Cygnet Hospital Derby

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

Well led- 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.

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

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.

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.

Staff knew and understood the provider’s vision and values and could describe how they applied them in their day-to-day work. The provider’s purpose, vision, and mission – to deliver safe, compassionate care within a culture of openness, honesty, and inclusivity – were clearly communicated and visible across the service. Managers explained that these values were initially shaped with input from both patients and staff and that they are embedded into recruitment, training, supervision, and decision-making about disciplinary matters.

Senior leaders promoted an open culture with a clear emphasis on equality, diversity, and inclusion (EDI). Staff described a strong “diversity push” across Cygnet, supported by a range of staff groups and forums. They provided examples of empowering service users, such as involving them in staff interviews, training sessions, formulation meetings, and ward forums. These initiatives helped staff, particularly HCAs and clinical teams, better understand patient journeys, pathways into services, and how to interact respectfully and meaningfully with people.

Staff had opportunities to contribute to discussions about the strategy for their service.

Managers shared updates through monthly newsletters and ward round summaries, ensuring all staff were kept informed. Both clinical and non-clinical staff benefited from tailored training packages to ensure they understood the ward environment and patient needs.

Staff reported that they felt empowered to request resources and had not experienced requests being declined when these improved quality of life for patients. They also reflected that they understood the need to balance delivering high-quality care with available budgets, though this did not act as a barrier to innovation or improvement.

Leaders at all levels demonstrated the skills, knowledge, and experience needed to perform their roles effectively. They understood the services they managed and could clearly explain how teams were delivering safe, high-quality care.

Leaders remained visible on the wards and approachable to both staff and patients. Staff reported that leaders maintained an open and transparent culture, where concerns could be raised without fear. Ward round summaries were shared with all staff to keep everyone informed.

The provider’s vision and values were clearly communicated and embedded into daily practice.

Leaders promoted an inclusive culture rooted in openness, equity, diversity, and respect. Service users and staff actively shaped the service through participation in interviews, training, formulation meetings, and people’s councils.

Leadership development opportunities were available to staff. Staff received support to develop their skills, and non-clinical staff were offered additional training to build understanding of the ward environment.

Leaders were supported to develop their leadership and management skills through development programmes and Cygnet apprenticeship pathways.

Managers highlighted that requests to improve the quality of people’s lives had never been declined, even when these required additional resources.

The service fostered a positive and open culture where patients, carers, and staff were encouraged to speak up and their voices were heard.

Patients had several opportunities to provide feedback in ways that suited their needs. They could raise concerns directly with staff, contribute to regular community meetings, and share views through ward representatives and the people’s council. Patients told us they were supported to raise concerns, felt listened to, and received feedback on outcomes that were generally positive and communicated back to them.

The service provided a clear framework to support staff to speak up. A Freedom to Speak Up policy was available, and posters displayed across the hospital outlined how to access the service. A designated Freedom to Speak Up Guardian provided confidential advice and support to staff who wanted to raise concerns.

Staff reported that they felt confident raising issues without fear of reprisal. Managers promoted openness and transparency and acted with integrity when concerns arose. Leaders investigated sensitively and shared learning to drive improvement.

The provider ensured escalation routes were available beyond the local service. Staff and patients had opportunities to meet with senior leaders during visits, further strengthening the culture of openness.

When things went wrong, leaders demonstrated honesty and transparency. Staff reported that patients received timely explanations and apologies where appropriate, along with information about actions taken to prevent recurrence.

Managers supported flexible working arrangements for staff to accommodate caring responsibilities, health needs, or other personal circumstances. They put reasonable adjustments in place to help staff carry out their roles effectively. Leaders ensured they were inclusive of their workforce cultural beliefs and adjusted shift patterns and hours to accommodate them.

The provider monitored workforce equality through formal mechanisms, including the

Workforce Race Equality Standard (WRES) and the Workforce Disability Equality Standard (WDES). The organisation maintained a Workforce Strategic Plan covering equality, diversity, inclusion, and workforce development and published a Gender Pay Gap Report.

Staff accessed structured development and progression opportunities, including apprenticeships, nursing and occupational therapy pathways, preceptorships, and senior staff nurse development plans.

Staff shared their views through a Staff Relations Group (SRG), which facilitated communication, feedback, involvement in policy decisions, and team morale initiatives. Staff reported that the group effectively gave them a voice.

These measures demonstrated that the service actively monitored and supported workforce equality, diversity, and inclusion, and provided staff with opportunities to progress and be represented within the organisation.

The service established clear responsibilities, roles, systems of accountability, and governance arrangements.

A risk register was in place. The identified risks were aligned to quality improvements service plans and regulatory improvement service plans. Leaders reviewed these plans every 3 months to monitor compliance and service improvements. Staff accessed the risk register and escalated concerns to senior leaders. Staff raised concerns were recorded on the risk register.

The service implemented a clear framework for ward and team meetings to ensure essential information was shared and discussed. Staff reviewed and analysed mortality data, incidents, complaints, and safeguarding alerts in regular meetings, and implemented recommendations at the service level. Staff participated in local clinical audits and acted on the results where needed.

One to one named nurse sessions were audited to ensure that staff were complaint with providing one to one time with patients. Outcomes of the audits were discussed in monthly clinical governance meetings and individual supervision to ensure compliance.

Patient in Care Race Equality Framework (PCREF) was in place. Monthly meetings were held with the PCREF leads. These meetings fed into the bimonthly PCREF leadership team who over saw the hospital wide PCREF action plan.

Staff completed a closed culture audit and scored 88%. This indicated notable good practice. Although there were some areas that needed to be addressed to avoid closed cultures. It was evident that leaders had identified the required actions they needed to take.

Staff understood arrangements for collaborating with other teams within the provider and externally to meet patient needs. Senior leaders worked collaboratively with senior leaders from other secure hospitals in order to meet the statutory requirement to complete external reviews of seclusion and long-term segregation as outlined in the Mental Health Code of Practice.

Concerns had been raised about the application of the national early warning signs score 2 (NEWS2) by commissioners. Leaders responded by supporting staff with additional training and competency assessments. Staff audit the application of the NEWS2 and found that improvements had been made.

The service maintained emergency plans for adverse weather, flu outbreaks, and other contingencies. Staff ensured that cost improvements did not compromise patient care.

The service collected data from wards and other Cygnet hospitals using systems that did not burden frontline staff. Staff accessed the equipment and information technology necessary to do their work. Information governance systems protected the confidentiality of patient records.

Senior leaders and team managers accessed timely, accurate, and easily understandable information on service performance, staffing, and patient care, enabling them to identify areas for improvement.

Staff and leaders were open and transparent and collaborated with relevant external stakeholders and agencies. Staff worked in partnership with external stakeholders and commissioners to support to patients whilst they were receiving care and planning for discharge. In addition, they worked in partnership with key organisations to support care provision, service development, and joined-up care.

Patients and staff had opportunities to meet with members of the provider’s senior leadership team and commissioners to provide feedback.

Staff and leaders engaged with patients, communities, and partners to share learning that resulted in continuous improvements to the service. They used these networks to identify new or innovative ideas that could lead to better outcomes for people.

The service maintained a strong focus on continuous learning, improvement, and innovation across all areas. Staff developed and implemented innovative projects, leading to tangible improvements in patient care and outcomes. For example, a Quality Improvement project introduced a point-of-care device for finger-prick blood testing, reduced invasive procedures, and enabled timely treatment for patients on Clozapine. The device will be shared across the region, demonstrating the service’s commitment to system-wide innovation.

Trauma Informed Care (TIC) was embedded across the service, with a multidisciplinary group meeting monthly to review practices against TIC principles. This resulted in actions such as cofacilitating training and formulation meetings with service users, revising ward round request forms, developing Trauma Signature Booklets, and creating culturally and spiritually inclusive care plans. These initiatives improved patient experience, reduced restrictive practices, and strengthened therapeutic relationships. Staff delivered formulation sessions in collaboration with a psychology member of staff and patients. Patients were invited to help develop a presentation highlighting aspects of their childhood and life that they feel are important in telling their story.

The service implemented innovative approaches to carer involvement, including a monthly carers clinic, carer welcome packs, and an annual carers BBQ, enabling carers to actively contribute to care planning and patient recovery. Home assessments facilitated safe and supported home leave, while physical health meetings and tracking spreadsheets ensured timely access to national screening programs, improving equity of care for patients with mental health challenges.

Innovations extended to risk reduction and restrictive practice management. The co-produced RRP working group implemented hospital-wide changes, including adjustments to Section 17 leave, ward access, environmental checks, and unsupervised activities, reducing restrictions while maintaining safety. Safe wards and trauma-informed strategies were integrated to further enhance patient care.

Leadership actively supported continuous improvement through developing structured tools, including named nurse paperwork trackers, nurse-in-charge checklists, and the creation of a forensic database to ensure accurate information sharing and effective multidisciplinary decision-making.

The service participated in national research and preceptorship programs, including the INTERFACE project and studies on staff attitudes towards personality disorders, ensuring learning from external sources informed local practice. Accreditation from the Royal College of Psychiatrists for Alvaston Ward further demonstrates the service’s commitment to high-quality care, with teams sharing best practice nationally.

These initiatives demonstrated a culture of proactive learning, innovation, and improvement, with staff empowered to test new approaches, apply research findings, and implement best practice, resulting in safer, more effective, and person-centred care.