Cygnet Hospital Maidstone

Updated 26 February 2026

We assessed this hospital on 4 and 5 June 2025.

Following the last inspection in June 2023, the provider was issued a Warning Notice under Section 29 of the Health and Social Care Act 2008 due to our concerns regarding the management of ligature risks, and therefore patients were not receiving safe care and treatment under regulation 12 of the Health and Social Care Act 2008 (regulated activities). The provider was also in breach of regulation 10 (dignity and respect), regulation 9 (person-centred care), regulation 17 (good governance) and regulation 18 (staffing) of the Health and Social Care Act 2008 (regulated activities). We conducted this assessment to follow up on the concerns identified in the Warning Notice and due to patient safety concerns we had received from patients and statutory notifications.

Cygnet Hospital Maidstone is a purpose built, 63-bed mental health facility for adults. The hospital has 4 wards:

Roseacre Ward is a 16 bed service for women with a personality disorder. Roseacre Ward is designed to a Tier 4 specification, commissioned by Integrated Care Boards (ICBs). The aim of the service is to support patients to manage their mental health, develop coping strategies, reinforce daily living skills, and prepare for a return to independent living. Roseacre Ward provides a care pathway for patients who are preparing to step down to community living and uses a recovery focused model. The ward supports individuals with primary diagnoses of personality disorder, schizophrenia, schizoaffective disorder, bipolar affective disorder and depression.

Bearsted Ward is a 15 bed male Psychiatric intensive care unit (PICU) that accepts emergency and crisis admissions. Referrals are accepted from all areas, including acute and prison services. The ward provides support for individuals experiencing difficulties that present a risk to the well-being of themselves or others that cannot be treated in an open environment.

Kingswood Ward is a 16 bed ward providing acute and high dependency support for men with complex mental health needs. The service outlined their high dependency rehabilitation service as a recovery focused service delivering high quality care, balancing risk management with therapeutic optimism and encouraging men to build upon skills needed to move towards the least restrictive care option or return to the community. Kingswood Ward provides a pathway for men from Saltwood Ward requiring a stepdown to a lower level of security.

Saltwood Ward provides a 16 bed low secure service for men with enduring mental illness, including those with a personality disorder. Cygnet Hospital Maidstone is a core and active provider partner in the South East (KSS) Provider Collaborative for Adult Secure Services.

Cygnet Hospital Maidstone was registered with the Care Quality Commission (CQC) on 5 October 2018 to provide:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983,
• Treatment of disease, disorder or injury.

The service had a registered manager in place.

Our last comprehensive inspection of this service took place on 6 and 7 June 2023. Following that inspection, we rated the provider requires improvement overall with a rating of good in the responsive domain.

We assessed all 3 assessment service groups during this assessment. These were forensic inpatient and secure wards, acute wards for working age adults and psychiatric intensive care units, and Long stay or rehabilitation mental health wards for working age adults. At this inspection, we assessed all 33 quality statements across the Safe, Effective, Caring, Responsive and Well-led key questions.

We rated the service as good. The service had made improvements and is no longer in breach of regulations.

Updated 24 April 2025

We carried out a comprehensive on-site assessment on 4 and 5 June 2025 to determine if the service had made improvements since the last inspection. Following the last inspection in June 2023, the provider was issued a Warning Notice under Section 29 of the Health and Social Care Act 2008 due to our concerns regarding the management of ligature risks, and therefore patients were not receiving safe care and treatment under regulation 12 of the Health and Social Care Act 2008 (regulated activities). The provider was also in breach of regulation 10 (dignity and respect), regulation 9 (person-centred care), regulation 17 (good governance) and regulation 18 (staffing) of the Health and Social Care Act 2008 (regulated activities).

At this inspection, we assessed all 33 quality statements across the Safe, Effective, Caring, Responsive and Well-led key questions. During our last inspection in June 2023, Safe, Caring and Well-led were rated Requires Improvement. Effective and Responsive were rated Good.

On this inspection we found the service had made significant improvements and it is no longer in breach of regulations. The service now ensured that all ligature risks were managed well across the wards and that there were clear plans in place to remove or mitigate against such risks. The service had a robust ligature audit programme in place, and staff completing the ligature risk audit had the right training, skills and knowledge to complete the audits. The provider now ensured that patients had access to enough therapeutic activities during weekends. The provider ensured that patients had access to quality food and had a variety of food to choose from. The provider ensured the kitchen provided food to meet the dietary needs of patients.

The overall rating for this service is Good. We rated all five key questions as Good.

Mental Health Act and Mental Capacity Act Compliance.

Mental Health Act

The service admitted patients under the Mental Health Act 1983.

Staff had received face to face training on the Mental Health Act and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.

Staff had easy access to administrative support and advice on implementing the Mental Health Act and its Code of Practice.

Staff knew who their Mental Health Act administrators based at the hospital were.

The provider had relevant policies and procedures that reflected the most recent guidance and staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had easy access to information about independent mental health advocacy. Patients could access independent mental health act advocates if needed.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it. Records we reviewed demonstrated this.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.

Staff requested an opinion from a Second Opinion Appointed Doctor when necessary.

Staff stored copies of patients' detention papers and associated records correctly so that they were available to all staff that needed access to them.

Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits. The provider regularly completed audits on the Mental Health Act paperwork to ensure the correct and relevant paperwork was easily accessible and stored correctly.

Mental Capacity Act

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 received and kept up to date with training on the Mental Capacity Act and had a good understanding of the five principles. Training on the Mental Capacity Act was mandatory, and the compliance rate was 100% for all staff.

Staff knew where to get advice from the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. We saw evidence of this in patient records.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. We saw evidence of this in patient records.

Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies.

The service had arrangements to monitor adherence to the Mental Capacity Act.

Staff audited the application of the Mental Capacity Act and took action on any learning identified.

Updated 24 April 2025

We carried out a comprehensive on-site assessment on 4 and 5 June 2025 to determine if the service had made improvements since the last inspection. Following the last inspection in June 2023, the provider was issued a Warning Notice under Section 29 of the Health and Social Care Act 2008 due to our concerns regarding the management of ligature risks, and therefore patients were not receiving safe care and treatment under regulation 12 of the Health and Social Care Act 2008 (regulated activities).The provider was also in breach of regulation 12 (safe care and treatment), regulation 10 (dignity and response), regulation 9 (person-centred care), regulation 17 (good governance) and regulation 18 (staffing) of the Health and Social Care Act 2008 (regulated activities).

At this inspection, we assessed all 33 quality statements across the Safe, Effective, Caring, Responsive and Well-led key questions. During our last inspection in June 2023, Safe, Effective, Caring and Well-led were rated Requires Improvement, and Responsive was rated Good.

At this inspection we found that the service had made significant improvements and was no longer in breach of regulations. The service now ensured that all ligature risks were managed well across the wards and that there were clear plans in place to remove or mitigate against such risks. There was a robust ligature audit programme in place, and staff completing the ligature risk audit had the right training, skill and experience.

The overall rating for this service is Good. We rated all five key questions as Good.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. Staff had received training in the Mental Health Act and the ward was 100% compliant.

Staff had easy access to administrative support and legal advice on the implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

The provider had relevant policies and procedures that reflected the most recent guidance; which staff had easy access to.

Patients had easy access to information about independent mental health advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.

Staff requested an opinion from a second opinion appointed doctor when necessary.

Staff stored copies of patients' detention papers and associated records, such as, Section 17 leave forms, correctly so that they were available to all staff that needed access to them. We reviewed Section 17 leave forms and they were in good order. These were also regularly audited.

The service audited adherence to the Mental Health Act every six months.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. Staff had received training in the Mental Capacity Act and Deprivation of Liberty Safeguards and the ward was 100% compliant.

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 regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. We saw evidence of best interest decisions recorded in patient records.

The service had arrangements to monitor adherence to the Mental Capacity Act and this was audited every three months.

Updated 24 April 2025

We assessed this service on 4 and 5 June 2025. At this inspection we assessed all 33 quality statements across the Safe, Effective, Caring, Responsive and Well-led key questions.

We rated the assessment service group as good. The service had made improvements and is no longer in breach of regulations.

The service now ensured that the emergency bag checklist was kept up to date and included the full contents requiring checking. The service now ensured that the emergency bag seal was one that could be broken with ease to enable timely access to the bag. The service now ensured adequate record keeping and thorough checks on medicines. The service now ensured that there were cleaning records available which were audited to ensure staff maintained and cleaned clinic room equipment.

The service now ensured that ligature risk assessment audits were completed appropriately to identify the risks accurately and ensured suitable mitigations were in place. All staff had completed their ligature rescue training, and there was always a member of staff with this completed training on shift.

The service now has meaningful activities suitable for a long stay rehabilitation service and met the needs of the patient group. Leaders now have appropriate oversight of the recovery-orientated activities suitable for patients’ care and treatment on this ward and ensured appropriate action was taken to address shortfalls with this.

The service now appropriately identified and recorded restrictive interventions. Managers had oversight of these. Patients and staff actively reviewed these to ensure least restrictive practice.

The service now held regular team meetings to ensure appropriate and consistent information sharing.

The service now ensured all patients had a clear plan for discharge and that they, and where possible, their relatives, were involved and kept informed of recovery progress.

Patient choice and views were evident throughout care plans. Patients told us they understood their care plans and what they needed to do to meet their goals.

The service now ensured that the correct weekly food menu was displayed clearly for patients.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

All staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

The provider had relevant policies and procedures that reflected the most recent guidance. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had easy access to information about independent mental health advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted.

Staff requested an opinion from a second opinion appointed doctor when necessary.

Staff stored copies of patients' detention papers and associated records, such as section 17 leave forms, correctly and so that they were available to all staff that needed access to them. We reviewed section 17 leave forms, and they were in good order. These were also regularly audited.

The service audited adherence to the Mental Health Act every 6months. This was to ensure the Mental Health Act had been applied correctly.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. Staff had received training in the Mental Capacity Act and Deprivation of Liberty Safeguards, and the ward was 100% compliant.

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 internal advice from regarding the Mental Capacity Act, including Deprivation of Liberty Safeguards.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. We saw evidence of best interest decisions recorded in patient records.

The service had arrangements to monitor adherence to the Mental Capacity Act and staff audited these every 3 months. The service took action when learning had been identified as a result of Mental Health Act visits and audits.