Cygnet Aspen 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 inspection, we rated this key question good. At this inspection, the rating has changed to requires improvement. The service was in breach of the legal regulation relating to good governance.

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 care. Governance processes did not always operate effectively and there was a lack of significant improvement in areas identified at the previous inspection. However, we were assured the hospital manager had the skills, knowledge and experience to perform their role and make improvements. Staff felt respected and valued. Performance and risk were managed well. Teams had access to the information they needed. Staff collected and 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.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision and strategy. This was based on transparency, equality and human rights, engagement, and understanding challenges and the needs of people and their communities.

The service had a new hospital manager who had been in post for 4 weeks at the time of our inspection. The leadership team were working with frontline staff to develop a positive culture, with clear vision and values that applied to the work of their team. Leaders and managers were engaging with staff, people who use services, relatives and other stakeholders.

Leaders and managers told us staff were being given the opportunity to contribute to discussions about the improvements for their service. We spoke with the hospital manager about improvement plans for the service and they shared this with us. Improvements included reviewing blanket restrictions, patient involvement, patient documentation systems and implementation of frameworks such as Triangle of Care and PCREF. Staff felt able to raise concerns and highlight areas for improvement and this was acknowledged and supported.

In relation to closed cultures (recognising that a closed culture may lead to breaches of human rights including abuse or significant harm), the hospital undertook several actions to minimise the risk of a closed culture developing and to create a safe environment which was free from neglect and abuse. This included being open and transparent regarding incidents and safeguarding and the hospital followed a restorative just culture framework (an organisational approach that focuses on learning from incidents rather than assigning blame) for reviewing incidents. The hospital undertook a monthly audit of CCTV to review observation and engagement. The service implemented regular incident reviews and reviews of concerns and complaints and discussed lessons learnt and changes or improvements that could be made to reduce and action these.

External partners and relatives that we spoke with told us they were able to raise any challenges they encountered or concerns they had, and this was met with understanding.

Leaders and managers could explain how they were working to deliver care within the budgets available, and the hospital shared with us their project plans for a social hub. We observed improvements being made to the multidisciplinary meeting room, multi faith room and outside spaces during our on-site inspection.

We scored the service as 3. 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 hospital. They could explain clearly how the teams were working to ensure good care and discussed improvements being made to improve outcomes for people who use the service.

Leaders were visible in the service and approachable for people and staff. Recent improvements had been made to improve communication with the staff team, for example ensuring staff received regular support through supervision, team meetings and reflective practice opportunities.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The most recent service user satisfaction survey from April 2025 to March 2026 received 4 responses which were all positive. Reviewing and improving patient involvement was part of the hospital’s improvement action plan. The survey asked 18 questions to be scored from 1 to 5. The average score across all questions was 4.8. Patients and carers were involved in decision-making about changes to the service. We observed a patient engagement council meeting during our onsite inspection giving patients an opportunity to have a voice and updates were provided from staff in occupational therapy and psychology departments regarding activities and plans for the summer months.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Patient collaboration formed part of the hospital’s current improvement action plan.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback. In the most recent staff survey in 2025, 92% of respondents were aware of the organisation’s Freedom to Speak Up Guardian.

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.

We assessed that equality and diversity were actively promoted. During our inspection concerns had been raised by staff in relation to other staff and these were being investigated.

The hospital were working towards a PCREF action plan and arranging a masterclass for staff regarding the framework and implementation. This was reflected on the hospitals risk register whilst the initiative was being embedded. At the time of our inspection the hospital was asking for expressions of interest regarding a multicultural ambassador role for the hospital. The service had a dedicated multi-faith room which all staff and patients could use.

Staff had received appropriate training in equality and diversity and at the time of inspection, staff training compliance was 98%.

Staff we spoke with told us they were supported with reasonable adjustments or flexible working arrangements to support them to carry out their role and to account for personal circumstances, where relevant.

The current staff survey was underway at the time of our inspection, and the previous survey had been carried out between April and June 2025. Results indicated that 76% of respondents felt that the organisation recognised the challenges and inequalities faced by individuals due their protected characteristics. 90% of respondents were aware of the organisation’s Equity, Diversity and Inclusion Group. The organisation offered a range of other networks and groups that staff could be a part of, such as staff carers network, multicultural network, LGBTQ+ network, disability network, women’s and men’s health networks.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Our findings from other key questions demonstrated that some governance process did not always operate effectively at team level.

The providers policy outlined debriefs were offered for incidents categorised moderate or above or if requested but staff we spoke with told us that they did not always receive a debrief following an incident therefore this might not be fully clear to staff. The hospital recorded when incident support was offered and whether it was accepted or declined.

We found a lack of evidence to indicate whether patients were getting their 1 to 1 sessions with a named nurse. The new hospital manager was not aware of this and told us this was below their expectation. There should be a minimum of 2 1 to 1 sessions offered and documented every 7-10 days by a patient’s key worker and named nurse or a record to indicate this had been declined.

During our last inspection in 2022 we told the provider that they should ensure staff have access to regular team meetings and feedback from staff indicated that this had not been implemented until recently. Reflective practice sessions were not being held until the new hospital manager reintroduced them. Whilst it was positive these had been introduced recently; we could not be assured that systems were yet in place to ensure these continued to be embedded.

Staff we spoke with told us about activities within the hospital and we received some feedback from patients and relatives that some activities and access to the community occurred. We didn’t observe activities during our on-site inspection however the service provided data showing 100% of activity was offered in April and May and 53% engaged activity compliance. Team meeting and community meeting minutes indicated recent discussions regarding this we saw no evidence of concrete plans to address these gaps in service provision.

However, the new hospital manager had introduced 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 completed observations of a morning meeting, patients engagement council and multi-disciplinary ward rounds. We reviewed minutes from team meetings and local clinical governance meetings. There was a clear framework and agenda that staff followed, of what needed to be discussed to ensure that essential information, such as learning from incidents and complaints, safeguarding issues and any changes to risk was shared and discussed as a team.

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 externally, to meet the needs of the patients.

Management of risk, issues and performance was monitored on a regular basis. Hospital managers maintained and had access to the risk register which contained 5 current risks. These were updated when new risks were identified, reviewed regularly and included patients in discussions regarding restrictions. Staff told us that risks were well managed and could identify risks within the environment, which correlated with those noted on the risk register. The service had business continuity plans in place for emergencies.

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

The service used systems to collect data that were not over-burdensome for frontline staff.

Staff we spoke with told us they 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. Hospital managers and the head of care had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

Information governance systems included confidentiality of patient records. Information was in an accessible format, and was timely, accurate and identified areas 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.

The hospital had good working relationships with external providers such as adult social care, safeguarding, advocacy and community teams. We received feedback from external partners, which was positive, and they told us about collaborative working to support people who use the service. They told us that information was received in a timely manner.

Directorate leaders engaged with external stakeholders such as the Care Quality Commission, commissioners and Healthwatch.

We scored the service as 3. 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 used quality improvement methods and knew how to apply them.

The hospital manager spoke with us about several quality improvement initiatives in the hospital to improve hospital processes, systems, and outcomes for patients. We observed environmental improvements and a reduction of restrictions imposed on patients during our on-site inspection. Improvements were being made to the patient record systems, and the hospital were moving from a risk stratification approach to a formulation approach in line with current NICE guidelines. An introduction of a lessons learnt template, standard agendas for regular meetings, and a weekly medication review meeting had been introduced. The hospital was in the early phases of implementation of the patient and race equality framework (PCREF), working towards an action plan and planned PCREF masterclass for all staff to attend. The hospital was a trial site for a regional quality improvement project looking at medicines errors and the hospital was testing a new tool that aimed to reduce medicine errors.

The new hospital manager informed us that part of the hospitals action plan was to work towards accreditation schemes relevant to the service such as the Triangle of Care and accreditation for inpatient mental health rehabilitation services (AIMS).