You are here

CQC review of Cygnet Health Care finds some progress made but further work needed to improve safety of services

3 June 2021
Cygnet Health Care Limited
  • Media

The Care Quality Commission (CQC) has carried out a well-led review of Cygnet Health Care Limited, to follow up on areas identified as needing improvement during a previous well-led inspection in 2019.

The review, conducted between 27 January and 4 March 2021, considered additional concerns which had arisen at 13 Cygnet services following inspections that had taken place since the previous well-led assessment and feedback from stakeholders. This included ongoing serious incidents, whistleblowing contact from Cygnet staff to the CQC and safeguarding concerns across a number of Cygnet locations.

Overall, inspectors found Cygnet had made progress towards meeting the requirements from the previous well-led review, but further work was needed across the organisation to ensure sustainable improvements and the safety of services. Although improvements have been made at some Cygnet services, some are still not providing safe care, as highlighted by recent CQC inspections.

Since the previous well led assessment the senior leadership team has remained stable with the skills, knowledge and experience to support the delivery of services. The lack of external scrutiny of the executive team’s decisions was identified at the well-led review in 2019. Since then, Cygnet had appointed four independent advisory board members with a range of experience in human rights, strategic leadership and in health and social care.

At the previous well-led assessment CQC found that not all the required checks had been carried out to ensure that directors and members of the executive board were Fit and Proper Persons. This time inspectors were able to confirm that, for the executive director and three independent directors appointed in the last year, all the necessary checks were in place. However, at the time of the well-led assessment, employment tribunal findings were published raising potential Fit and Proper Persons Requirement issues and Cygnet were considering these findings.

Progress had been made in implementing an outline governance structure, however this required more time to be properly embedded. While the new governance systems gave improved oversight of safety there were still areas where further action was needed to safeguard people using services. These included staff recruitment and retention with staff turnover of over 30% each year. Further work was also needed to reduce ligature risks and to review the use of restraint in social care services.

Cygnet did not have a longer-term strategic plan and senior leaders could not articulate which groups of people Cygnet were planning to support in the future, or whether services would have the appropriate facilities and skilled staff to meet their needs. As a result of this Cygnet had continued to close and ‘repurpose’ services - at times with short notice and in response to serious concerns. The review found this could have an adverse impact on people receiving care, who found the experience of moving to a different service distressing.

Cygnet had successfully introduced systems across all services to help analyse data including patient care records and incident reporting, to support national governance. However, the data needed to be brought together so it could be used to better identify areas for improvement. A previous CQC recommendation of implementing a quality improvement framework to support continuous improvement was at an early stage and poorly understood by senior leaders.

Whilst good progress had been made with the recruitment and introduction of a Freedom to Speak Up Guardian and ambassadors, staff working for Cygnet still needed to feel more confident that they could speak up within the organisation and that their concerns would be heard and addressed without fear of retribution.

Jane Ray, CQC’s Head of Hospital Inspection, said:

“We carried out this review to check Cygnet were making sufficient progress with the improvements required, following our well-led review in 2019. We found a number of areas where progress had been made and where Cygnet were performing well. This review took place when Cygnet were dealing with the implications of the COVID-19 pandemic, and we found that they had largely managed the risks associated with this well.

“Appointments of independent advisory board members had been made to provide independent challenge to the executive team. Effective arrangements were now in place to identify and escalate risks from services to the leadership team. However, whilst work was underway to address issues at a leadership level, we found several areas that required significantly more work including development of a longer-term strategic plan to reduce repurposing of services at short notice, leading to a breakdown of people’s placements and care arrangements.

“Additionally, action is needed to improve patient safety and working culture, ensuring proper engagement and transparency across the wider healthcare system that Cygnet is a part of. People should be able to expect high-quality and safe care in all Cygnet services and staff should be supported to raise concerns. While most Cygnet services are providing good care there are some that still need to improve. While we are seeing progress in some services, we are concerned that some others are not providing safe care and are struggling to meet the needs of patients. We will continue to monitor and report on this through our inspection activity and take action where necessary.”

Action the provider must take to improve:

The provider must develop a longer-term strategic plan. This should use an organisational development approach to articulate which groups of service users they are planning to support in the future and how they will ensure they have the appropriate estate and skilled staff in place to meet their needs. Examples of success will be reductions in the unanticipated repurposing of services and the breakdown of service user placements. (Regulation 17: Good Governance)

The provider must move towards a balance between its improvement and assurance work with the associated cultural shift. Examples of success will be a reduced burden for services from assurance and a growth in the understanding of quality improvement alongside an empowerment at a service level for front line staff, team leaders, service managers and service users to drive improvements. (Regulation 17: Good Governance)

The provider must promote a culture where leaders throughout the organisation can continue to celebrate success but are also encouraged to be more reflective and self-critical so they can identify for themselves where further development or improvements are needed. (Regulation 17: Good Governance)

The provider must further develop their leaders throughout the organisation with a programme of coaching and mentoring to provide a more systematic individual development approach to those not performing and a talent management approach to those who are the potential leaders for the future. (Regulation 18: Staffing)

The provider must take a number of actions to improve patient safety. This includes improving staff recruitment and retention, especially of nursing staff and support workers; reviewing the levels of restraint being used with a focus on social care services; ensuring there is a clear programme with dates for ligature reduction work. (Regulation 12: Safe Care and Treatment)

The provider must ensure that the use of the Mental Health Act and Mental Capacity Act has appropriate oversight through the governance structures. (Regulation 13 Safeguarding Service Users from Abuse and Improper Treatment)

Reports from CQC inspections of Cygnet Beckton and Cygnet Acer Clinic have also published today.

For enquiries about this press release please email

Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here. (Please note: the press office is unable to advise members of the public on health or social care matters.)

For general enquiries, please call 03000 61 61 61.

Last updated:
03 June 2021

Notes to editors

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.