Cygnet Aspen Clinic

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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 as requires improvement. The service was in breach of legal regulation in relation to regulation 17 (good governance). The service had made improvements and was no longer in breach of regulations. The service has good local governance processes that feed into the regional and corporate governance structure. At this assessment the rating has changed to good. This meant the service was consistently managed and well led. Leaders and the culture they created promoted high-quality, person-centred care.

The service had a clear model of care that was shared with staff and patients. The service was engaged in national initiatives to improve care and support for patients and carers.

Managers were experienced and had a good understanding of the service and a clear overview of service performance. They were able to describe risks and challenges the service faced as well as actions to address them.

Staff knew who the managers were and felt able to approach them.

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 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 knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider had stated organisational values, vision, purpose and mission. The organisation’s values were integrity, trust, empowerment, respect and care. Staff told us that these were reflected in the work they did with patients. These were described and discussed as part of the staff induction programme, and were integrated into the appraisal system.

Staff had the opportunity to contribute to discussions about the strategy for their service. This included in staff meetings, daily handovers and multidisciplinary team meetings.

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.

Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Local managers were experienced, and had worked in the service for several years. They developed plans and made improvements to the service. Managers met with other Cygnet Healthcare services, and shared information and learning. They had support from other central departments when necessary, such as human resources. They participated in the daily morning meetings, that ensured patients’ care was reviewed and discussed, and that action was taken. Managers had pushed to ensure that improvements were made within the service, such as making the environment safer and more suitable for patients.

Leaders were visible in the service and approachable for patients and staff. Patients, staff and outside organisations such as advocacy told us that they felt able to raise concerns with the managers, and that they were generally responsive. Patients knew who the local managers were and felt able to approach them directly if they had concerns. Staff were aware of senior managers, who periodically visited the service.

Leadership development opportunities were available, including opportunities for staff. Regional governance meetings monitored the uptake of attendance at the organisation’s leadership and development programme, which local managers had completed.

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

The provider had a policy describing how staff could raise concerns, and affirming that they were protected in doing this. The provider had an executive lead for Freedom to Speak Up (FTSU) and a FTSU guardian, who were responsible for implementing, overseeing and reviewing FTSU or whistleblowing across the organisations. At service level, the manager was responsible for the implementation of the policy, but there was also a local FTSU ambassador who staff could approach directly if they had concerns. Contact details and information about the process was on display in the service, and available on the staff intranet.

Staff knew how to raise concerns and felt able to do so. Most staff told us they felt able to speak out and raise their concerns, and felt that they were listened to, even if they did not always get the outcome they wanted. Managers had not had any concerns raised with them through the FTSU process. However, they said staff approached them directly with concerns or issues, and they responded to these.

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.

Most staff are aware that there are equality and diversity networks within the wider organisation. This included the equity, inclusion and diversity network, multicultural network, women’s network, LGBTQ+ network and the disability network. Information about these networks was included on induction. The most recent staff survey findings are from February to April 2024 (the findings of the most recent staff survey are yet to be published). There were 57 responses, which was 93% of staff. Of these staff, from 77% to 88% were aware of each of the networks. 7% of staff responded that they were not aware of any of them. 91% of staff felt that the organisation recognised the challenges and inequalities faced by people due to their protected characteristics. 89% felt that the organisation acted fairly with regards to suspensions and disciplinary procedures regardless of protected characteristics.

Staff are able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues.

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.

The provider had a clear governance process that ensured information was shared from ward level up to the board. Meetings took place at set time periods so they could feed into one another. The service had a monthly governance meeting which fed into the quarterly regional meeting which fed into the corporate clinical governance committee and to the Board. The local governance meetings were comprehensive and had a set agenda that included safety, training and education, clinical effectiveness, patient and carer experience, leadership and lessons learned. This included a detailed review of all incidents.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. This included changes to the physical environment, and to practice within the service.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. They included audits of care records, cleaning and infection control, and medicines.

Managers had access to the risk register at hospital level, and could make recommendations to add items to it. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register.

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.

Team 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. Managers could access their line managers, in addition to support from human resources and finance.

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 hospital provided a specialist service, so patients were admitted from across England and Wales, and were often not from the local area.

Managers and staff shared information with commissioners, who were routinely involved in reviewing patient’s care and progress. Commissioners were positive about their engagement with the service, and did not raise any significant concerns. Although it was ultimately the commissioner’s choice to place patients in the service, they noted that it could be challenging to support patients to visit relatives or potential placements, because of the geographical distance between the service and the patient’s home area. However, patients were still supported to keep in touch with relatives and go on visits.

Managers and staff worked with other services, both within Cygnet Healthcare and in the broader community, to share information and learning. This included working with other healthcare services, and patient support groups such as advocacy and experts by experience.

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.

Staff used quality improvement methods and knew how to apply them. The service had achieved ‘Triangle of Care’ level 1 accreditation from the Carers Trust, which is a charity that promotes support for unpaid carers.

‘Enabling environments’ is a network established by the Royal College of Psychiatrists (RCP) to support services to create positive psycho-social environments. The service was in the initial process of information gathering and auditing, with a view to ultimately meeting all ten standards following the submission of evidence and independent assessment through the network.