Cygnet Fountains

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 outstanding. At this assessment the rating has
changed to good. This meant that there were sufficient systems and processes in place to ensure safe
care delivery.

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 patients and our communities.

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

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff spoke about being able to contribute to co-production initiatives, such as a conference, that were ongoing in the service. Staff had access to staff surveys. Recent staff and culture surveys had been conducted that were positive and improving. Action plans had been developed to ensure further improvement. There were network events where shared learning could be discussed and explored with other provider services. Staff could also contribute via discussions directly with the registered manager and via supervision sessions.

Staff could explain how they were working to deliver high quality care within the budgets available. Staff said they endeavoured to give the best care possible.

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. However, there were issues that required improvement that had yet to be fully developed.

Leaders had the skills, knowledge and experience to perform their roles and had a good understanding of the services they managed.

At the time of inspection there were 10 patients clinically ready for discharge who did not have a firm plan for leaving the service. There was a variety of rationales provided for these delays. Managers demonstrated awareness of these issues and took proactive steps to address them, including regular liaison with care managers, commissioners, and the local NHS trust. The service held weekly multidisciplinary discharge meetings and worked collaboratively to progress patients’ rehabilitation and discharge planning.

Leaders were visible in the service and approachable for patients and staff. We observed the registered manager to attend the daily morning meeting which was normal practice. Staff said that the registered manager was approachable and that they were comfortable raising concerns to them.

Leadership development opportunities were available, including opportunities for staff. The registered manager was completing an extended diploma in management to support them in their role.

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

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Patients could give feedback informally to staff and during community meetings and patients council meetings. Patients and carers could also feedback about the service via the complaints process. There had been no carer surveys recently and a small patient survey.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. An outside gym was being considered as part of a coproduction project. Patients were consulted about changes to the environment.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. The regional facilities manager visited the service monthly and the operations director visited every 2 weeks. The Director of nursing visited annually. During these visits, patients and staff were encouraged to discuss any concerns or compliments they wanted to raise.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for patients who work for us.

There were equality and diversity champions and an equality and diversity lead within the service.

Managers made reasonable adjustments for staff members to help them carry out their role. All staff were able to apply for flexible working via 2 requests per year as per policy. There were a number of staff across many disciplines who had applied to work part-time, nights or set shifts. These flexible working agreements were to account for personal circumstances such as caring responsibilities and health issues. All staff could also request to work from home on two occasions per year.

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. The service employed staff of varied ethnic backgrounds to ensure the staffing group was diverse and matched the patient group.

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

Management of risk, issues and performance was largely effective. Governance processes had identified issues relating to delayed discharge, and as a result leaders had implemented a monthly discharge meeting with the NHS Trust to look at ways to improve discharge to ensure it was more timely. Leaders told us they had also applied for additional funding to employ an internal social worker who could focus on discharge work but at the time of inspection this role had not been confirmed.

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 undertook or participated in local clinical audits. We reviewed a sample of audits that were comprehensive and contained actions for improvements.

There was however 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. Daily morning meetings followed a standard agenda which covered all aspects of patient care. Detailed information was shared and acted upon and managers delegating tasks to individual staff members where appropriate.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. Changes had been implemented following incidents, such as clearer communication with patients to avoid misunderstandings. Recommendations from shared learning were communicated via a lesson’s learnt update that was emailed to all staff and discussed in team meetings. This included information regarding self-harm via aerosols and hidden blades in keyrings and other small objects.

The service had areas for improvement such as the quality of the care plans, lack of activities and issues with admissions and discharges. However, managers were slow to address these issues. Systems and processes did not promptly identify and rectify these problems in the service. Despite some plans being in place, many issues were long-standing such as the lack of weekend activities.

Staff maintained and had access to an effective and well-structured risk register that captured local, controllable risks with clear mitigation actions. Broader system pressures, such as delayed discharges or patient acuity variations, were monitored and managed through the service’s operational governance framework rather than the risk register, recognising that these factors are influenced by external system constraints. The service demonstrated a proactive approach to oversight through regular multidisciplinary discharge meetings, commissioner liaison, and flow management processes.

The service had plans for emergencies – for example, adverse weather or a flu outbreak. There was a business continuity plan and policy and associated documents to ensure managers had clear plans to follow in the event of an emergency.

Where cost improvements were taking place, they did not compromise patient care.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. The registered manager had access to an electronic operations dashboard containing data from various sources and provided managers with an overview of hospital compliance. This included vacancy rates, agency usage, bed occupancy, mandatory training compliance and the number of extra hours worked due to increased patient observations.

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. The electronic patient record system was password protected. Paper records were stored securely in locked cupboards in locked rooms.

The hospital manager and head of care had access to the information they needed to support them in their role. This included information on the performance of the service, staffing and patient care. There were regular audits in place to monitor patient care. There were electronic alerts to highlight issues such as low mandatory training compliance which was promptly addressed. Staffing levels were regularly reviewed to ensure they matched the needs of the service and patient group. There were a set of key performance indicators for managers to judge performance of the service. These indicators included cleanliness scores and agency usage.

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

We understand our duty to collaborate and work in partnership, so our services work seamlessly for patients. We share information and learning with partners and collaborate for improvement.

The service engaged with external stakeholders. There were regular meetings with local stakeholders who were invited to pertinent patient meetings and attended if possible.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. The regional facilities manager visited the service monthly and the operations director visited every 2 weeks. The Director of nursing visited annually. During these visits, patients and staff were encouraged to discuss any concerns or compliments they wanted to raise.

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

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. There were 14 recent suggestions made by staff for service improvements.

Improvements were taking place in the service as a result of patient feedback. Patients had made 13 suggestions for service improvements including more football sessions, more bedroom storage and more multi-cultural events. More multi-cultural events had taken place and planned for the future.

The upstairs social hub room had been decorated and equipped using co-production with patients. An expert by experience had been employed and had been actively involved with introducing a peer buddy mentor scheme and appointing a patients council lead. Patients and staff were encouraged to attend external co-production conferences to network and share ideas. Co-production conferences are meetings where staff and patients can get together to exchange new ideas for service improvements.

The service had started the process towards the accreditation for inpatient mental health services (AIMS), scheme. Following the outcome of the AIMS accreditation, the service planned to introduce changes and quality improvements guided by the AIMS outcome. There was no current quality improvement plans in place.

The service was already accredited by the Triangle of Care scheme for involving patients and carers to improve the quality of care delivered in a mental health setting.