Cygnet Bury Forestwood

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• 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

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 assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff we spoke with were able to tell us the values, which were care, trust, integrity, empowerment and respect. These were aligned to supervision and appraisal.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. We saw posters on the walls and nurses, support workers and members of the multi-disciplinary team were familiar with them.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. This included discussion at clinical governance meetings, team meetings, morning meetings and at appraisal and supervision.

Staff could explain how they were working to deliver high quality care within the budgets available. Leaders ensured that there were enough staff available to respond to ward acuity and individual patient need. This also included the provision of equipment as required. Ward managers informed us that new referrals were carefully considered and they did not feel under pressure to accept patients if they were unsure of being able to meet their needs or if there may be a negative impact on existing patients.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, honesty and openness.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Managers and staff were clear about their roles and responsibilities and were highly committed and accountable to patients, colleagues and leaders. There were robust governance processes in place which were embedded into the service, and enabled leaders to effectively manage the service. Managers had a high level of oversight and this was a clear improvement from the previous inspection.

Leaders were visible in the service and approachable for patients and staff. All of the staff that we spoke with knew the names of senior leaders, said that they routinely walked around the wards and that they were friendly and supportive.

Leadership development opportunities were available, including opportunities for staff. Ward managers spoke of a 12-month leadership development program and some support workers had been supported to complete their nurse training.

We create a positive culture where people feel that they can speak up and that their voice will be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Patients attended the monthly People’s Council meeting at which issues were raised and feedback was given on the progress of projects. Restrictive practices were reviewed along with maintenance issues, staff attitudes and any other topics of concern or interest.

Regular feedback was received from carers from various platforms such as meetings, surveys, through the family ambassador service and through face-to-face events. The team ensured that feedback was logged and discussed which helped to implement

change across the service. Cygnet Bury Forestwood had recently been accredited with the Triangle of Care accreditation, developed by the Carers’ Trust, after successfully attending the panel in February 2025.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. For example, staff had purchased individual labelled net laundry bags for washing so that patients’ laundry did not get mixed up or go missing.

Patients and carers were involved in decision-making about changes to the service.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. The service also employed two experts by experience who were previously patients, who visited monthly and provided a report highlighting their findings on patients’ experiences. Examples of these included ensuring consistent service user involvement in Care Programme Approach (CPA)s and ward rounds, enhancing menu variety and dietary choices and increasing Multi-Disciplinary Team presence in community meetings.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

There were equality and diversity champions within the service and a variety of staff networks including Lesbian Gay Bisexual Transgender+, Equity Inclusion and Diversity, Disability and Women’s network. From the most recent staff survey, 82% of staff felt that the service recognised the challenges and inequalities faced by individuals due to their age, disability, gender reassignment, marriage or civil partnership, pregnancy, maternity, race, religion, gender or beliefs. Across the service there were a number of Freedom to Speak Up Guardians whom staff could approach for support.

Staff could apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues.

Staff told us that managers were compassionate and promoted work life balance. Managers put reasonable adjustments in place for staff members to help them carry out their role. This included phased returns after sickness and welfare checks if staff were injured or on long term sick.

The provider undertook equality monitoring of staff within the service to monitor diversity in and representativeness of the patient group.

We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

Teams had well established systems and processes at ward team and senior management level. There were robust governance processes in place which were embedded into the service, and enabled leaders to effectively manage the service. We saw in the minutes of the monthly clinical governance meetings, staff meetings and morning meetings that risk management, learning from incidents and complaints were communicated promptly and actions were taken to improve services and maintain the safety of patients and staff. Managers had a high level of oversight and this was a clear improvement from the previous inspection.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. For example, mouldable play sand was banned on all wards as someone on Primrose ward had used it to block the lock on their door.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. There was liaison with external services such as the local authority, childrens' services and community services and within the ward teams and the onsite school. Teams were collaborative and cohesive and shared a vision and determination to deliver high quality sustainable care.

The organisation had systems and processes in place to manage current and future performance. There was an effective and comprehensive process to identify, understand, monitor and address current issues and future risks. The service reviewed its processes and ensured that staff at all levels had access to the information that they needed. Where challenges arose, leaders dealt with them quickly and effectively.

Staff maintained and had access to the risk register at ward or directorate level. New risks were discussed at the team meetings and ward managers escalated concerns to the clinical services lead and the registered manager. We reviewed the risk register and saw that staff concerns matched those on the risk register.

There were plans in place for emergencies for example, adverse weather conditions or service interruption in the case of failed IT systems.

Where cost improvements were taking place, they did not compromise patient care. Additional staff were provided to cover ward acuity, increased observation levels, medical appointments, staff breaks and training and annual leave.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. Information governance systems included confidentiality of patient records.

Ward managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. We were shown the electronic dashboards which enabled managers to maintain oversight of their ward.

Information was in an accessible format, and was timely, accurate and identified areas for improvement.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

Leaders engaged with external stakeholders such as commissioners and updated them on incidents, information and feedback. They were open and transparent with their communications.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. This took place at People’s council meetings and routinely on the wards, as senior leaders were visible and approachable and encouraged feedback.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. Staff discussed ideas and career development in supervision, appraisal and at team meetings.

Staff had opportunities to participate in research. Ward managers told us that they were involved in research exploring the use of alternative injection sites for intramuscular medication injections. Staff on Primrose ward were doing some research on the length of stay for patients on their ward.

There were a variety of innovations taking place in the service including a garden project to create a therapy garden and installing a trampoline for the young people.

The service was participating in a quality improvement programme for reducing restrictive practice and Mulberry ward staff were undergoing training on the use of safety pods for physical interventions.

Wards participated in accreditation schemes relevant to the service and learned from them. This included use of the Safewards model and participation in the Quality Network for Inpatient CAMHS Standards for Services (QNIC)The service collaborated with other network members to share best practice at a national and international level.