Kneesworth 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

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 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 felt respected, supported and valued. Governance processes operated effectively. Performance and risk were 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.

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

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.

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 were applied in their work. The service had 5 core values. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in the service. The values were displayed in the ward offices.

Leaders ensured staff were connected with the values of the service. Leaders discussed core values with staff in their personal development reviews. Values were considered in quality walk arounds.

Staff described a positive working culture within the service, and spoke highly of their colleagues. They told us they had confidence in their team and trusted their colleagues.

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. Leaders had a good understanding of the services they managed. They were aware of service performance and aware of challenges faced by the service. They collaborated with one another and other staff to develop solutions or mitigations and were supported by management at provider level.

Staff felt supported by managers and told us that they were approachable and engaged well with them. Leaders were visible within the service and had the experience, capacity, capability, and integrity to ensure that the organisational vision could be delivered, and risks were well managed.

Leaders demonstrated a passion for the service and the people who use it. Staff told us one of the service leaders often visited the ward at weekends with activities for the patients and held parties for patients on bank holidays.

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 process if staff wished to raise concerns confidentially. Staff told us they felt they could raise concerns with their managers and that they would be dealt with appropriately. The hospital had 4 freedom to speak up guardians.

Leaders at provider level collected staff feedback. We reviewed the hospital-wide staff survey from April 2025. Staff understood how their work made a difference to patients’ lives and they felt supported by their line managers. However, staff had less confidence in senior leadership. Hospital leaders created an action plan to address the concerns raised by staff. Staff shared feedback at a local level by attending team meetings.

Patients had the opportunity to provide feedback about the service. They knew how to raise concerns and received a response. Staff facilitated regular community meetings on the wards, which were dynamic and gave patients the opportunity to give feedback and receive updates about progress or changes following their feedback.

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.

The provider had a range of equity, diversity and inclusion networks that staff could access. These included an internationally recruited colleagues network, LGBTQ+ network and a race, equality and cultural heritage network which were all open to staff to join.

The service employed a diverse team of staff from international backgrounds. Employment practices promoted equality of opportunity. Staff did not raise any concerns about discrimination.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Meetings at team and management level followed a clear structure to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Clinical governance meetings discussed multiple topics including safeguarding, lessons learned, staffing and health and safety. Actions were documented and detailed how information was shared with the wider staff group. Ward team meetings included topics such as staff morale, ward acuity and boundaries. They also included actions and progress was updated.

Leaders maintained and had access to a comprehensive risk register which included appropriate risks and actions in place to mitigate them. The risks were allocated to an individual and reviewed regularly. Progress was monitored on a regular basis. The risks identified were rated by their severity. Issues raised by staff matched what was on the risk register.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. For example, clinical staff completed audits of mental capacity and high dose antipsychotic monitoring on a regular basis.

Managers had access to information to support them with their management role. This included information on the performance of their wards, staffing and patient care. The electronic system used by the service allowed managers to have access to information such as whether care plans, physical health checks and legal status were up to date. They also had access to information on staff training compliance. Service performance was discussed in clinical governance meetings.

The service had plans for emergencies – for example, adverse weather or an outbreak of illness. The hospital had a business continuity plan in place for all wards. The plans identified the process to be followed in the event of a number of different emergency scenarios.

Staff did not always have access to the information technology needed to do their work. Internet connectivity did not work well in some areas of the hospital which impacted staff being able to complete certain tasks in a timely manner.

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 shared information and learning with partners and collaborated for improvement.

Service leaders engaged with external stakeholders, such as integrated care boards (ICB), local authorities and the police. The acute service had developed a good relationship with an NHS trust that commissioned the service through a block-booking arrangement. Leaders and staff developed and maintained effective working relationships to support patient care and maintain their safety.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. Patient feedback was included in clinical governance meetings which were attended by the senior leadership team. Patient representatives from across the hospital were invited to attend the first part of clinical governance meetings.

Staff told us that when they held lead roles such as a health and safety lead, they had more contact with senior leaders as part of this additional responsibility. Staff told us that senior leaders visited their wards.

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.

The service focussed on continuous learning, innovation and improvement across the organisation. Regular audits, ongoing monitoring and actions drove improvement across the service and the wider hospital.

Leaders had initiatives in place to improve the quality of care plan completion across the hospital. A mentorship programme for staff was also developed. This included a new structure of career progression for healthcare support workers.

Innovations were taking place in the service. The service was involved in a trial of a new screening system for searching patients. It was less invasive and more effective than the current method used. It also benefited patients with a history of trauma as there was less requirement for intrusive searches that could be triggering for some people.

The hospital recently held an awards ceremony celebrating patient achievements. Patients were involved in planning the event and feedback received confirmed patients felt it was a positive event. There was also an awards ceremony that celebrated staff successes.