Cygnet Hospital Oldbury

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.

This is the first assessment for this newly registered service. This key question has been rated Good

However,

The service was in breach of regulation for good governance as staff had not identified all or new environmental risk issues and as a result timely action had not been taken to remove or mitigate these risks.

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

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 people and our communities.

Leaders told us that the hospitals visions and values were focused on delivering person centred care and working in collaboration with the patient and multi disciplinary team to ensure positive outcomes and effective recovery.

Most staff we spoke to understood the vision and values of the organisation and believed the hospital was delivering care in line with these values. Some staff who were less experienced told us that they sometimes lacked confidence in practice but believed that they were being supported to develop

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.

All staff we spoke to told us there was a positive culture within the hospital. Staff told us they worked well as a team, supported each other and were proud that their involvement had led to successful outcomes and achievements for patients.

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. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Managers understood the needs of the patient group and followed a recognised strength-based model of treatment and care that focused on the patient’s skills and abilities.

Both patients and staff told us that managers were visible and approachable, and that management had an open-door policy.

Managers made themselves available for patients if they wanted to speak to them. We observed how managers knew the patients and offered support patients when needed.

Staff told us that they respected that managers were on the ward to support patients and them also. The service welcomed preceptorship nurses and offered supported nursing placements. We were told that the service supports ‘growing their own’ and has development opportunities for all staff. Various health care support workers had told us that the Registered Manager took an interest in their development and discussed potential opportunities with them.

We create a positive culture where people 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 on Emmeline ward did not give positive views on how the hospital responded to feedback however patients on Rosa told us that they were supported and actions were taken following feedback. We saw that community meetings took place on a regular basis on both wards and that changes had been implemented as the result of feedback

Managers and staff had access to the 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 were given the opportunity to be involved in the recruitment of staff. One patient told us that they had been involved in interviewing potential staff.

The hospital had a Freedom to Speak Up Guardian. Contact details were displayed in the nurses’ offices.

Staff said they felt confident in raising concerns about poor professional practice or inappropriate conduct towards patients.

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

The hospital promoted equality and diversity within the service. Managers put reasonable adjustments in place for staff members to help them carry out their role. This included opportunities to change hours or ways or working due to personal circumstances such as caring responsibilities and health issues.

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 provider 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.

Our findings from the other key questions demonstrated that governance processes did not always operate effectively at team level and that performance and risk were not always managed well.

Although managers and staff quickly addressed risk issues and quality concerns that we raised during the inspection, we were concerned that governance processes had not enabled staff to identify or act on these concerns prior to the inspection. Whilst environmental risk audits had been completed, staff had not identified all or new environmental risk issues and as a result timely action had not been taken to remove or mitigate these risks. These issues included access to items that may cause potential harm to patients, blind spot in the garden area, cluttered and disorganised store cupboards and issues with the seclusion room. We found that when we informed staff of these issues, staff were responsive and motivated to take immediate action to make improvements.

Governance systems and processes had not led to the identification and resolution of care plans being person centred and patient friendly.

Staff interaction and responsiveness to concerns was also a concern to patients. Leaders were aware of the concerns around potential staff attitudes. They had implemented disciplinary procedures in some instances and had implemented additional training to promote a positive culture.

The service was proactive in other areas particularly regarding staffing, recruitment, multi-disciplinary approaches and ensuring a full programme of therapeutic activities. The role of the expert by experience was fully integrated into the governance processes. The expert by experience was visible within the hospital and regularly met with patients and facilitated community meetings.

There was a system of governance meetings which enabled the escalation of information upwards and the cascading of information. Ward managers attended quality and team meetings. These were forums to review incidents, performance issues and planning. Key performance indicators and monthly audit processes were in place to help give oversight of the service and where improvements where required. We saw that the leadership team was committed to developing and were proactive in ensuring that all staff were updated on issues that affected patients and lessons learned were shared through a variety of means.

Staff maintained and had access to the risk register. The risk register for the hospital included 4 open risks. These included risks associated developing a new team, alarms being too loud, drop kerbs and parking outside of the hospital. The risk register included a score for the severity of each risk, actions being taken to address the risk (including immediate mitigation) and timescales for completing those actions.

Staff had access to the equipment and information technology needed to do their work.

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

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. Leaders told us that they worked in positively with external agencies including various local authorities, other mental health providers, advocacy, housing, and police. They shared that there had been challenges when working with patients that were out of area but were committed to building relationships with partners to ensure the best outcomes for patients.

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

The service focussed on continuous learning and improvement across the organisation. The service had a positive and robust approach to improvement and learning from incidents and all staff we spoke to were able to give us good examples of where lessons had been learnt and changes made after incidents.

Leaders told us that as a new service current priorities were focused on building solid foundations however there were also focused on making improvements where possible. For example, the manager told us that plans were in place to develop a sensory room for patients.

Three staff members were trained in Quality Improvement (QI) and although no QI projects had officially commenced the provider informed us that following our inspection and feedback given around care plans that they were looking to commence a quality improvement project on developing care plans with patients. Background work had begun on this project and feedback had been gathered from one patient.