Cygnet Hospital Woking

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

However, we found the provider to be in breach of Regulation 17, Good governance.

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 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 focussed on supporting staff wellbeing and ensuring everyone promoted a culture of good practice, good quality, and safe care and treatment. Staff we spoke with told us they had the opportunity to contribute to discussions about changes within the hospital.

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, openness and honesty.

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 seasonal events. Staff felt the service was well managed.

Senior staff appeared proactive and responded quickly when areas of improvements were identified. Leaders recognised success and celebrated their staff.

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

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 had opportunities to give feedback on the service they received. For example, through community meetings, one-to-ones with staff and the complaints form. 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. However, patients did say they would like more frequent surveys carried out to give more regular feedback.

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.

The provider valued diversity in the workforce and had several initiatives to promote an inclusive and fair culture for their staff. Staff were able to access several staff networks through the wider provider. These included LGBTQ+ network, disability network and a multicultural network.

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.

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.

Findings from the other key questions demonstrated that most localised governance processes were effective in identifying issues and driving improvement. However, we found a small number of areas where further work was needed and where the services internal governance processes had not identified the concerns we found during the inspection.

The service’s governance and assurance processes had not identified that medicines were not always managed in line with national guidance or legislation. Staff told us medicines were routinely supplied for patients on leave by on ward dispensing. Patients own prescribed medicines and stock medicines were not always stored separately. This had been previously highlighted internally; however, it was unclear what actions had been taken to reduce risk. The service did not always record which rapid tranquilisation medicine was first line when multiple medicines were prescribed. We saw medicines were generally administered in line with Mental Health Act consent to treatment authorisations. We reviewed 10 records and saw that one consent to treatment forms did not reflect the persons current medication.

The service’s quality improvement processes had not identified that certain aspects of the ward environments needed attention and repair in respect of cleanliness and maintenance. They also had not identified the blind spots in the patients’ bedrooms.

However, 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 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 hospital had a business continuity recovery plan in place. They had plans for emergency situations, such as, a loss of electricity, a fire or water leakages.

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.

The service worked well with other agencies including the local NHS Trust and health and social care professionals involved in patient’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.

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.

There was a quality improvement plan in place that contained a range of recommendations and actions to improve areas, including clinical governance, learning and development, compliance, safeguarding, and incidents. There were also actions in place to improve clinical practice.

There were opportunities for patients to contribute and be part of the clinical governance meetings. There was also a patient’s council which met regularly to discuss issues about the hospital.

The provider had a green energy initiative in place for all Cygnet services. Their goal was to become a net zero company by 2040. The provider plan was to implement electric vehicles, solar panels, energy efficient lighting upgrades and increase their recycling.