The Care Quality Commission
  • Mental Health
  • Independent mental health service

Cygnet Hospital Maidstone

Overall: Good read more about inspection ratings

Gidds Pond Way, Weavering, Maidstone, ME14 5FT (01622) 580330

Provided and run by:
Cygnet Health Care Limited

All Inspections

During an assessment of Acute wards for adults of working age and psychiatric intensive care units

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.

During an assessment of Forensic inpatient or secure wards

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.

During an assessment of Long stay or rehabilitation mental health wards for working age adults

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.

During an assessment of the hospital overall

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.

6 and7 June 2023

During a routine inspection

Our rating of this location went down. We rated it as requires improvement because:

  • The provider did not manage ligature risks well. There were multiple ligature points across the ward which were not sufficiently mitigated. The provider's ligature risk assessment process was not robust enough to remove ligature risks. Staff had not received training on how to complete a thorough and detailed environmental and ligature risk assessment. Due to the nature of the concern, the provider was issued a warning notice immediately after the inspection to address this concern. A warning notice is what we serve to a provider where we identify a concern with the quality of care they are responsible for that requires a current need for significant improvement.
  • Staff did not ensure that patients’ medicines were managed safely. Staff did not ensure that medicines were safely administered and recorded. Staff did not ensure that the physical health of patients who were administered rapid tranquilisation were sufficiently monitored to mitigate against or reduce the risk of harm. For example, patients were administered overdose of rapid tranquilisation medicines above the recommended limits. Staff did not ensure that controlled drugs were appropriately signed for. On Kingswood ward, staff did not always ensure the emergency bag check list was up to date with the relevant contents in the bag. The index on drugs liable for misuse was not completed. There were no cleaning records or audits in place for clinic room equipment. The emergency bag was not sealed with a standardised fitting which meant that it required cutting with scissors to gain access.
  • Not all patients had a care plan that met their holistic needs, and care plans were not always written to reflect patients’ views. For example, on Saltwood ward, one patient who had been prescribed medicines for substance misuse disorder did not have a specific substance misuse management plan in place. Some patients told us they had refused their care plans because they did not reflect their views or assessed needs. One patient was discharged from their section following a tribunal, but staff did not have aftercare plans in place. On Kingswood ward, care plans we reviewed did not identify whether a patient had signed or been given a copy of their care plan. In addition, recording of patient involvement was not seen in all care plans.
  • The provider did not always ensure the provision of meaningful activities suitable for the rehabilitative needs of patients. On Kingswood ward, there was no focus on recovery- orientated activities within care planning, ward rounds or team meetings. When meaningful activity engagement was recorded as below 25 hours per week on the ward, leaders did not put in place actions to address this. Patients on Saltwood ward told us that planned activities were sometimes cancelled. Some patients reported that their section 17 leave was often cancelled.
  • Staff did not always treat patients with kindness and compassion. Four out of six patients we spoke with on Saltwood ward told us that night staff did not always care for them well or treated them kindly. Patients said that staff did not always listen to them or respected their wishes. Two patients on Saltwood ward reported that staff did not respect their dignity or privacy and often walked in on them in the shower. On Kingswood ward, four patients said the night staff were disrespectful, were not caring and did not respect their privacy and dignity.
  • Governance processes around quality assurance and audits were not robust enough to mitigate or reduce risks. We saw that there were concerns in prescription charts and care records which had previously been identified in the pharmacy audit but had not been acted upon. When lessons were learnt following an incident, the provider did not ensure that the actions were embedded to reduce such risks. For example, there were two battery swallowing incidents within a 48 period in February 2023. Although the provider took some action, we saw that another battery swallowing incident occurred again in May 2023. The provider did not ensure that actions following Mental Health Act 1983 (MHA) monitoring visits were completed and improvements were fully embedded.

However:

  • The ward environments were clean. The wards had enough nurses and doctors. They followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. Staff engaged in clinical audits to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision, and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Spoke highly of the culture and the senior leadership team. They felt the senior leaders were very supportive and valued them. Staff reported that managers cared for their wellbeing and gave them opportunities and support to grow in their careers.

2 and 3 December 2019

During an inspection looking at part of the service

We carried out a focused inspection in response to concerns shared with us from members of the public, external agencies and intelligence held by the CQC. Concerns included: patient safety; patient risk and management of risk; high use of observation levels; the number of incidents on the ward; staffing levels; high use of agency staff; staff training; and culture and morale on the ward. The concerns were specific to Roseacre ward and we therefore only inspected this ward.

We did not re-rate the service following this inspection. The ratings from the comprehensive inspection on 19 and 20 March 2019 stay the same. The service was rated good overall. However, a requirement notice was issued for breach of Regulation 12, safe care and treatment. This was specific to Bearstead ward only. The inspection found patients’ risk assessments were not always completed and did not mitigate risks, and action taken to respond to incidents on the ward was not always appropriate.

During this focused inspection we inspected the safe, effective and well-led questions for Roseacre ward and we found:

  • The recording of risk information was variable and inconsistent. Patients risk assessments were not always updated following an incident or reflective of all risks identified during assessment or following an incident. The governance processes and audits for monitoring the quality of patients’ individual risk assessment records was not always effective.

  • Staff did not always report incidents on time. Some incident forms were completed sometime after the incident happened and the senior clinical team were not aware of those incidents until a later date. Incidents forms were not always fully completed and lacked some information which was needed. The process for monitoring and responding to reports of incidents submitted late and not in line with their policy was not effective.

    However:

  • Ward staff, senior managers and patients on Roseacre ward told us that the last few months prior to the inspection had been challenging on the ward but they felt things had improved a lot recently. Staff felt respected, supported and valued. They felt able to raise concerns without fear of retribution. Patients told us they felt safe on the ward and were happier now the ward had settled down and less agency staff were on duty.

  • The service had enough nursing and medical staff, who knew the patients and received basic training to keep patients safe from avoidable harm. Managers made sure they had staff with a range of skills needed to provide high quality care. They supported staff with appraisals, supervision and opportunities to update and further develop their skills. Managers provided an induction programme for all new staff.

  • The service managed all reported patient safety incidents well. Staff recognised incidents. Managers investigated all reported incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

  • Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.

19-20 March 2019

During a routine inspection

We rated Cygnet Hospital Maidstone as good because:

  • The ward environments were safe and clean. The wards had enough nurses and doctors. They managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • On most wards, staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
  • The service was well led by senior managers and the governance processes ensured that most ward procedures ran smoothly.

However:

  • On Bearstead ward, which is a psychiatric intensive care unit, the staff did not always assess and manage risks to patients well. The lack of clear communication between the team, for example during handovers, meant that staff were not clear on the current risks for patients and how these should be mitigated. This meant that incidents were continuing to take place which could have been potentially prevented.
  • There were some inappropriate blanket restictions across all three wards including access to some areas of the ward and access to fresh air and outside space. Patients on Bearstead ward did not have access to drinking cups for water. However, the ward staff participated in the provider’s restrictive interventions reduction programme and were working to reduce restrictions.
  • The staff team on Bearstead needed more support to develop the skills and experience to support the patients who had complex needs. This included the need to improve the therapeutic engagement with patientst.
  • The local management of Bearsted ward did not fully support staff to manage patient safety risks. However, the hospital director was aware of the need to provide additional support to this ward and team.