Cygnet Acer Clinic

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

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

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 analysed data about outcomes and performance. They used this to identify improvements.

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 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. 

Service leaders described clear priorities for the service, including improving patient safety, reducing incidents and using data to inform care. They successfully communicated the provider’s vision and values to the frontline staff in this service.  

Staff had opportunities to contribute to discussions about service development and improvement. One staff member told us, "Staff can share their thoughts on improvements at any time, including through supervision, reflective practice, community meetings, or by giving their ideas directly to management." 

There was a shared focus on patient safety, rehabilitation and improving the experiences of patients using the service.  

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. They demonstrated an understanding of the service, including patient safety, risk management, rehabilitation pathways, and discharge planning. They identified service priorities and demonstrated awareness of challenges affecting the service, including discharge delays, staffing pressures, and patient feedback regarding the balance of male and female staff, and were able to describe actions taken in response. 

Leadership development opportunities were available, including opportunities for staff to develop their skills and knowledge through supervision, appraisal, training, reflective practice, and involvement in service development activities. Leaders provided support for staff development and progression. 

The service fostered a positive culture where patients felt they could speak up, and their voice would be heard. 

Leaders supported and encouraged staff to raise concerns, provide feedback, and discuss issues affecting the service. Staff  felt able to raise concerns and contribute ideas for service improvement without fear of reproach.  

One staff member said, “I am able to speak up and raise concerns without fear of repercussion as there are means available for staff to make complains in person or anonymously.” Leaders utilised a range of mechanisms through which staff could share feedback, including supervision, team meetings, reflective practice sessions, and staff surveys. 

Leaders demonstrated that they were aware of issues raised by staff and patients and could describe actions taken in response. For example, leaders acknowledged concerns regarding staff cliques and described measures implemented to reduce the risk of a closed culture, including staff rotation, reflective practice, and monitoring team dynamics. Leaders emphasised the importance of remaining vigilant to behaviours that could undermine the positive culture of the service. 

Patients felt able to raise concerns and provide feedback about the service through discussions with staff, community meetings, and advocacy support. During our assessment of the service, patients shared a range of views about the service, including concerns about staffing levels, the use of agency staff, access to leave and aspects of the ward environment. This demonstrated that patients were willing to speak openly about their experiences and raise concerns directly with staff and external professionals when required. 

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. 

Leaders promoted equality, diversity and inclusion within the service and took steps to create a culture where staff felt respected, valued, and supported. 

Staff requested flexible working arrangements to support personal circumstances, including caring responsibilities and health needs. One staff member said, “Our leaders promote an open and positive culture by engaging with staff positively, listening to their concerns and making appropriate adjustments, and supporting them when necessary.”  

Leaders implemented reasonable adjustments, which supported staff to carry out their roles effectively. Leaders monitored workforce equality and diversity and reviewed policies and procedures to promote fair and inclusive working practices.  

Leaders took action to promote an inclusive culture and sought opportunities to engage with staff from a range of backgrounds and experiences through staff networks and staff forums. These included the LGBTQ+ Network, Women's Network, Multicultural Network, Men's Health Network, Staff Relations Group, Freedom to Speak Up Guardian and Anti-Bullying Officer roles. Leaders also reviewed staff survey feedback and developed a psychological safety action plan in response to issues identified by staff.

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 on information about risk, performance and outcomes and shared this securely with others when appropriate. 

Leaders understood key service priorities, current challenges, and areas for improvement, including incident reduction, improved patient safety, and using trends data to inform service delivery. 

Leaders demonstrated oversight of service performance, risks, and patient outcomes. They described reviewing incidents at ward and individual patient level to identify patterns, trends, and emerging risks. Leaders used information from incidents, observations, positive behaviour support plans, daily safety summaries, and multidisciplinary reviews to inform decision-making and adapt care and support arrangements.  

Leaders had governance processes in place to review quality and performance. Staff completed a range of audits and outcome measures to monitor care and treatment, including occupational therapy outcome measures, admission and discharge outcome assessments and mental health act audits. They then acted on the findings to improve patient care. Leaders also described reviewing service development plans throughout the year and monitored progress against improvement objectives through governance processes. 

Staff understood how to escalate concerns and leaders demonstrated awareness of issues affecting both patients and staff. Concerns regarding staffing and continuity of care had been recognised by leaders and actions had been taken in response, including recruitment activity and workforce planning measures. 

However, we identified some gaps in care planning documentation that had not been fully addressed through existing governance processes. For example, asthma and catheter care plans did not always provide sufficient detail regarding the signs and symptoms staff should monitor for or the actions staff should take if concerns were identified. We also identified concerns regarding continuity of care associated with the use of temporary staff who were not always familiar with patients' individual triggers, warning signs, and support needs. Leaders were aware of these issues and had already begun to act through recruitment initiatives, workforce planning, and review of care planning documentation.

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. 

Staff and leaders understood the importance of working in partnership with external agencies and services to support patients throughout their care journey. We saw evidence of effective multidisciplinary working and collaboration with commissioners, community teams, healthcare professionals, and family members to support care planning and discharge arrangements. 

Leaders were open and transparent with external stakeholders and demonstrated a willingness to work collaboratively to improve the service.  

The service achieved the stage 1 Triangle of Care accreditation, reflecting its commitment to strengthening collaboration between carers, patients, and healthcare professionals. This supported greater involvement of families and carers in care planning and treatment decisions. 

Staff shared information appropriately with partner agencies to support continuity of care, which ensured patients received coordinated support. Feedback from multidisciplinary team members was positive regarding joint working and communication between services. 

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. 

Leaders demonstrated a commitment to continuous learning and improvement. They used feedback, outcome measures, audits, and incident reviews to identify learning and opportunities for development. Leaders demonstrated a willingness to develop and introduce innovative approaches to care delivery. For example, leaders described the introduction of a formulation-based approach to risk assessment, which supported a more individualised understanding of patient’s risks and protective factors. 

Community meeting minutes and staff survey results demonstrated that feedback and governance information were used to identify issues and implement actions to address them. 

Staff told us they were encouraged to contribute ideas and feedback to improve the service. One staff member said, “We are involved in service improvements by communicating about our observations on the floor and contributing ideas for the improvement of the ward.”