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 good. At this assessment the rating has remained good.

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

At our last assessment we rated well-led as good. At this assessment the rating has remained good. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff mostly felt respected, supported and valued. Performance and risk were mostly managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

However, governance processes did not always operate effectively and audits did not always identify concerns in relation to environmental risk.

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 scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they applied to the work of their team. For example, staff could tell us about the 5 core values and told us they discussed these in supervision and during reflective practice. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The service’s values were incorporated into interview questions and discussed during staff appraisals and the service’s vision was shared through weekly email communications.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff told us this was discussed in team meetings and was reflected in the meeting minutes.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. There was evidence of leaders undertaking continuous professional development including quarterly continuous professional development for ward managers and clinical service managers, and registered managers taking part in the quarterly hospital managers development programme.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. The service operated a management visibility programme in order to maintain high standards of care, this included weekly walkabouts, nightly drop-ins and monthly drop-in sessions.

Leaders were visible in the service and approachable for young people and staff. Staff told us that leaders were present on the wards, supportive and had an open-door policy. Staff felt able to speak to leaders regarding any concerns they had.

Leadership development opportunities were available, including opportunities for staff.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a freedom to speak up guardian and staff were aware of this. Staff felt they could raise concerns and that these would be taken seriously. The service had a monthly staff forum and nurses meeting.

Young people and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. For example, there was a service user satisfaction survey, patient discharge surveys and carer and service user action plans based on feedback from young people and carers. Proposed actions from feedback included introducing enhanced de-escalation training and new buddy system to help young people feel safer on the ward and reviewing menus and catering options in response to concerns about food.

Managers and staff had access to the feedback from young people, carers and staff and used it to make improvements. For example, a plan was in place to delegate protected named nurse time in response to concerns that staff were busy and that contact with named nurses was sometimes inconsistent.

Young people and carers were involved in decision-making about changes to the service. Young people and staff could meet with members of the provider’s senior leadership team and governors to give feedback. Staff told us there was an open-door policy and felt they could raise concerns with members of the leadership team.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were a range of networks in the organisation including a multicultural network, a disability network, a carers network and an LGBTQ+ network. There were champions on the wards who helped arrange events such as a silent disco to support LGBTQ+ young people and staff events such as a football tournament.

Staff were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. Managers mostly put reasonable adjustments in place for staff members to help them carry out their role. However, staff raised concerns about the processes in place to support them when they had received a work-related injury.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability. They mostly acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Governance meetings were thorough and detailed, and staff reviewed individual issues and themes and trends.

Staff had implemented recommendations from reviews of incidents and safeguarding alerts at the service level. For example, staff received extra training following incidents where young people had self harmed by swallowing items on the ward and bendy pens were used on one of the wards following an incident where a young person had swallowed a pen. Incidents across the Cygnet services were discussed in meetings and learning was shared with staff.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Staff carried out a range of audits including record keeping audits, Mental Health Act audits, audits of the environment and medicines audits. However, environmental audits were not always effective and they did not identify some of the concerns we identified during inspection.

Staff understood the arrangements for working with other teams, both within the provider and externally, to meet the needs of the young people. For example, staff worked closely with education staff and with safeguarding where this was required. Governance meetings included a range of staff including the head of occupational therapy, the head teacher at the onsite school, the lead social worker and experts by experience.

The service did not always have effective systems in place for managing risk. Some environmental risks such as blind spots, and environmental risks had not been identified or mitigated and there were concerns about the monitoring of rapid tranquilisation.

Managers dealt with concerns about performance promptly and took disciplinary action if required.

Staff maintained and had access to the risk register. The risk register was up to date and contained actions to reduce risks identified. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register.

The service had plans for emergencies. For example, there was a business continuity plan in place which was shared with staff during team meetings.

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. Systems included password protection and privacy screens and there were systems to ensure staff shared information in line with information governance.

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. This was reviewed regularly and discussed at governance meetings. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Directorate leaders engaged with external stakeholders – such as commissioners and safeguarding. We received positive feedback from stakeholders, who told us that staff worked closely with them, investigated concerns thoroughly and shared feedback with services. Commissioners told us staff worked collaboratively with them and that communication was positive.

Young people and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. For example, young people could provide feedback through the people’s council, and experts by experience represented young people’s voices in governance meetings.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff were given the time and support to explore opportunities for improvements and innovation and this led to changes. Nurses were involved in continuous professional development and the occupational therapy team had carried out a project to streamline their assessments and to embed sensory pathways into the service.

Staff had opportunities to participate in research. For example, one of the consultants was involved in research looking at how beneficial it was for young people with specific disorders to be in hospital.

Innovations were taking place in the service. For example, the service had switched to using silent alarms which helped reduce noise levels that could be distressing for young people.

Staff used quality improvement methods and knew how to apply them. For example, Mulberry ward carried out a quality improvement project around reducing restrictive practice and this resulted in a reduction in incidents on the ward.

Wards participated in accreditation schemes relevant to the service and learned from them. For example, the Forestwood school received accreditation by the National Autistic Society, and the hospital received triangle of care accreditation, which meant they had demonstrated a commitment to making a difference to the lives of carers.