Cygnet Kenney House

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• 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 Require Improvement.

Requires improvement: This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Leaders did not always have 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 did not always feel respected, supported and valued. Governance processes did not always operate effectively. Performance and risk were not always managed well. Staff had not taken action following incidents to avoid a reoccurrence. Teams did not always have access to the information they needed to provide safe and effective care.

This service scored 61 (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 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.

We scored the service as 3. 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 their team. The providers values were; care, respect, empower, trust and integrity.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. These had also been shared with patients via the welcome booklet.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. As the service was new, a number of staff had joined the service before it opened and were involved in the development of the service.

Staff could explain how they were working to deliver high quality care within the budgets available. Staff talked about their aim of reducing the use of bank and agency staff to enable more permanent staff to provide more consistency to patients.

We do not always 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 do not always have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 2. The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leaders did not always have the skills, knowledge and experience to perform their roles. Several leaders were relatively new into their role and there were leaders not in permanent positions. Although leaders were keen to develop, we saw how leaders in the service were struggling to keep up with the demands of the role. Minutes were not always available for supervision sessions that were recorded to have taken place. The clinical supervision was evidenced by staff recording in the de-brief book at the end of the shift, although there were some very negative comments from staff showing stress, burn out and staffing challenges. No action seemed to have been taken by leaders regarding these concerns.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. However, they acknowledged that the majority of their previous experience had been within secure settings rather than rehabilitation settings.

Leaders were visible in the service and approachable for patients and staff. Patients told us that the ward manager was approachable and listened to them, however the support provided by the ward manager to patients was not always recorded within the care records.

Leadership development opportunities were available, including opportunities for staff, the ward manager was accessing the ward manager development training.

We do not always create a positive culture where people feel that they can speak up and that their voice will be heard.

We scored the service as 2. The evidence showed some shortfalls.

Patients had opportunities to give feedback at the community meetings. However, the actions from these meetings were not always carried forward to the following meeting, therefore you do not know if the actions were achieved.

Patients and carers had opportunities to complete feedback questionnaires. However, the results of the questionnaires were not broken down to wards, therefore, it was unclear if the feedback was about the rehabilitation ward, the acute ward or the psychiatric intensive care unit.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. An action plan was created following the responses from the questionnaires. Themes included challenges with communicating with the ward, quality and choice of food, activities available, staffing levels and access to advocacy.

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.

We scored the service as 3. 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 e.g. LGBT+, BAME etc. The service had a multicultural network which staff were informed about as part of their induction.

Managers would put reasonable adjustments in place for staff members to help them carry out their role, however that was not applicable at the time of the assessment.

The provider undertook equality monitoring of staff during the recruitment and selection process.

We do not always have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We do not always act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 2. The evidence showed some shortfalls. The service 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, or 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 was shared and discussed. There were no standard agenda items relating to complaints, however this was shared via the lessons learnt bulletin. Incidents were included in the team meeting agenda and minutes.

Staff had not taken action following incidents to avoid a reoccurrence, there had been an incident where staff could not gain access to emergency equipment, the location of the equipment had not changed at the time of the assessment.

Staff undertook or participated in local clinical audits. These included a blanket restrictions audit, and a ligature and blind spot audit had been completed in August 2025. However, the ligature risk assessment did not include the outside space which had a ligature risk of a drainpipe. The sensory room was locked due to a ceiling projector that posed a ligature risk and was awaiting boxing in, however there was a free standing lamp in the room which was not included in the ligature risk assessment. The ligature and blind spot audit was a very lengthy document, comprising of over a 100 pages which did not make it accessible to staff. The audits were not sufficient to provide assurance.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Records showed external teams were involved in the patient reviews.

Patients and staff told us and records confirmed there were not enough staff allocated to enhanced observations to enable staff to have a break and the service was not adhering to best practice guidance. Complaints showed that staff were not conducting their enhanced observations as prescribed to ensure patients were safe. The service had not identified this and had not taken action to address this.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required.

The service had plans for emergencies – for example, adverse weather or a flu outbreak. The service had support from an operations director and other central support from the provider including a referrals team, this meant the service were not involved in assessing the new referrals prior to admission.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. Daily managers meetings took place where incidents, staffing and directorate updates were discussed.

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. However, stakeholders and carers found it difficult to get through to the wards at times and did not receive regular updates from the ward.

Information governance systems included confidentiality of patient records.

Team managers did not always have access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. There was no oversight in place for the inductions of bank and agency staff into the hospital. The recording of supervisions on the electronic system included the date that supervision took place, but minutes were not required to be uploaded. We saw a combined managerial and clinical supervision template in use for the recording of the supervision however these were not completed for all of the dates recorded. This meant we were not assured that supervision took place. Clinical supervision was not taking place as expected, dates of clinical supervision were samples of the entries into the debrief booklet that was completed by staff at the end of each shift and was not a separate clinical supervision session. This meant staff were not given the opportunity to reflect, learn from others and seek guidance about clinical situations.

Information was in an accessible format, and was timely, accurate and identified areas for improvement. Governance meetings took place monthly. Although actions were identified within the minutes, these were not discussed at the next meeting, according to the minutes, this meant we were not assured if actions had been achieved.

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.

We scored the service as 3. 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. Stakeholders confirmed that the service invited them to visit the service and attend ward rounds for patients.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. A garden party had taken place where patients, staff and commissioners and external professionals were present.

We do not always focus on continuous learning, innovation and improvement across our organisation and the local system. We do not encourage creative ways of delivering equality of experience, outcome and quality of life for people. We do not actively contribute to safe, effective practice and research.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Staff were given the time and support to complete their required training.

Staff did not have opportunities to participate in research. However, the medical director identified this as an area for improvement and had discussed clinical audit and liaison with the Royal College of Psychiatrists regarding research in the medical advisory committee meeting.

Innovations were not taking place in the service. The service was still developing.

Staff did not use quality improvement methods.

Staff participated in external audits relevant to the service and learned from them. These included audits from the pharmacy provider who identified areas for improvement in relation to Mental Health Act documentation.

The ward did not participate in accreditation schemes relevant to the service.