Cygnet Health Care

Enforcement actions and Violation Tracker

Using the website Violation Tracker, a UK wide database of enforcement actions brought against companies by government regulators, as of February 2023, Universal Health Services has 9 enforcement actions listed from 2016-2022. This includes actions brought by the CQC, but only those resolved and is the tip of the iceberg of concerns over the safe care of patients. As can be seen from the overview below, Cygnet Health has been subject to numerous damming reports from the CQC and 'inadequate' ratings for its hospitals.

Safety and care concerns

Cygnet has been repeatedly criticised by the CQC for unsafe and poor care. Most recently in March 2023 a Joint Domestic Homicide Review and independent mental health homicide investigation reported that the decision to discharge Jonathan MacMillan from a Cygnet Health Care unit in Maidstone into the community was ‘flawed’. Following his release MacMillan stabbed his father to death in June 2019. The review found that the assessments completed while he was detained at Cygnet Health Care were inadequate.

From October 2018 to January 2020, 10 of Cygnet Healthcare’s 124 hospitals were rated “inadequate”. More bad reports of the company's hospitals have been published since.  Such was the level of problems at the company's hospitals, in April 2021, NHS England wrote to Cygnet that it will ‘not tolerate failures’. In a letter, reported in the HSJ,  Claire Murdoch, the national mental health director, and John Stewart, national commissioning director, warned Cygnet that “patients deserve better” and they will “not hesitate to take further action” if improvements are not made. Cygnet has difficulties with recruiting staff, a problem not confined to the private sector, but it is also clear from many of the damning CQC reports that there are major issues with the management of the company and leadership within the hospitals.

In June 2021, the CQC published a review of Cygnet Healthcare. The review continues on from the one in early 2019 produced as a result of the Whorlton Hall scandal (although Cygnet did not own this hospital at the time of the scandal), which raised concerns over the use of physical restraint, high reliance on agency staff and vacant management positions, that care and treatment did not always follow best practice, clear lines of accountability were not always apparent, and that ‘fit and proper’ person checks had not been carried out for its executive board. The new review also considered additional concerns that had been raised at 13 Cygnet services during inspections, including ongoing serious incidents, whistleblowing contact and safeguarding concerns.

Some of the most damning conclusions to come from the review concerned the management within the company. The CQC found that the company does "not have a longer term strategic plan" and "members of the senior leadership team were not able to articulate which groups of service users they were planning to support in the future and how they would ensure they had the appropriate estate and skilled staff to meet their needs. "

There have been at least 21 deaths of patients at Cygnet hospitals across the UK since 2011, according to the organisation Inquest. In March 2022, an inquest concluded that the death of Emma Pring at Cygnet's Maidstone hospital in April 2021 could have been prevented by the hospital, with the jury finding there had been an “insufficient level of observation, and a misjudgment of Emma’s actual risk”. Emma was not placed on one-to-one observations which might have prevented her death. Emma was supposed to have been observed by staff every 15 minutes, a timeframe which the inquest found was not always adhered to.  The coroner is considering whether to issue a prevention of future deaths notice to Cygnet hospitals. An inquest following the death of 17-year-old Chelsea Blue Mooney at a Cygnet hospital in Sheffield in April 2021, found that “insufficient care” at the hospital had led to her death.

The hospital 'failures' continued after the letter from NHS England in April 2021. Most recently, in September 2022 the CQC rated Cygnet Bury Forestwood "requires improvement". The regulator concluded that the hospital, which provides services for young people aged 13-18, “did not always provide safe care".

In September 2021 the CQC rated Cygnet Views, the company's hospital in Matlock as 'inadequate'. The hospital, which cares for up to 10 women with learning disabilities and complex mental health needs. The CQC is damning of the hospital's care, noting the following:

• "Patients didn’t always receive safe care.
• Managers did not always follow good practice with respect to safeguarding and
  the use of restrictive practices.
• Opportunities to prevent or minimise harm were missed.
• Local risk assessments failed to identify significant ligature
  points across the hospital.
• Staff didn’t always have the skills required to support this patient group. The provider only made specific training
  available for some staff which meant not all patient needs were understood and addressed.
• Patients were not always supported with their physical health or encouraged to live heathy lives by staff.
• Staff did not always understand how the Mental Capacity Act 2005 related to the patients they supported.
• The hospital was not always well led, and the governance processes did not ensure that hospital procedures ran
  smooth."

In August 2021, it was reported that the CQC had sent an urgent enforcement notice to Cygnet's Appletree Hospital in Durham, following an inspection in April and May 2021. The unit provides services to female patients needing inpatient mental health care, including patients funded by NHS England. The hospital was found to have "ineffective leadership" and there were concerns over bullying and "inappropriate" restraint. The CQC had also been told of concerns of under reporting of safety incidents and safeguarding issues, high use of intramuscular medication on patients, and incidents where medication was administered at higher levels than prescribed.

Failures in 2020 and earlier

Following an inspection of Cygnet's hospital in Colchester in October 2020, the CQC told the hospital must remain in special measures with improvements still needed. The inspection followed reports relating to the safeguarding of patients and the reporting, investigation and management of incidents. Inspectors found an allegation of abuse had not been reported appropriately and that staff did not always follow correct Covid-19 policy or infection prevention and control guidelines.

An unannounced inspection by the CQC at the company’s CAMHS at the Godden Green hospital in Kent in October 2020 identified serious concerns about environmental risks and staff’s ability to keep patients safe from harm and injury. The CQC had received complaints from other professionals and relatives. Inspectors found a culture of negativity had developed among some staff, with patients referred to as ‘difficult’ and ‘troublemakers’ in records. Cygnet has now decided to close this service and focus on adult patients at this hospital.

In September 2020 the CQC carried out an unannounced inspection of Cygnet Yew Trees, a 10 bed facility for women with learning disability. The CQC reviewed 21 episodes of closed-circuit television footage and found nine that showed staff “abusing patients, acting inappropriately or delivering a poor standard of care”. Managers suspended eight permanent members of staff from working at the hospital. Referrals have also been made to the police. The CQC criticised Cygnet’s management for allowing a culture to develop at this hospital which led to people suffering abuse.

In January 2020, the CQC told Cygnet to take “immediate action” to improve its management following an investigation of the company and its hospitals.  The CQC found that Cygnet-run hospitals were more likely to use seclusion and physical restraint on patients than other NHS providers of mental health care. The incidents of self-harm and assaults by other patients were also much higher. The CQC report also found that checks to ensure directors and members of the executive board were “fit and proper” were not carried out. The full-scale review was triggered by a BBC Panorama report in May 2019 into Whorlton Hall, a centre for people with learning disabilities. As a result of the programme ten people were arrested for abusing patients.

From January to September 2019, mental health units run by the company have been found to be inadequate by the CQC six times. In November 2019, the CQC ordered that the Cygnus Acer Clinic in Derbyshire must stop admitting new patients due to serious concerns over patient safety. CQC inspectors found that clinic patients had opportunities to hang themselves, and the unit had escalating levels of patient self harm, and a huge shortage of trained staff. In 2019 there were two serious incidents, one of which resulted in a patient taking their own life by hanging. The report notes that whilst inspectors were at the clinic in August they witnessed patients congregating in a ward near the reception and banging on the windows to get help from staff, but the staff were nowhere to be seen. Three whistleblowers have contacted the CQC, one prior to the visit and two whilst the CQC inspectors were present.

In October 2019 an inspection report on Cygnet’s Newbus Grange hospital in Darlington, noted how the CQC had found a patient with “unexplained injuries”, and there were opportunities for patients to kill themselves and staff asleep while on duty.  The unit was put into special measures and its 10 patients moved elsewhere.

In July 2019,  the CQC downgraded the hospital at Godden Green to “requires improvement”. The CQC also imposed two requirement notices on the hospital in relation to safe medicines management and making sure they have a permanent registered manager. As a result of the visits restrictions on the provider’s registration were imposed by the CQC, saying it could not admit any young person to the ward without prior agreement with the CQC. This remained in place for a month.

In June 2019, HSJ reported that multi-agency investigation had been launched into Cygnet’s 65-bed hospital in Maidstone, whose 15-bed male psychiatric unit had had a “disproportionate” number of safeguarding alerts for patient-on-patient attacks.

The CQC inspected the Knole Ward at the Cygnet Hospital at Godden Green, in Kent, in July and August 2017 after it was informed of concerns about the safe care and treatment of young people.

Whorlton Hall in County Durham, a home for vulnerable adults, owned by Danshell, now owned by Cygnet, was the subject of a scandal in 2018. Whistleblowers told the BBC Panorama team of a culture among staff of bullying and mistreatment of the vulnerable by care workers. Panorama sent in an undercover reporter working as a care worker. The reporter found many care workers actively aggravated, tormented and talked about patients in the most appalling ways, including taunting and deliberate winding up of patients. The investigation led to criminal investigations. After the Panorama programme, Cygnet, which had only just acquired the home, suspended all staff and transferred patients to other hospitals. The CQC produced a review of Cygnet in 2019 following the scandal and identified ‘serious concerns’ over Cygnet’s governance and leadership.