Cygnet Hospital Godden Green

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 Good. At this assessment the rating has remained as Good. 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 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with were aware of the vision, values and strategy of the provider and the service. They told us they thought there was a positive, open culture and they felt respected and valued by their colleagues on the wards and by the managers at the service. They said they worked well together as a team and enjoyed coming to work and felt safe to do so.

The hospital director had a clear vision for what they wanted to achieve at the service and was developing and implementing processes focused on supporting staff wellbeing and ensuring everyone promoted a culture of good practice, good quality, and safe care and treatment.

The service had a diverse workforce and staff we spoke with told us managers promoted a positive work culture, where staff were supported to develop their skills. Managers were open and inclusive; they had regular meetings with staff to listen to their ideas and feedback. Staff said they were well supported by managers with their training and development needs, which made them feel valued. They said managers empowered them to apply for other job opportunities within the service. Staff wellbeing events took place across the year such as coffee mornings and seasonal events. Staff felt the service was well managed.

Leaders said they had an open culture, free from blame or fault and they actively encouraged and supported staff to raise any issues or concerns that they had, either with the leadership team at the service or with those outside of the service. Leaders said they encouraged staff to feedback on areas within the service which they felt may be able to be improved upon either operationally or within patient care. Leaders said raising issues or concerns enabled the organisation to learn lessons which drove improvement and maintained the direction in which they wanted to go. Leaders said they wanted staff to feel comfortable and confident with the provider’s vision, to take ownership and feel involved.

The provider had a whistleblowing (protected disclosure) policy and procedure in place. The policy encouraged staff to raise concerns internally and promoted the value of doing so. The policy signposted staff to external organisations if they felt the need to report concerns outside of the service. This included access to a freedom to speak up guardian to whom they could raise concerns.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The service carried out friends and family surveys to get their feedback. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

Staff were positive about working at the service. They felt they were treated well and equally. The service respected staff with protected characteristics and made efforts to make reasonable adjustments should these be needed.

The service had an ongoing inclusive recruitment programme and had good recruitment processes and ongoing checks to ensure all staff met the legal requirements to work at the service.

The service had clear management and accountability arrangements in place. There were processes to identify, understand, monitor and address current and future risks. Staff we spoke with were able to describe these to us and understood their purpose. There were pathways to enable the service to raise concerns at hospital and provider level. Leaders and senior managers demonstrated a good understanding of the issues and challenges faced by the service.

The service’s governance and assurance processes had not identified medicines audits were not always effective as they had not identified the care plans were not always being followed in respect of patients’ medicines or that Rapid tranquilisation on the wards did not always follow national recommendations for what medicines to use or that physical health checks following the use of rapid tranquilisation were not always being completed appropriately.

The service was involved in a range of projects to improve this including the delivery of co-production sessions by an individual with lived experience. The role of the expert by experience was fully integrated into the provider’s governance processes. The expert by experience visited the hospital regularly, met with patients and helped facilitate community meetings. They met with the hospital director and other managers to give feedback on patients’ experiences. This was then discussed at the provider-wide regional governance meeting. The provider had a ‘lived experience advisory group’ that met four times each year with the Chief Executive and the Director of Nursing.

A series of regular meetings were held which addressed different issues such as key areas of performance, risk, audit, quality and governance. The service submitted performance reports to commissioning bodies and were part of monthly governance and quality contract meetings. Staff undertook or participated in regular audits to ensure quality. Monthly clinical governance and operational governance meeting were held to draw key clinical and operational information together so it could be used to drive improvement at the service, escalate issues and provide assurance to the provider’s senior leaders.

A daily multidisciplinary meeting was held to ensure the service was able to respond to immediate service delivery issues. Good practice was recognised and celebrated throughout the service and wider provider.

The service had a risk register which included items and included a score for the severity of risk for each item, actions being taken to address the risk, including immediate and longer-term mitigation, and timescales for completing those actions

The service worked well with other agencies including the local NHS Trust and health and social care professionals involved in people’s care and the local authority safeguarding team.

Patients we spoke with told us about using leave to access the local community and community facilities.

Managers described positive relationships with key external stakeholders including commissioning bodies.

Staff undertook quality improvement programmes such as a positivity board where messages of support, mindful quotes and compliments from staff to staff were posted to help motivate and support people to have a good day and positive mindset.

The service had created a social hub where patients and staff could go and interact and socialise.

A self-harm framework had been produced, and quick read cards were given to staff so they could reference the help and advice, and they could help patients in times of distress.

Sensory strategies to help support patients when in distress and in seclusion were co-produced. These gave ideas on, what sensory items can be offered to patients, such as listening to music, aromatherapy sprays, sensory lights and cuddle toys and were personalised to a patient’s risk level.

The service focused on learning from incidents to improve care for patients.