- Independent mental health service
Cygnet Maple House
Assessment report published 24 August 2026
Contents
Ratings - Long stay or rehabilitation mental health wards for working age adults
Our view of the service
We assessed Cygnet Maple House on 10 June 2026. This assessment included an on-site inspection visit. The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.
However, the information shared with CQC about the incident indicated potential concerns about the management of risk of harm from restricted and risk items. This inspection examined those risks.
Cygnet Maple House is a 16-bed specialist high-support inpatient rehabilitation service for women who may be informal or detained under the Mental Health Act 1983. The service is based in East Bridgford, Nottinghamshire. At the time of our assessment, 13 of the 16 beds were occupied.
We rated the service as inadequate. As this assessment was carried out in response to specific concerns, we looked at 7 quality statements across the key questions of safe, caring and well-led. In the acute ward for adults of working age and psychiatric intensive care units, we found breaches of regulations in relation to safe care and treatment, safeguarding service users from abuse and improper treatment, and good governance.
We have asked the provider for AN ACTION PLAN in response to the concerns found at this assessment.
People's experience of this service
We spoke with 3 patients during the assessment. Patients described feeling shocked, upset and affected by the death, particularly those who had been close to the patient.
Patients gave mixed feedback regarding their experience of care. Several patients spoke positively about staff and described them as caring, compassionate and supportive. One patient told us staff were "nice, compassionate and helpful" and another said they felt "as safe as I can be". Patients described positive relationships with nursing and psychology staff and felt emotional and therapeutic support was available when required.
However, some patients raised concerns about safety, safeguarding and observation practices. One patient told us they did not feel safe and described feeling unheard when raising safeguarding concerns. They reported concerns regarding inappropriate comments allegedly made by a member of staff and told us they felt their concerns had initially been dismissed by some staff members rather than being treated as a safeguarding matter.
Patients also raised concerns regarding the management of risk. A patient told us the quality of observations varied between staff and felt some checks were more thorough than others, although they reported observations had improved following the incident.