Health Act

Staff were trained in, and had a good understanding of, the Mental Health Act (MHA), the Code of Practice, and the guiding principles.

Staff had easy access to administrative support and legal advice regarding the implementation of the MHA and its Code of Practice. They knew who their Mental Health Act administrator was.

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

Staff had easy access to local MHA policies, procedures, and the Code of Practice.

Patients had easy access to information about independent mental health advocacy. We saw posters displaying advocacy information, and patients told us that advocates attended the service weekly.

Staff explained patients’ rights under the MHA in ways patients could understand. Staff repeated this information when required and documented each discussion.

Staff ensured that patients could take Section 17 leave (permission to leave the hospital) when it had been granted. We reviewed the service’s Section 17 leave documentation and found that staff completed it fully and appropriately.

Staff requested a second opinion appointed doctor (SOAD) when necessary.

Staff stored copies of patients’ detention papers and associated records, such as Section 17 leave forms, correctly and in a way that ensured they were accessible to all staff who needed them.

The service displayed a notice to tell informal patients that they could leave the ward freely. This was found on the entrance door and exit of the service.

The evidence did not always show a good standard. The service did not always work well across teams and services to support people. However, they did make sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

We saw evidence that staff held regular and effective multidisciplinary meetings. Staff recorded these meetings and stored the records in individual patient files.

Staff shared information about patients during effective handover meetings. We reviewed handover documentation and observed a handover during our assessment. The meetings followed a consistent structure and allowed time to go through each patient. Although staff shared information verbally during handovers, we were not assured that all information was recorded effectively. For example, we saw documentation indicating that information had been passed from the MDT to staff, but this was not always visible in the written handover record. Staff told us they received information both face to face and through written documentation.

Leaders and staff told us they had effective working relationships with external teams, including local authority safeguarding services and the local GP practice.

The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximize their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported patients to live healthier lives, for example through healthy‑eating advice and cancer‑screening opportunities. Women’s health groups took place regularly at the service.

Activities at the service promoted healthy lifestyles. Staff facilitated walking and talking groups, group outings, and activities that supported patients’ personal interests. For example, some patients participated in a local choir or attended the local church. Staff also encouraged patients to join cooking sessions focused on healthy eating.

Staff offered activities of daily living, which included patients making their own drinks and snacks. However, due to out-of-date food items in the ADL kitchen we were not assured patients received appropriate advice in relation to food safety. The service also encouraged patients to do their own laundry and take responsibility for cleaning their rooms.

One patient said that they receive advice on eating and healthy sleep.

The evidence did not always show a good standard. However, the service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff at the service used recognised rating scales to assess and record severity and outcomes. These included the National Early Warning Score (NEWS), Health of the Nation Outcome Scales (HoNOS), DIALOG, and the Global Assessment of Progress. The service also used its own Daily Risk Assessment tool to support transparent decision‑making around risk and to provide corporate oversight of the level of risk within the service.

However, we were not assured that this method was always effective due to the level of incidents. Although the service monitored incidents, we found errors in staff recording and there did not appear to be embedded learning or a reduction in incidents despite the monitoring systems in place.

The service conducted clinical audits to ensure that outcomes were being met.

Patients told us that they had access to psychology sessions and activities.

The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

The service cared for both formal and informal patients. Cygnet Maple House was a level 2 rehabilitation service with locked doors. We saw notices on the door informing patients of their rights and explaining how they could leave the ward. Consent‑to‑treatment documents had been completed for all patient care records we reviewed. When patients requested family involvement, staff invited family members to attend ward round meetings.

Patients’ families and carers were involved in decisions where appropriate.

Patients said that staff tried their best to help them understand their rights. However, patients were not entirely confident that they understood their treatment.

Staff told us that when patients lacked capacity, they made decisions in the patients’ best interests and considered the individual’s wishes, feelings, culture, and history.