Cygnet Maple House

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

There was an increased risk that patients could be harmed as staff did not always assess and manage risks to patients well. However, all wards were clean, well equipped, well furnished, well maintained and fit for purpose. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines.

The service is in breach of legal regulations in relation to safe care and treatment.

We have not awarded this service a score for Safe.

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

The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Staff and leaders, spoke highly of the service’s least restrictive practice and explained that patients are often shocked when admitted because there are limited restrictions on risk items. Staff and leaders stated that this approach promotes positive risk‑taking for patients. However, the patients we spoke with felt confused by this and expressed concerns. We found when reviewing the welcome pack for patients there was no clear explanation on the approach. We did however see that prohibited items were mentioned. We were not assured that patients would fully understand the expectations of the service through the welcome pack alone.

Staff knew how to record incidents and that they could access debriefs after incidents. They also said the MDT team supports them with this.

We reviewed incident data that leaders provided. From 1 January 2025 to 31 December 2025, staff recorded 530 incidents at the service. Of these, 511 were categorised as self‑harm incidents, and 499 recorded that harm occurred to the patients involved. Leaders showed us how they audit incident data using an electronic recording system. They explained that the system allows them to review and analyse the data in detail to learn from incidents.

Although the incident recording system was in place and leaders demonstrated how they review and sign off incident data, we are not assured that this results in a proactive approach to support patients or prevent harm.

We reviewed an incident where a patient had self‑harmed. Staff completed an incident form, and the event was recorded in handover documentation between shifts. However, within 24 hours, the patient self‑harmed again, and this required hospital treatment. We reviewed the daily notes for this patient. We found no evidence that staff had taken proactive steps to prevent further escalation of the patient’s distress. The patient used the same risk item again, and we saw no record that staff had attempted to check the patient’s room or remove risk items.

One patient told us that they felt they were not kept safe. That this was due to having access to bladed articles. They told us that they have been able to take overdoses. They told us that they felt it was not safe and that the service was testing their resolve.

The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that staff received all essential information about each patient to determine whether the service could safely meet their needs. After discussing the importance of pronouns with leaders, they identified that the pre‑assessment form did not include a question about pronouns. They raised this with the Cygnet regional team, who amended the form to include it.

Staff involved all relevant healthcare and social care services to ensure patients received continuity of safe care, both within the service and following discharge. The service had established strong relationships with the local integrated care board and the local authority.

The service told us they had clear admission and exclusion criteria and understood the importance of ensuring that the setting was appropriate for each patient’s needs.

However, whilst the service stated it accepted referrals from Tier 1 to Tier 4 mental health services (with Tier 4 representing the highest level of specialist care for individuals with severe and complex needs), we were not assured that the service could prevent avoidable harm. This was due to concerns about how high-risk items were managed, particularly for patients transitioning from Tier 4 services. For example, some patients reported finding the transition difficult, especially adjusting to increased access to items that had previously been considered high risk.

The evidence showed significant shortfalls. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and completed alerts when appropriate.

Staff gave examples of how they protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. However, based on patient feedback, we were not assured that all staff supported patients in ways that protected them from discrimination. Patients described occasions where staff had spoken to them in a manner that was potentially discriminatory. For example, some staff were not accepting of same sex relationships and some attributed religious perspectives to women’s health issues.

Staff knew how to identify adults and children at risk of, or experiencing, significant harm, and they worked in partnership with other agencies. The service had strong links with the local safeguarding team, who asked the service to produce a patient‑made video on “making it personal” in relation to safeguarding practices.

Staff followed safe procedures for children visiting the service. A meeting room located near the entrance of the patient environment contained children’s toys and books for use during visits.

The service recorded low numbers of restraint. Staff recorded six episodes of restraint in December 2025, compared with three episodes in November 2025. Leaders used a comprehensive dashboard to analyse and audit episodes of restraint.

Due to the service’s model of care, restrictive practice remained minimal. The service worked hard to support a therapeutic community environment that enabled patients to live in a less restrictive way. However, patients reported feeling unsafe because of this approach. Some patients told us that, prior to this placement, they had been on enhanced observations in more restrictive wards, and transitioning to this service felt like a shock which contributed to them feeling unsafe. There was a lack of appropriate information within the welcome pack available for patients upon admission.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, particularly the five statutory principles.

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 from within the provider regarding the Mental Capacity Act. The service had a Mental Health Act administrator; they monitored the adherence to the Mental Capacity Act. The Mental Health Act administrator audited the application of the Mental Capacity Act and acted on any learning that resulted from it. All detention paperwork at the time of our assessment was in date and correct.

The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff ensured that patients could access advocacy services. Patients could see advocacy staff, who attended the ward weekly. They were commissioned by the provider.

Staff enabled patients to give feedback on the service. Patients said they could take part in community meetings.

As part of our assessment, we reviewed 5 patient care plans, including associated risk assessments. The risk assessments highlighted key risk areas for each patient. We found them detailed and reflective of each patient’s views. However, one care plan for a transgender patient listed incorrect pronouns.

During our review, we found one care plan and risk assessment that did not document a known physical health condition. This condition could cause seizures, yet we found no guidance for staff on how to support the patient if a seizure occurred. This meant patients could potentially be placed at risk.

At the start of each shift, staff held handovers, and each morning they held daily meetings. We observed a morning meeting attended by the MDT, where staff reviewed each patient, discussed incidents from the previous 24 hours, and confirmed each patient’s observation level and Mental Health Act status.

The service recorded daily risk assessments for each patient (“DRAs”) in individual pink notes. During our assessment, we reviewed one patient’s care plan and noted in their pink notes that they had recently self-harmed. Staff had recorded the incident for review, and through observing morning meetings, we gained assurance that staff shared risk information face to face. However, we were not assured that the system effectively protected patients from harm. In one example, a patient repeatedly told staff they felt unsafe and intended to harm themselves. Although staff recorded these concerns and the patient sought support from the MDT, we found no evidence of actions taken to keep the patient safe, and the patient self-harmed that evening.

The service promoted a proactive least restrictive approach, meaning patients had access to risk items such as razors and lighters. We saw in risk assessments that staff applied restrictions for some patients to reduce risk. However, patients told us they felt unsafe due to the volume of risk items available. One patient said that they felt unsafe from the things that they could do to themselves, they said that they were given everything that they could hurt themselves with. They felt that the staff wanted them to get tired of self-harming.

Only one patient said they felt safe in the service.

During our visit, we learned that a patient had been able to order a hazardous substance online the previous evening. The patient had a safety plan stating that only qualified nurses should be present with them when they open and check their post. However, a support worker opened the delivery despite a nurse being on shift, placing the patient at potential risk. Staff prevented the patient from ingesting the substance. Leaders were investigating the incident and had introduced immediate actions to ensure staff understood that nursing staff must support certain patients when checking their post.

Patients were on general observations, meaning staff checked on them every hour, with levels increased if risks escalated. As part of our assessment, we reviewed observation records and found inconsistent recording, particularly at night. In one of the 17 records we reviewed, staff had written over the original times. We checked this record against CCTV footage.

While reviewing CCTV, we noted that due to a self-harm incident overnight, a patient had been placed on 15‑minute observations. We compared the observation record with CCTV footage between 3am and 5am and found that the documented times did not match the actual checks. In one instance, staff did not check the patient for 21 minutes instead of within the required 15 minutes. We immediately informed service leaders, who said they were investigating and would conduct spot checks during night shifts to ensure observations were completed correctly. However, we were not assured that patient observations were being carried out effectively.

Instances of restraint were low. We reviewed the most recent episode and saw that MDT members worked together effectively to support the patient. Staff spoke to and monitored the patient throughout the restraint. Once the MDT became involved, the restraint was managed well. All staff, including MDT members, were up to date with restraint training.

As part of the service model, patients could access the ‘Activities for daily living (ADL)’ kitchen to promote activities of daily living. Patients could make drinks, prepare meals, and store food items as part of their recovery. During our environmental tour, we reviewed this kitchen and found several patient-owned food items that were out of date or mouldy. The service had no effective system for stock control or for educating patients on food labelling. We instructed the provider to remove these items immediately and explain the reason to patients. Before completing our assessment, we received assurance that the issue had been resolved and saw that the food cupboard was better organised and appropriately labelled.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The service had a full-time maintenance team who responded promptly to any issues. During our assessment, a patient reported that their bathroom was leaking sewage through the toilet and sink. The service closed the bathroom and informed the patient to use the communal facilities until repairs were completed. The problem was resolved whilst we were onsite. However, staff did not record this issue in the maintenance log, which meant we were not assured that the maintenance recording system was effective, although we found no concerns with the maintenance work itself.

Staff completed regular risk assessments of the care environment. We found no potential ligature anchor points, or staff had mitigated the risks appropriately.

The service used heat maps to highlight areas of potential ligature risk. This document was accessible to all staff, and we found the ligature risk assessment to be up to date.

During our tour of the environment, we found a large mirror in the communal bathroom that differed from the rest of the mirrors in the building. The mirror did not have sloping corners, which are a feature of anti-ligature furniture. Leaders told us that patients had requested this mirror. Although it did not pose a current risk, leaders said they would review whether it needed to match the other anti-ligature mirrors in the service. We were informed that a decision was made to round off the corners during our visit.

The service had a large garden that provided patients with expansive views of the local landscape. The garden was well maintained, and we saw clean, well-kept outdoor furniture available for patient use. The service did not use security-style fencing and took pride in maintaining an open, therapeutic environment. The garden could be accessed by members of the public as no fences were in place. When patients needed to be restricted to specific areas of the garden, staff relied on observation and guidance rather than limiting access to open space and countryside views. The garden reflected the therapeutic model of care the service aimed to deliver.

During our tour, we saw that the layout of the service allowed staff to observe all areas effectively.

Staff had easy access to alarms, and patients had access to nurse call systems where required. Staff we spoke with were able to explain how these systems worked.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency medicines, which staff checked regularly.

We were not assured that all staff knew how to evacuate patients with mobility needs. In our review of electronic care plans, we did not find any personal emergency evacuation plans (PEEPs) for individual patients. Leaders told us they were found in the reception area for easy access. However, the PEEP does not go into detail regarding how to support patients with mobility needs if in case of emergency they were located on the first floor of the hospital.

Although the service was a non-smoking environment, we observed vaping paraphernalia in the communal lounge and saw patients vaping indoors without staff intervention.

Due to the service model, items that posed a risk were present in communal areas and patient bedrooms. During our assessment, patients told us they had items in their rooms that they could use to harm themselves. One patient told us they had blades in their room, and their care plan identified risk related to cutting. We informed staff, who conducted a room search and found four blades. We reviewed incident forms showing that staff sometimes conducted room searches following self-harm incidents, but not consistently. The service had implemented some blanket restrictions, such as prohibiting plastic bags, and we saw how these were communicated and managed.

The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

We reviewed staffing data at the service and saw that staffing levels met the establishment figures set by service leaders.

Leaders shared the regional operational governance document dated December 2025, which stated that the only vacancy at the time was for a kitchen assistant.

Leaders had calculated the required numbers of qualified nurses and support workers. They explained that the service operated with two to three qualified nurses and five support workers on day shifts, reducing to two qualified nurses and four support workers at night. The service had a full multidisciplinary team (MDT).

At the time of our assessment, sickness levels were low at 1%. The governance data shared by leaders showed that the turnover for November 2025 was at 7.5 % and the annual turnover rate was recorded as 52.5%.

We reviewed staffing rotas and saw that the numbers of nurses and support workers matched the required levels on all shifts.

When necessary, leaders deployed bank nursing staff to maintain safe staffing levels. The service had not used agency staff since opening. Our review of rotas showed that leaders used familiar bank staff to promote continuity of care.

The staffing levels enabled patients to have regular one‑to‑one time with their named nurse. Patients confirmed that this took place. There were enough staff to carry out physical interventions, such as observations and restraint, safely.

The service had adequate medical cover both day and night, and a doctor could attend the ward quickly in an emergency.

Managerial supervision compliance was 95% and clinical supervision compliance was 96%.

Although staff had received and were up to date with mandatory training and overall compliance for this was 98%, we were not assured that this was effective as during our assessment a patient raised concerns that staff often slept during night shifts, which affected observations and we found discrepancies in observation record keeping and incident reporting when compared with CCTV footage. We informed service leaders. They reviewed CCTV footage and confirmed these discrepancies had occurred.

After our assessment, the service identified further examples of staff sleeping on night duty. Leaders acted immediately, suspended the staff involved, and began an investigation. They assured us that the incidents did not occur during times when patients required observations. Leaders said they would continue to monitor the situation and carry out unannounced night‑time visits.

Additionally, patients raised concerns over staff projecting their religious beliefs onto them making them feel unsafe.

The evidence did not always show a good standard. The service did not always assess and manage the risk of infection. They did not always detect and control the risk of it spreading. However, they did share concerns with appropriate agencies promptly.

Staff maintained equipment effectively and kept it clean. All ward areas were clean, well‑furnished and well‑maintained. The décor met a high standard, using calming and inviting colours. The building’s design provided additional seating areas outside of the main lounges. Window seats were available on the ground floor, and there was a quiet area on the first floor.

We observed the domestic team maintaining the environment, and they told us they always had access to the equipment and products they needed. They demonstrated a good understanding of the patient group and explained that they supported patients with cleaning their rooms when required.

Cleaning records were up to date and showed that ward areas were cleaned regularly.

Staff adhered to infection‑control principles, including appropriate handwashing.

However, we found multiple examples of out-of-date food in the ADL kitchen. We were concerned this posed a risk of infection as patients still had access to it. This meant we were not assured of patient safety in this area.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff followed good practice in medicines management—including transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, and the use of covert medication—and did so in line with national guidance. The service had one clinic room, which we found to be in good order. The service used an external pharmacy that supplied the required medicines and provided oversight through weekly pharmacy audits.

The service operated an effective medicine‑ordering system, which also covered any over‑the‑counter medicines patients might need.

We found no evidence of over‑stocking, and all medicines were labelled and stored correctly.

We reviewed medicine administration and saw that staff supported patients to understand what medication they were receiving.

Staff regularly reviewed the effects of medication on patients’ physical health in line with National Institute for Health and Care Excellence (NICE) guidance. Several patients were prescribed medicines that required routine monitoring for side effects, and we found that staff completed these checks correctly and in a timely manner.

However, during our assessment of the emergency resuscitation bag stored in the clinic, we found a missing signature on the daily check sheet. Staff must check the bag daily to ensure that all contents are present and fit for use in an emergency. We brought this to the attention of nursing staff, who told us that a bank nurse had failed to complete the check. Although only one date had been missed, we were not assured that nursing staff would have identified this omission as there was no audit data for these checks.