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 means we looked for evidence that people were protected from abuse and avoidable harm. At the previous inspection, this key question was rated inadequate. At this assessment, there was insufficient evidence to rate.

The service was not effective at identifying, managing and mitigating risks to patients. Safeguarding concerns were not consistently recognised, investigated or escalated appropriately. Risk management plans did not provide staff with sufficient guidance regarding how identified risks should be managed or escalated when a patient's presentation deteriorated.

We identified concerns regarding observation practices, incident reporting and leadership oversight of risk. Not all incidents had been reported through governance systems and records did not provide assurance that observations were always being completed effectively or in line with patient need.

The service was in breach of regulations relating to safe care and treatment and safeguarding service users from abuse and improper 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.

Risks were not consistently recognised, escalated or managed appropriately. Opportunities to address concerns, learn from incidents and drive improvement were not always embraced. We identified failures to notify the Care Quality Commission (CQC) of incidents affecting the health, safety and welfare of people using the service. This issue had also been highlighted at the previous inspection, indicating that sufficient action had not been taken to ensure sustained improvement and regulatory compliance.

Incidents were not always appropriately investigated and reported. We identified incidents that had not been reported through the provider's incident reporting system. For example, a self-harm incident that resulted in a patient being placed on continuous observations had been documented within clinical records but had not been reported as an incident. This reduced leaders’ oversight and limited opportunities to identify themes, learn from events and improve patient safety.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

There were not effective systems, processes and practices to ensure patients were protected from abuse and neglect. We identified significant concerns regarding safeguarding arrangements, leadership oversight and safeguarding practice within the service. Leaders had not ensured that safeguarding concerns were consistently recognised, recorded, escalated or managed in line with local safeguarding procedures. As a result, leaders could not be assured that safeguarding concerns were identified promptly, progressed appropriately or subject to effective oversight.

Staff and leaders did not demonstrate a sufficient understanding of safeguarding responsibilities and local safeguarding procedures. Although safeguarding training compliance was reported to be high, this was not reflected in practice. During the assessment, inspectors identified safeguarding concerns requiring immediate action, including matters that met the threshold for referral to the local authority, which had not been recognised or acted upon by staff.

The service did not demonstrate a proactive approach to protecting people from abuse and neglect and was not always working effectively with partner agencies to safeguard patients. For example, a safeguarding disclosure concerning alleged inappropriate conduct had not been managed in accordance with local safeguarding procedures, and a required Person in a Position of Trust (PIPOT) referral had not been completed. This meant patients remained exposed to the risk of further harm because leaders had not taken the necessary action to protect them from the source of the alleged abuse.

Inspectors identified these concerns during the assessment and remained on site until leaders had completed the required safeguarding referrals and statutory notifications. This raised concerns regarding the effectiveness of safeguarding oversight and the service's ability to identify and respond appropriately to safeguarding risks without external intervention.

Patients were not always appropriately supported when they felt unsafe or had experienced abuse or neglect. While some patients told us they felt safe, others described occasions where safeguarding concerns had initially been dismissed or not taken seriously by staff. One patient told us they felt unheard and not believed when attempting to raise concerns. Another patient reported concerns regarding photographs being shared inappropriately and comments allegedly made by a member of staff. These accounts indicated a culture in which patients could not always be assured their concerns would be listened to, acted upon and investigated appropriately.

The evidence showed significant shortfalls. The service did not work well with patients to understand and manage risks.

Patients were not always informed about risks and how to keep themselves safe. Staff identified a number of risks for patients during their assessments but did not complete supporting risk management plans that included all identified risks or guidance for staff to follow in relation to management of risks. In all four care records reviewed, risk assessments and risk management plans were not fully aligned. Staff did not complete crisis plans for all patients. Whilst staff supported patients to identify coping strategies, records did not consistently describe what actions staff should take if these became ineffective or risks escalated.

The service identified plastic carrier bags as prohibited items due to the risks they presented. However, inspectors reviewed an incident where a patient was able to self-harm using a plastic carrier bag. This demonstrated that measures to restrict access to prohibited items were not consistently effective and increased the risk of patients coming to harm.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.