Cygnet Nield House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We reviewed all 7 quality statements in the well-led key question. This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question as Requires Improvement. At this assessment the rating has changed to Good.

Managers had a good understanding of the service and a clear overview of service performance. They were able to describe risks and challenges the service faced as well as actions to address them.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew and understood the provider’s vision and values and how they were applied to the work of their

team. Staff told us that these were reflected in the work they did with patients, and that the organisation’s values are

included as part of the service’s appraisal structure.

The provider had stated organisational values, vision, purpose and mission. The organisation’s values were integrity, trust, empowerment, respect and care. These were described and discussed as part of the staff induction programme.

Staff knew the providers values and were able to discuss how they reflected these in their day-to-day work.

Managers we spoke with had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed and were visible in the service and approachable for patients and staff. Managers we spoke to demonstrated a good understanding of the challenges their services faced and were able to describe plans to address them.

Leaders and managers in the service had access to leadership and development training. Senior managers were supported by the wider organisation, such as by finance, human resources and facilities.

Staff we spoke with knew who their Freedom to Speak up Guardian was and felt they could raise any concerns with them without fear of reprisal. Although staff felt confident raising concerns, some staff did not feel confident that action would be taken by hospital management .

The provider had a Freedom to Speak Up (FTSU) and whistleblowing policy. Staff could contact the Freedom to Speak Up Guardian, or the local FTSU champion. The FTSU Guardian had visited the service.

The provider carried out an annual staff survey. The response rate for this service was 68%, and confirmed staff were aware of the FTSU Guardian. Managers created an action plan following this survey to address key areas.

Not all staff were aware of any equality and diversity champions at the hospital . Staff could apply for flexible working arrangements, within the scope of working in an inpatient service.

Cygnet has staff networks for equality, inclusion and diversity; a multicultural network; an LGBTQ+ network; a women’s network; and a disability network. These were accessible to all staff, and were included in the corporate induction workbook.

Staff we spoke with understood their roles and responsibilities. They were able to describe how different roles and professions within the multidisciplinary team worked together to deliver care and treatment.

Managers we spoke with were able to describe the governance and reporting structure at ward and hospital level as well as the quality and assurance processes in place with commissioning bodies. Staff we spoke with knew how to raise concerns and reported that they received feedback when they submitted incidents. They told us they felt empowered to make suggestion for improvement .

Managers led a monthly governance meeting where information about the service was monitored and discussed. Managers implemented the provider’s annual audit schedule, and reported and took action from the findings in the monthly governance meeting. Actions from previous meetings were followed-up, and there was feedback into and from the regional and corporate governance process. This showed that action was taken in response to concerns, or where improvement was required.

Managers maintained a risk register for the hospital. This identified potential risks to within the service, and actions that had been or needed to be taken to remove or mitigate against them. This was a live document, and included previous risks that had now been removed.

Staff had access to a suite of policies, procedures and operational guidance to support them in the delivery of care. Staff could access further support from hospital and provider level teams and specialists where required.

We did not ask patients specific questions around partnerships and communities. However, none of the patients we spoke with raised concerns in this regard. Patients we spoke with did talk about using leave to access the local community and community facilities.

Managers described positive relationships with key external stakeholders including commissioning bodies. Staff were knowledgeable about local support services.

The local host commissioners requested feedback from commissioners for each patient on the ward, in order to any identify any themes and trends, or areas of positive or concerning practice. The hospital managers and local host commissioners met every 3 months, and reviewed information submitted by the managers. No issues were raised about this quality statement.

Beds were block booked and access was managed through arrangements with NHS trusts. There were appropriate governance and reporting structures in place to support effective monitoring of quality and performance.

All staff we spoke with were up to date with their mandatory training. Staff were able to access additional training that was relevant to their role if they wished.

Learning from incidents was disseminated to staff within morning meetings and via email.

The provider had a corporate quality improvement (QI) handbook. The handbook clearly described how to carry out a QI project, using recognised approaches.

The service had focused on learning form incidents to improve care for patents.