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 is the first assessment for this newly registered service. This key question has been rated good. This meant the service was consistently managed and well-led. 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. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements. Overall, governance processes operated effectively; however, management needed to improve some areas of risk management.

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 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 patients and their communities.

Leaders clearly communicated the provider’s vision and values to frontline staff. The provider developed a 5-year strategy from 2022-2027. The provider’s ambition was to provide outstanding services. 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. Staff understood these values and applied them consistently in their daily work. They contributed to discussions about the service’s strategy through regular team meetings.

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding. Cygnet’s mission was to deliver compassionate care and a positive culture by making sure staff had good days at work. Staff we spoke to told us that leaders made sure staff felt valued and knew that they mattered. Leaders promoted a culture of speaking up and safety. Staff were encouraged to constructively challenge each other by being open and honest and raising concerns. Most staff we spoke to confirmed that leaders were visible on the wards and fostered an open-door policy.

The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered 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.

Most staff said that leaders had the necessary skills, knowledge, and experience to effectively lead and manage their team. They had a good understanding of the service they managed and were able to explain how the team worked together to provide care to their patients. When we raised concerns during the inspection, leaders acted immediately to ensure that mitigations were put in place to reduce risk.

We spoke with 13 members of staff, most felt that leaders were visible, supportive and approachable for patients and staff. One staff member said that senior leaders in the hospital were “highly knowledgeable, transparent, nothing is too much trouble”.

However, some staff reported limited support from senior leaders, particularly when the wards were busy. While ward managers provided day-to-day support, some staff said senior leaders, including the hospital director and head of care, were not consistently visible on the wards.

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.

The provider maintained a clear Freedom to Speak Up policy and visible systems to support staff in raising concerns. An active Freedom to Speak Up team provided guidance and reassurance.

Staff felt that they could speak up if something was not going well and there were opportunities to discuss any issues and provide suggestions for improvements to the service.

We found that when concerns were raised, leaders acted promptly. They investigated issues sensitively and confidentially, and they ensured that learning was shared and used to improve the service.

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.

Leaders actively reviewed and improved the organisation’s culture in relation to equality, diversity and inclusion. The provider implemented a comprehensive Equality and Diversity policy and supported staff through a range of networks, such as multicultural and women’s groups, which promoted inclusion.

Managers enabled flexible working and made reasonable adjustments to support staff in their roles. The workforce reflected diverse backgrounds and the needs of the patient group, and the service monitored equality through the Workforce Race Equality Standard (WRES).

Staff reported fair treatment, did not raise concerns about discrimination, and felt supported with opportunities for personal and professional development.

The evidence showed significant shortfalls. The service did not always act on the best information about risk or share this securely with others when appropriate.

Governance processes did not always identify or address areas of concern. We found gaps in patient risk management and were not assured that risk items were always managed safely. The ward did not have clear procedural documentation and guidance for managing restricted, prohibited or ‘contraband’ items. This meant staff did not have consistent direction on how to manage these items safely. Leaders later informed us that documentation and guidance were strengthened following the inspection.

Documentation for the safe management of controlled drugs were not robust. Although all medicines were accounted for, records on Fern and Bramble wards were inconsistently completed. PRN medication documentation lacked sufficient space for staff to record enough detail, increasing the risk of unsafe administration.

However, leaders and staff used a clear framework to guide discussions at ward, team and directorate meetings, ensuring essential information, including learning from incidents and complaints, was shared.

Staff undertook and participated in local clinical audits in line with the provider’s policy and staff maintained and had access to a risk register, and they were able to escalate concerns when required.

Staff also had access to the equipment and information technology needed to carry out their duties. The information technology infrastructure functioned effectively and supported improvements in the quality of care. Information governance systems were in place and ensured the confidentiality of patient records.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They share information and learning with partners and collaborate for improvement.

The service worked effectively in partnership with a range of agencies, including health and social care professionals. Multidisciplinary collaboration was embedded in practice, with ward rounds involving community mental health care coordinators and external partners such as police, probation and social workers to support coordinated care and risk management.

Staff and leaders engaged with the local Multi-Agency Safeguarding Hub (MASH), attending monthly meetings to review incidents and escalate concerns appropriately.

The service actively sought and used patient feedback to improve practice. Feedback gathered at discharge informed initiatives such as the “Farewell Ferns” display, demonstrating a commitment to involving people and learning from their experiences.

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 patients. They actively contribute to safe, effective practice and research.

Staff and leaders demonstrated a strong understanding of how to drive improvement, using a consistent approach that included measuring outcomes and evaluating impact. The service actively participated in research and clinical audits and used findings to deliver meaningful improvements.

Doctors at the service engaged in research, including initiatives such as ‘Reducing Excessive Weight Gain in Inpatient Mental Health Services: A Quality Improvement Initiative’, supporting evidence-based practice.

The service used clinical audit results to drive rapid improvement. For example, when Fern ward identified a drop in NEWS2 audit compliance, the ward manager conducted a detailed review, identified specific issues and staff responsible, and addressed these through individual meetings, supervision, and clear expectations. This resulted in a significant improvement, with compliance increasing to over 90% within one month.

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. Staff told us managers encouraged and supported their professional development.

The service actively participated in relevant accreditation schemes, including AIMS (Accreditation for Inpatient Mental Health Services) and QNPICU (Quality Network for Psychiatric Intensive Care Units), both run by the Royal College of Psychiatrists, and used these frameworks to drive quality improvement. Ward managers introduced weekly drop-in sessions, enabling patients to raise concerns and share feedback.

Leaders recognised an increase in patients with complex physical health needs being admitted to the service and responded by introducing targeted improvements. They appointed a dedicated physical health nurse and implemented on-site diagnostic equipment, including a portable ECG machine and a blood analysis machine, to enhance assessment and enable timely lab testing.