Cygnet Raglan 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

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 well-led as outstanding. At this assessment, the rating has changed to good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 their team’s work. Staff felt respected, supported, and valued. Governance processes operate effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected data analysis about outcomes and performance. They used this to identify improvements.

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 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 people and their communities.

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

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff told us that they had the opportunity to contribute via staff surveys and team meetings, daily huddles and during supervision and appraisal sessions.

Staff told us there was a positive culture within the hospital and they worked well as a team, by supporting each other in achieving successful outcomes and achievements for patients.

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.

Leaders had the skills, knowledge, and experience to perform their roles. Leaders had a good understanding of the service they managed, and the patient group they supported. Senior leaders worked closely with staff, and were regularly onsite, meaning patients and staff could speak with them.

Leadership development opportunities were available, including opportunities for staff to progress their careers.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up, and their voices would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. We saw evidence of feedback groups where patients and carers were encouraged to be involved in decision-making choices.

The provider also developed a carers ambassador group, which focused on understanding the importance and value of the involvement of carers and loved ones in people’s individual recovery journeys.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

Staff knew about the provider’s whistleblowing policy. Staff told us they felt comfortable using it to report concerns. There were posters of the Freedom to Speak up Guardian in communal areas, which encouraged everyone to speak up freely.

The most recent staff survey had a high 91% completion rate. Staff said they stayed in work because they loved doing meaningful work, enjoyed working with their teammates, and felt supported by their managers. However, staff also said they wanted better pay, less workload pressure, and more staff on the wards.

Patients and staff met with members of the provider’s senior leadership team and governors to share their feedback. They told us that they felt part of the team. They said senior managers listened to their ideas and acted on what they heard.

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.

There were Equality and Diversity champions within the service. Staff told us that there were also diversity leads, who planned events like cultural days, Christmas, Eid, Mubarak, Chinese New Year and Diwali.

There was an opportunity for staff to work flexibly to account for personal circumstances, such as caring responsibilities and health issues. Staff also told us that the shift patterns can be discussed to with the management to fit in with their schedule.

We reviewed the service's 2024/2025 'Quality Thematic Review: Culture Assessment', which grades the workplace culture across 55 areas. The service achieved an overall score of 92.7% in 2024 and 85% in 2025. According to the provider’s framework, any score over 87% represents notable good practice.

Managers put reasonable adjustments in place for staff members to help them carry out their role. Staff had been provided with specialist equipment like display screen equipment assessments or occupational health recommendations.

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. They had a local multicultural Network Ambassador who helped patients and staff meet their cultural needs.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted and were aware on the information about risk, performance and outcomes, and 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. We saw evidence of this in MDT and ward team meetings minutes, daily risk assessments, clinical governance meetings.

A quality thematic review approach was used by the provider. The requirements of this review were matched to CQC standard requirements. This was done to ensure regulatory expectations were met and patient care was improved.

Staff had implemented recommendations from reviews of deaths, incidents, complaints, and safeguarding alerts at the service level.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. There was evidence that the provider worked with local authority, CQC, Integrated Care Board (ICB) and other external commissioners.

Staff undertook or participated in local clinical audits. The clinical audits were sufficient to provide assurance and staff acted on the results when needed. We saw evidence of clinical audits including the environment and, care records audits. However, Staff did not ensure wet floor warning signs were stored safely. Yellow wet floor signs were left under a cupboard in the day area, accessible to patients, instead of being kept in a locked housekeeping room.

We also identified an unrepaired heater with a hole in the top, demonstrating that the provider was not effectively identifying or resolving environmental hazards.

But, when we told staff of these issues, they were responsive and took immediate action to rectify some of them and make improvements.

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 raised about environment and other risk matched those on the risk register. We saw evidence of the action plan tracker which ensured that actions were actioned in a timely manner.

The service had plans for emergencies, for example, adverse weather or a flu outbreak. Where cost improvements were taking place, they did not compromise patient care. Management showed they were responsive to the changing needs of the patient group.

The service used systems to collect data from wards and directorates which 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 was in an accessible format, and was timely, accurate and identified areas for improvement. We saw evidence of the Refurbishment Plan 2026, which was due to start in March to November this year.

Information governance systems included confidentiality of patient records. Information technology systems, laptops, and computers had passwords for each staff member.

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 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.

Directorate leaders engaged with external stakeholders – such as commissioners and Healthwatch.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. The manager told us that the Chairman did visit the unit and spoke with staff and patients.

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 opportunities for improvements and innovation and this led to changes. Staff told us they felt involved in the improvement process and gave clear examples, of how care improved showing a robust approach to lessons learned from incidents and mistakes to keep patients safe.

Innovations were taking place in the service. The provider showed an innovative and responsive approach to meeting patient complex needs.

Staff participated in national audits relevant to the service and learned from them. Wards also took part in accreditation schemes relevant to the service and learned from them.

Staff had opportunities to participate in research and used quality improvement methods and how to apply them.