Cygnet Kidsgrove Hospital

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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 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. Governance processes did not always operate effectively. Performance and risk were not consistently managed well. Staff collected and analysed data about outcomes and performance. They used this to identify improvements although actions recorded in some audits were repeated in the subsequent months with the same issues reoccurring.

The service was in breach of the legal regulations in relation to Regulation 17 Good Governance.

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 their team. The provider’s five core values were care, respect, empower, trust and integrity.

Staff told us how their views were listened to and they had the opportunity to contribute to discussions about strategy and ways to improve. The service moved staff from working exclusively day or night shifts with the aim of reducing the risk of closed cultures. These changes had been discussed with staff during team meetings. Staff told us that recent changes, including updates to shift patterns, had been made after speaking with them. The leaders had listened to staff concerns and adjusted where required for certain staff.

Staff were given opportunities to discuss the strategy of the service and the organisation's core values during team meetings, morning meeting and during supervision and appraisal sessions.

The evidence showed some shortfalls. Not all leaders understood the context in which The service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. 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 were new in post and keen to develop their managerial skills. However, we saw and heard that members of the MDT were struggling to keep up with the demands of their roles. Staff told us they were feeling burnt out due to the ongoing pressures. The leadership team had responded to these concerns, as well as feedback from patients and staffing levels had been reviewed and, as a temporary measure staffing had been increased above the agreed staffing matrix.

Most staff and patients we spoke with felt that staffing levels on the ward were a concern, with both groups telling us the ward did not always feel safe. Although there was a process to escalate staffing concerns to leaders, it was clear that staff did not feel the changes made to increase staffing had gone far enough. Staff also told us that the service had currently frozen recruitment for an assistant psychologist, resulting in the psychology department being under resourced.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Leaders were visible in the service and approachable. However, due to the acuity and level of incidents on the ward, leaders were frequently needed to manage and provide support. This resulted in reduced time they had to complete their leadership duties. Leaders told us they were sometimes required to be counted in the nursing numbers, which we also observed during our assessment. We saw leaders responding to incidents on the ward whilst we were on site.

Leaders were visible in the service and approachable for patients and staff. Leadership development opportunities were available, including opportunities for staff to progress within their career.

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.

The service had a whistleblowing policy and procedure in place to support staff with raising concerns. The provider had a Freedom to Speak Up Guardian. During a staff survey carried out between 15 and 10 June 2025, all staff who completed the survey were aware of who the providers Freedom to Speak Up Guardian was and the managers had an open door policy for staff.

Patients had opportunities to give feedback during community meetings. However, these meetings were not consistently well attended by patients on the ward. Managers and staff had access to feedback from patients, carers and staff and used it to make improvements.

The service had a patients and carers feedback questionnaire form. We did not see any evidence of any questionnaires having been completed. The carers we spoke to had not provided feedback via these forms but had done so verbally and through the website.

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.

Managers put reasonable adjustments in place to support staff in carrying out their roles. This included offering changes to working hours or ways of working to accommodate personal circumstances such as caring responsibilities or health needs. Adjustments were also made for neurodiverse staff, including providing ear defenders during fire alarm activations to reduce noise exposure.

The wider organisation provided various networks championing equality and diversity such as the multicultural network, women’s network, disability network, carers network, LGBT+ network, and an equity, diversity and inclusion group. These were accessible to all staff.

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.

There was a clear governance 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. However, the clinical governance meeting minutes for October, November and December lacked sufficient detail. Although audits were noted as having been completed, the minutes did not record any associated outcomes or actions. Lessons learned and duty of candour were listed as standing agenda items, but there was no evidence of discussion about learning at a governance level or of actions required to drive improvements.

Staff had implemented recommendations from reviews of incidents, complaints and safeguarding alerts at service level. For example, all post delivered to patients was routinely checked to ensure that no restricted or high‑risk items were being received, following a previous incident.

Staff undertook or participated in local clinical audits. However, it was not clear that these audits were sufficient to provide assurance, or that staff consistently acted on the findings. Our review of MAR charts and controlled drug records showed ongoing concerns that were not being discussed in governance or staff meetings. These included missing patient photographs on MAR charts and in patient health files, as well as second signatures in the controlled drug book not being consistently recorded.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

Staff had access to the risk register at both ward and directorate level, and staff on the ward were able to escalate concerns when needed. However, when we reviewed the risk register, we noted that no new risks had been added or existing risks reviewed between 23 June 2025 and 14 January 2026. For example the short supply of oxygen due to adverse weather conditions had not been recorded.

The service had emergency plans in place for situations such as adverse weather or a flu outbreak. However, while on site we noted that an oxygen delivery had been delayed due to adverse weather, and this issue had not been resolved in a timely manner.

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 governance systems included confidentiality of patient records. However, it was noted that in the clinic room patient information was left on the side in piles in a disorganised manner. This was raised at the time with the nurse on the ward who stated that they would ensure that they were securely filed.

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. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

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.

Leaders engaged with external stakeholders, including commissioners, community health services and the police. We received feedback from the local authority in relation to its relationship with staff within the service, which was positive. We saw evidence in multi disciplinary team meetings of external agenices such as community mental health services being involved in discharge planning. However, feedback from one relative that a patient had been discharged without a safe placement to go to and that partnership working had not been effective.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

The service had invited the local police force on site to discuss future partnership working.

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.

At the time of inspection, there were no active innovation projects underway on the ward, due to this being a new service.

The service was completing internal audits which generally showed high levels of compliance with policy and process.

Staff participated in external audits relevant to the service and demonstrated learning from them. These included audits completed by the pharmacy provider, which identified several areas requiring improvement. However, not all of these improvements were acted upon. For example, there were repeated instances where a second signature was missing from the controlled drugs register.