Cygnet Joyce Parker Hospital

Leaders did not have the experience, capacity, capability and integrity to ensure that risks were well managed. We were concerned that the provider’s policies in relation to ligatures and resuscitation were not adequate to prevent potential harm to children and young people. Leaders were not always alert to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff. Managers did not ensure staff were aware of their responsibility to raise concerns, 12 staff observed the abusive incidents and failed to report them. Staff spoken with were not aware of the term closed cultures.