The Care Quality Commission has identified “serious concerns” about Cygnet Health Care’s governance and the effect on the quality of care of some of the services it provides.

CQC carried out a provider review of Cygnet between 2 July and 2 August last year, after significant concerns were identified regarding safety and culture at Cygnet Whorlton Hall, following a BBC Panorama programme aired on 22 May of the same year. 

During the review, CQC inspectors found that a clear line of accountability could not be established across all of Cygnet’s locations. 

It found the governance structure and processes in place did not support the executive board to identify emerging issues effectively. The commission found that Cygnet used different information systems to notify and manage risks across the organisation, so the executive team did not have oversight of significant risks identified by regional teams.

The CQC also said that care and treatment carried out by Cygnet did not always include best practice and that there was a high use of physical restraint and seclusion across its services, compared to similar services delivered by other mental health providers. 

The number of patient assaults by other patients and self-harm recorded were also higher in Cygnet, compared with NHS providers of similar services.

In addition, the CQC found the executive team did not ensure all locations had a registered manager in post and as of June last year, 8% of locations didn’t have a registered manager. 

Kevin Cleary, deputy chief inspector for mental health and community services at CQC, said: “During the well-led review, we identified serious concerns about Cygnet Health Care’s governance and leadership and the impact of this on the quality of care being provided to vulnerable people in some services. Since our review, Cygnet have commissioned a corporate governance review from an independent person and are taking action to make improvements at a number of locations. We will be closely monitoring the provider to ensure the necessary improvements continue to be made to ensure patients are receiving safe care.”

Vicki Nash, head of policy and campaigns at Mind, the mental health charity, commented: “This review is a stark reminder of the poor quality of care too many people receive from mental health services. High self-harm and patient assault rates are unacceptable in any healthcare setting. No matter what happens, at the very least, people receiving treatment and support for their mental health should expect to be kept safe, treated with dignity and compassion."