Cygnet Victoria 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

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. Some governance processes operated effectively, however, audits were not always effective at identifying issues in the environment or with medication management and showing where action had been taken to rectify concerns. Performance and patient 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 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.

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 felt empowered to speak out about any concerns. Staff were happy, motivated and felt valued.

The provider’s five core values were:

• Care – Listening to and caring for others
• Respect – Treating people fairly and understanding the value of diversity
• Empower – Giving people the power to make informed decisions
• Trust – Building and maintaining trust
• Integrity – Being trustworthy, fair and ethical.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff within the service.

Staff were given opportunities to discuss the strategy of the service and the organisation's core values during team meetings, daily huddles and during supervision and appraisal sessions.

Managers ensured staff completed their required training in relation to equality, diversity and inclusion. At the time of our inspection, 100% of staff within the service had completed their equality, diversity and inclusion and 98.6% of staff had completed Promoting Human Rights training.

We scored the service as 3. The evidence showed a good standard. The service had

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. Managers understood the needs of the patient group and their current health status and spoke with staff and patients on the wards. The registered manager and a clinical manager had a good understanding of the challenges staff faced and oversight of issues and concerns.

Leaders were visible in the service and approachable for patients and staff.

Leadership development opportunities were available, including opportunities for staff not currently in management roles.

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.

Staff were able to raise concerns without fear of reprisals. They knew how to access the provider's whistleblowing policy and information about the freedom to speak up guardian on the intranet. The service had Freedom to Speak Up Guardians, which could be contacted through an email or a button on ‘MyCygnet’.

Managers and staff had access to feedback from patients, carers and staff and used it to make improvements. Patients and carers were involved in decision-making about changes to the service. Patients and staff could meet with members of the provider’s senior leadership team to give feedback.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs such as community meetings, during 1-to-1 time with their named nurse and via the provider’s complaints process.

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.

Staff were able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their role.

There was a mix of staff from different backgrounds and ethnicities on the wards which were representative of the patient group. The provider had various networks championing equality and diversity such as the multicultural network, women’s network, disability network, carers network, LGBT+ network, and an equity, diversity and inclusion group.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. Equality monitoring was undertaken by the provider's human resources team and via recruitment processes.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register. However, documentation did not always clearly show that actions had been taken where environmental audits had identified issues, such as annual checks on water and heating, kitchen appliances, gas and fire safety. We could see audits were done and actions identified, but we could not see these had been rectified. Audits had failed to identify the lack of patient photos in medication administration records and instances where medication had not been administered in line with patient care plans. Audits had also failed to identify out of date stock medications and gaps in clinic room cleaning records. We have raised these concerns within safe environment and medicines optimisation and asked the provider for a plan of action to improve these areas of concern.

The service had plans for emergencies – for example, adverse weather or a flu outbreak.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff.

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. The provider completed an annual Staff Survey to assist them with understanding this. The most recent staff survey had taken place between April and June 2025 and 71% of the staff group had responded to this.

Information was in an accessible format, and was timely, accurate and identified areas for improvement.

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 share information and learning with partners and collaborate for improvement.

We received feedback from the local authority in relation to its relationship with staff within the service. The feedback was positive and stated having an in-house social worker at the hospital worked well in terms of the relationship between the two organisations.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

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.

Staff were given the time and support to for improvements and innovation and this led to changes. Staff had opportunities to participate in research. Innovations were taking place in the service.

The service had recently undertaken a QI project in relation to space utilisation which explored potential changes to the hospital environment and proposed changes which would be beneficial to the patient group and staff team. A list of quick wins was established as well as larger environmental changes which are underway with work due to commence September 2025.

Albert Ward were taking part in the Culture of Care programme, delivered by NHS England and Royal College of Psychiatrists, as part of a learning network with other mental health providers and wards. The programme involved developing change ideas on a ward level, based off staff and patient feedback as well as input from lived experience workers. Several change ideas had been implemented which included anti-racism board, patient welcome packs, sensory room development and a translator pen with new ideas being developed and discussed regularly.

The service had also been recently awarded level 1 accreditation of the triangle of care programme and they were a Member of Quality Network for Psychiatric Intensive Care Units (QNPICU) which supports service and quality improvement through a peer review process and sharing good practice. There were due to be peer reviewed themselves and were undertaking peer review for two other units later this year.