Cygnet Sherwood House and Cygnet Hospital Sherwood

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

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 changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of regulation 17 for 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.

The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider’s senior management team communicated the provider’s vision and values to the frontline staff in this service.

The provider’s five core values were:

Care – Listening to and caring for others

Respect – Treating patients fairly and understanding the value of diversity

Empower – Giving patients the power to make informed decisions

Trust – Building and maintaining trust

Integrity – Being trustworthy, fair and ethical.

Most staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

However, not all staff consistently demonstrated the provider’s five core values. During our inspection, we observed staff smoking in the garden with patients, which did not align with the service’s policy or the provider’s values of integrity, trust, empower, respect, and care. This behaviour indicated that some staff were not fully embedding these values into their practice.

Not all managers understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Managers did not always lead effectively.

Managers did not always lead effectively. Although managers were keen to develop, we observed them struggling to meet the demands of their positions. The hospital manager acknowledged that staff had found it difficult to adjust to their management style. Staff told us that managers were not always visible, and they did not feel supported by managers during a recent incident involving illicit drug use on the ward, and several reported low morale, with one staff member stating they had “never known morale to be so low.” We found that staff were not routinely rotated between night and day shifts. This lack of rotation can lead to staff working in isolation for extended periods, reducing opportunities for team integration and oversight. This practice increased the risk of a closed culture developing, where poor practices may go unchallenged. Managers delivered clinical supervision in a group setting but failed to recognise the impact this might have on staff who were less confident speaking in a group. Although individual supervision was available, managers did not consider how this might make staff feel singled out. We saw evidence of staff experiencing stress, burnout, and staffing challenges. We saw evidence that nursing staff did not always feel involved in decision-making on the unit and did not always feel valued.

However, managers had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care, but some acknowledged that the majority of their previous experience had not been within a rehabilitation setting.

Staff did not always feel they could speak up and that their voice would be heard.

Managers accessed feedback from staff and stakeholders through various channels, including meetings and surveys. However, we found limited evidence that they consistently acted on this feedback to drive improvements. Concerns regarding the height of the fence in the back garden were discussed during staff supervision meetings and acknowledged as a concern by the ICB, however, managers had failed to act on these concerns in a timely manner.

However, staff raised concerns without fear of reprisals. They accessed the provider’s whistleblowing policy and information about the Freedom to Speak Up Guardian through the intranet. The service had a Freedom to Speak Up Guardian who supported staff in raising concerns.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for patients 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 diverse 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 service did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance, and outcomes.

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 was shared and discussed. This included discussion of complaints at local and regional clinical governance meetings. However, staff meeting agendas did not include standard items on complaints, which limited opportunities for managers to review and learn from them in a structured way with all staff. Managers shared some information through the lessons learned bulletin, but this approach lacked consistency and visibility. Without a formal process to discuss complaints directly with all staff regularly, the service limited opportunities to identify trends, share learning, and implement improvements at ward level. This reduced assurance that feedback and complaints were driving meaningful change across the service.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. However, staff and managers did not always take appropriate action following incidents to prevent recurrence. Our review of the local risk register showed that some risks identified in 2023 remained unresolved. For example, the management of risk items was added to the register in 2023, yet during our assessment we found no system for signing items in and out of the ward. Managers told us the risk remained on the register to maintain them as a priority for staff.

Clinical governance minutes from April 2025 showed that managers were aware most incidents involved illicit substances and noted that security on the unit was “possibly getting worse.”” The minutes noted that managers had discussed several ways to manage these difficulties and acknowledged that the service would “benefit from having more substances interventions at the service”. However, security and illicit drug use incidents continued to take place which indicated that managers were not effectively addressing known risks which compromised patient safety and staff confidence in governance processes.

Staff undertook and participated in local clinical audits, including ligature and blind spot audits. Despite these processes, we identified blind spots in the patient garden and fairy lights on the back fence that posed a ligature risk. These hazards had not been captured in the ligature audit, which indicated that audits were not always robust or effective in identifying environmental risks. Leaders at the service were not aware of all risks identified by the inspection team.

However, staff understood the arrangements for working with other teams within the provider and with external partners to meet patients’ needs, and records showed external teams were involved in patient reviews. The service maintained plans for emergencies, including adverse weather and flu outbreaks. Staff accessed the equipment and information technology they needed to carry out their work effectively. The IT infrastructure, including the telephone system, operated reliably and supported improvements in the quality of care.

Managers implemented information governance systems that protected the confidentiality of patient records. Managers accessed information to support their management responsibilities, including data on service performance, staffing, and patient care. Information was timely, accurate, and presented in an accessible format, which helped identify areas for improvement.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for patients. They shared information and learning with partners and collaborated for improvement.

Directorate managers engaged with external stakeholders such as commissioners and Healthwatch.

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

Staff made notifications to external bodies when required, and we saw examples where the service had notified CQC appropriately.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We were not assured that effective governance and oversight existed for risk management and learning from incidents. We found evidence that learning from incidents was not consistently acted upon, and repeated incidents were raised during supervision and staff team meetings.

However, staff participated in accreditation schemes, including the ‘Triangle of Care’, a framework that promotes collaborative care in mental health services by involving carers as equal partners alongside patients and staff. The provider demonstrated its commitment to supporting carers and improving their experience through this initiative.

Staff had time and support to identify opportunities for improvement during daily huddles, team meetings, appraisals, and supervision sessions.

The hospital participated in research and national audits and used the findings to improve services. The hospital manager told us, “The MDT and the doctor are very engaged. We review things in governance, and the psychologist looks at national guidance for the NHS and wider health and care system. We are in the final part of AIMS accreditation. The doctor recently conducted a study tracking patients after discharge to learn about the continuation of therapies and their impact.”

Meeting minutes from community, team, and governance meetings showed that continuous improvement initiatives were discussed within governance structures, ensuring all staff were aware of projects, accreditation, audits, and research and had opportunities to participate.