Cygnet Kidsgrove Hospital

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 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 providers values were care, respect, empower, trust and integrity.

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 told us how their views were listened to and they had the opportunity to contribute to discussions about strategy and ways to improve. We were told that some changes made were in consultation with staff such as changes to shift patterns. Staff were moved from working solely days or nights with the intention of reducing closed cultures. This had been discussed in team meetings. The leaders had listened to staff concerns and made adjustments where it was required for certain staff.

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 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 in managing incidents. This resulted in reduced time to complete their leadership duties and availability for staff and patients. Although leaders were keen to develop, we saw and heard how members of the MDT were struggling to keep up with the demands of the role. Staff told us they faced feeling burnt out due to the ongoing pressures on the ward. The leadership team had responded to these concerns and those shared by patients. Staffing had been reviewed and the ward and as a temporary measure staffing had been increased above the agreed staffing matrix.

Most staff and patients we spoke to felt that staffing was an issue on the ward with both groups telling us the ward did not always feel safe. Although there was a way to escalate staffing concerns to leaders it was clear that staff did not feel that the changes made to increase staff had gone far enough.

Leaders recognised that some staff needed to develop further experience of working in the ward environment and this put pressure on other more experienced staff members who patients would tend to go to for support.

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

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.

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. The ward had not received any whistleblowing or freedom to speak up feedback since opening. We saw freedom to speak up posters in staff areas, and we were told that leaders were approachable.

Staff told us that the providers senior leadership team attended the service regularly and they would be able to feedback to them if they needed to.

Patients had opportunities to give feedback at the community meetings. Although meetings were not regularly well attended by patients on the ward. Feedback was discussed in staff meetings, however, clear outcomes from actions taken were not recorded.

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. One family member was happy with the outcome from their complaint.

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 for staff members to help them carry out their role. This included opportunities to change hours or ways of working due to personal circumstances such as caring responsibilities and health issues. Adjustments were made for neurodiverse members of staff who were provided with ear defenders if the fire alarm was activated to reduce the level of noise they were exposed to.

There were equality and diversity networks available to staff within the wider organisation. This included the equity, inclusion and diversity network, multicultural network, women’s network, LGBTQ+ network and the disability network. Information about these networks was available in staff areas. The most recent staff survey findings of staff awareness of equality and diversity networks showed that 65% of staff were not aware of groups, with only 51% having awareness of relevant groups they could access.

The provider did not undertake equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group.

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 meetings so 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 information. It was noted that audits were taking place but did not record any outcomes or actions. Lessons learned and duty of candour were standing agenda items but did not record any discussion around lessons learned at a governance level or actions to be taken to make improvements. Managers also recognised that attendance at staff meetings was low and had looked at ways of improving this.

Staff had implemented recommendations from reviews of, incidents, complaints and safeguarding alerts at the service level. An example of this was that all post being delivered to patients was routinely checked to ensure that there were no risk or restricted items being delivered.This was as a result of a patient self harming with an item received in the post.

Staff undertook or participated in local clinical audits. However, it was not clear that these audits were sufficient to provide assurance and staff acted on the results when needed as we saw reoccurring themes. Our review of MARS charts and the controlled drug records showed ongoing issues which were not discussed in governance or staff meetings. These included patient photographs missing from MARS charts and patient health files and second signature not being consistently recorded over dates from November into December.

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 ward rounds.

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 plans for emergencies for example, adverse weather or a flu outbreak. However, whilst on site we noted that an oxygen delivery had been delayed due to adverse weather and this had not been resolved in a timely manner.

Daily morning 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, we saw that patients’ physical health needs were assessed and documented although they were not consistently recorded in the same way with some documentation being in the online system and others in paper files such as bowel management charts.

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 such as commissioners, community health services and the police. Stakeholders confirmed that the service invited them to visit the service and attend ward rounds for patients. The hospital told us that they were working with the police to support partnership working.

Staff told us that there had been some delays in accessing support from approved mental health practitioners when an informal patient needed to be assessed under the Mental Health Act. After discussion with leaders, they were considering ways in which to escalate concerns around these delays to the relevant agencies.

MDT meetings involved external partners such community mental health teams and commissioners, and we saw positive outcomes for patients. For example, 1 patient was supported to move back to their local area.

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

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.

The service had a continuous approach to learning and improvement they had considered new ways of working and innovations in the way in which they carried out their care planning. They were in the process of implementing the diamond framework on the ward which had been developed by another Cygnet hospital. They had also introduced safety summaries as an alternative way of accessing risk instead of the PARA risk assessment used in other wards across the provider. However, there had been a delay in training all staff in the diamond framework which had been due to staff being pulled back on to the ward to cover. Leaders told us that staff were keen to learn but were not given the time to ensure that training was delivered consistently.

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. Although, these areas for improvement were not always acted upon such as the multiple occasions that the second signatory was missing from the controlled drugs register

The ward did not participate in accreditation schemes relevant to the service but was looking at accreditation for the triangle of care in the future.