Cygnet Maple House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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

This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care. Leaders did not always have the skills, knowledge and experience to perform their roles. Staff did not always know and understand the provider’s vision and values and how they applied to the work of their team. Governance processes did not always operate effectively. Performance and risk were not always managed well. However, teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements. Staff felt respected, supported and valued.

The service was in breach of regulation for governance at the service.

We have not awarded this service a score for Well-led.

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

The evidence showed significant shortfalls. The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Staff did not always know or understand the provider’s vision and values, or how these were applied within their team. We requested a copy of the model of care used at the service and found that the provider was using the Cygnet Personality Disorder Inpatient Services – Model of Care (Medium and Low Secure Services). However, the service’s website describes Cygnet Maple House as “a 16‑bed highly specialised service providing assessment, treatment and rehabilitation for women with personality disorder and complex needs.” It does not state that it is a medium or low secure unit, and we found no evidence in practice that it operated as one.

We were not assured that the service’s strategy and vision were clear enough for staff and patients to understand. Although the provider had a model of care when we reviewed this it did not match up with what they were actually providing. It related to low and medium secure services. However, staff told us they were providing a therapeutic community. We were concerned by the lack of clarity around what model of care was being provided as it could potentially confuse staff and was making some patients feel unsafe. This meant that there was a risk of patients being placed at risk.

Staff told us the provider’s values were “empathy, caring, compassion, independence and honesty,” but one staff member said that they were not aware of the strategy.

When discussing the culture of the service, a staff member told us, “Everyone has the end goal of wanting the patient to succeed and do well.”

Patients told us they understood Maple House was a rehabilitation ward and that staff were there to support them. However, not all patients we spoke to felt supported by the staff and service provided and said that they continued to feel unsafe.

The evidence showed significant shortfalls. The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

At the time of our assessment, the registered manager—known as the hospital manager—was on scheduled leave. The provider appointed the former head of care as the interim hospital manager. As they had been the head of care since the hospital opened in 2023, they felt they knew and understood the service well. They had been in the interim role for only eight weeks. When we asked about the support available to them, they told us they had access to senior regional management and could contact other local Cygnet hospitals if needed.

Leaders were visible within the service and were approachable to both patients and staff. However, although staff felt supported by management they felt anxious about possible changes due to the recent management transition. Staff were very complimentary about the interim hospital manager and said they had always felt supported by them in their previous head‑of‑care role.

The change in leadership created development opportunities for staff. We saw that the head‑of‑care vacancy had been filled by a nurse in charge who had also worked at the service since it opened in 2023.

We were not assured that leaders had the full skills, knowledge, and experience needed to perform their roles. When we raised some concerns with leaders, they were unable to answer questions and responded that they had only been in post for 8 weeks however, we would expect leaders to have a higher level of understanding of the issues that they faced and plans to mitigate any risks, even within this timeframe.

The evidence showed significant shortfalls. People did not feel they could speak up and that their voice would be heard.

Staff and leaders encouraged patients to provide feedback, and we saw a “You Said, We Did” board displayed within the service. It showed examples of how patient feedback had influenced changes. However, the display was not dated, so patients could not tell when the actions had taken place.

Staff felt confident raising concerns internally. They were also able to access information about Cygnet’s Freedom to Speak Up and whistleblowing policies via the provider’s intranet.

During our assessment, we found a culture of speaking up among staff. Staff raised concerns, and those who did— including external whistleblowers—were supported without fear of detriment. When concerns were raised, leaders investigated them sensitively and confidentially, and they shared and acted on lessons learned. However, patients felt that speaking up would not lead to change. As previously stated in this report, 5 patients out of 8 said they would not raise concerns with the service. One patient told us that they would be scared to complain because their care would be affected and staff would treat them differently. An example of this was when we reviewed care plans of a patient who was clearly telling support staff they were struggling and suggesting they would harm themselves and nothing was done to prevent the incident which later occurred. The patient had actively requested support and it appears they were ignored as nothing was done to prevent the harm caused. We were not assured that patients felt protected or safe to speak up about their care. When we shared this feedback with leaders, they told us they had been unaware that patients felt this way.

The evidence showed some shortfalls. The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff were able to apply for flexible working arrangements to support personal circumstances such as caring responsibilities or health needs.

Leaders put reasonable adjustments in place to help staff carry out their roles effectively.

The provider monitored staff diversity to ensure the workforce was representative of the patient group. However, we were not assured that leaders took appropriate steps to remove bias from staff practice. For example, one patient told us that some staff did not accept same‑sex relationships. Another patient told us that during a group discussion, when patients were openly sharing their views, a staff member walked out, stating that the discussion topic was “morally wrong.” This demonstrated that the staff member projected their personal bias onto the patient group.

The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Staff maintained and accessed the risk register at ward or directorate level. Ward staff could escalate concerns when required.

Staff had access to policies and procedures designed to guide safe practice and maintain the quality of care. However, we had concerns about the policy for searching patients following Section 17 leave. We reviewed several incidents which involved hazardous items being brought into the service by patients following leave which were not prevented through this process. For example, one patient was able to bring in a hazardous substance, and another patient was able to bring in cleaning fluid. This meant patients were potentially placed at risk of avoidable harm.

Although staff completed searches when they identified specific risks, the policy itself was a provider‑level policy rather than a service‑specific one. We were not assured of its effectiveness because it did not reflect the needs or risks of this particular service.

The service had plans in place for emergencies, such as adverse weather or a flu outbreak.

Staff had access to the equipment and information technology required for their work. The IT infrastructure, including the telephone system, functioned well and supported good quality care.

During our assessment, we found a clear framework outlining what should be discussed in ward, team, or directorate meetings, including essential information such as learning from incidents and complaints. However, when we reviewed incident records, we found examples where patients experienced avoidable harm because the service did not act on information it already knew. When we observed a multi-disciplinary meeting information from the previous 24 hours there was no plan or actions recorded on the learning from the incident and how to support the patient. We were not assured that the systems for sharing and escalating information were effective.

We were not assured that the service effectively managed risk, issues, or performance. Leaders were unaware that staff had been sleeping during night shifts. Patients raised this concern with us, and when we informed leaders, they investigated and reviewed CCTV footage. They found more than one staff member asleep during the night shift. Leaders took immediate action and confirmed that their investigation would continue.

We were not assured that the governance systems in place to manage risk were effective in protecting patients from repeated and avoidable harm. When reviewing incident records, we found an entry describing a patient who had self‑harmed and required hospital treatment. Notes from the MDT meeting following the incident stated that nothing could be done to mitigate risk and that “due to the nature of swallowing any items the team have discussed that nothing will be restricted due to the environment being so open.” After returning from hospital, the patient experienced three further incidents of swallowing items, one of which required hospital treatment.

We were concerned that leaders categorised incidents in which patients harmed themselves using risk items accessible within the service as self‑neglect. it should have been categorised as ‘serious injury to a person using the service’. This suggested that the provider did not accept responsibility for harm occurring under its care. We raised this with the service who assured us that they take full responsibility and that they will review risk categorisation.

Leaders did not have processes or systems to review staff adherence to nursing observations to keep patients safe. We found that records of the observations have been amended and when we reviewed CCTV we found that staff had not completed the observations at the required time. Due to the lack of governance process for nursing observations leaders could not be assured that staff were doing all they could to keep people safe.

We also highlighted discrepancies between CCTV timestamps and times recorded on observation forms. Leaders explained this as “CCTV time.” However, the Information Commissioner’s Office (ICO) checklist requires services to ensure that CCTV timestamps are accurate, including adjustments for seasonal time changes. We were not assured that the service complied with this requirement. Inaccurate timestamps compromise the ability to investigate incidents safely and effectively which could put patients at risk of harm.

We were not assured that leaders fully understood their responsibilities to notify the CQC of all incidents that affect the health, safety, and welfare of people using the service. While reviewing four case‑tracked patients, we found 14 incidents requiring hospital treatment for self‑harm. Leaders acknowledged they had failed to notify the CQC of 11 of these incidents. We were given no reason why they had failed to do this. They submitted retrospective notifications as an immediate action.

Staff undertook or participated in local clinical audits. However, the audits did not always provide sufficient assurance or lead to necessary actions. For example, there was no audit system for the patient kitchen, where we found numerous items that were out of date or mouldy. Leaders took immediate action to resolve this issue.

Given the concerns identified throughout our assessment, we were not assured that the service had effective systems to mitigate risks or protect patients from avoidable harm.

The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Leaders of the service engaged with external stakeholders, such as commissioners and local authorities, and had formed strong working partnerships with them. They told us that the local authority safeguarding team had worked with the service and co‑produced a piece of work with patients.

The service had recently hosted a joint meeting with other independent mental health providers and the Integrated Commissioning Body (ICB).

Members of the provider’s senior leadership team were visible within the service and provided support to the interim hospital manager.

The service had established strong links with the local community and with local primary care services that would be involved in supporting patients.

However, during our assessment we found that the service had failed in its duty to notify the Care Quality Commission of serious injuries sustained by patients using the service. We were not assured that the service was effective in being transparent about incidents that occurred.

The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Staff were given time and support to explore opportunities for improvement and innovation, and this led to changes within the service. However, leaders told us that the quality improvement team had been reduced, which limited the support available for developing new projects.

Leaders within the MDT provided evidence that they had applied for Enabling Environments accreditation through the Royal College of Psychiatrists and were awaiting confirmation of the outcome.

Staff and leaders had a good understanding of how to implement improvements. Their approach was consistent and included measuring outcomes and evaluating impact. Processes were in place to ensure that learning occurred when things went wrong and from examples of good practice. Leaders encouraged reflection and collective problem‑solving. However, we were not assured that their approach was effective, as feedback from patients including feeling unsafe to speak up contradicted what leaders and staff believed patients were experiencing.