Cygnet Elowen 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

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.

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. The service was in breach of regulation for governance at the service.

The provider’s vision and values were clearly communicated, but staff and patients did not always experience transparency, collaboration, or fully consistent application of these values in practice. New leadership had begun making improvements, but at the time of the inspection leaders did not consistently demonstrate the ability to manage all aspects of care effectively. Staff were encouraged to raise concerns, but some missed opportunities for challenge meant not all voices were heard. Leaders promoted an inclusive and diverse workforce and made reasonable adjustments for staff, creating an equitable working environment. Governance and accountability systems were in place, but audits and risk management were not consistently effective, and some administrative shortfalls impacted compliance and oversight. Staff and leaders engaged with external partners and communities, but patient and family involvement in service improvement and innovation was limited and in early stages. The service showed a developing culture of learning, but improvement initiatives were still in the early stages, and some recurring issues persisted despite efforts to address them.

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 provider’s stated values were to care for service users, staff, and visitors; to respect them; to build trust; to empower patients and staff; and to deliver quality services with integrity. Staff were aware of these values and understood the provider’s vision to deliver high-quality, sustainable specialist services and foster a positive, inclusive culture.

However, in the months prior to our inspection, the service faced challenges in fully living up to these values. Staffing resources were limited, and the multidisciplinary team was not yet fully established, meaning specialist professionals were not always available to support patients. Some staff had limited experience in delivering specialist care for disordered eating and had not yet accessed additional training, which impacted the consistency and quality of therapeutic support.

Leaders had identified these gaps and had begun addressing them ahead of our inspection. Recruitment of the full multidisciplinary team was completed, and staff were receiving the necessary training to develop their specialist skills. These actions have started to embed the provider’s values into practice, creating a culture that is increasingly person-centred, compassionate, and focused on delivering high-quality specialist care.

The Alina ward leadership team, with support from a newly appointed hospital manager, had begun to make improvements in service delivery and oversight. Leaders demonstrated a good understanding of the service, clearly explained how teams worked to provide care, and recognised the key priorities for addressing previous shortfalls.

Most patients and relatives described leaders as visible and responsive to concerns. However, earlier concerns about care, treatment, and support continued to affect patients’ experiences.

The hospital was required to have a registered manager in post. At the time of our inspection, the hospital manager was in the process of registration, which means they had been appointed to the role but were still completing the formal approval process with the regulator to confirm they were legally authorised to manage the service.

Leaders understood the requirements and recommendations made by CQC. For example, shortfalls identified during a recent inspection of another ward led to an audit being completed on this ward to provide assurance and identify any similar risks. Leaders kept up to date with relevant changes and communicated these effectively to their teams.

Leaders had taken positive steps to strengthen oversight and improve service delivery. However, the impact of longstanding issues meant that leadership was not yet consistently demonstrating a fully capable, compassionate, and inclusive approach in practice. Leaders needed to continue embedding improvements and strengthening consistency to ensure patients experienced sustained, high-quality care.

Patients and carers had opportunities to give feedback about the service and, in most cases, felt that their concerns led to meaningful changes. Managers and staff actively sought feedback from patients, carers, and staff and used this to inform improvements. Patients and carers were generally involved in decision-making about changes to the service.

Staff and leaders promoted a culture of openness and encouraged staff to raise concerns. The service had a Freedom to Speak Up policy in place and access to a Speak Up Guardian, who acted as an independent and impartial source of advice. Staff told us they felt confident to raise concerns and believed their voices would be heard. Staff described a culture where they could speak up and felt supported to do so. For example, one staff member used the whistleblowing policy, an internal process that allows staff to report concerns about unsafe or poor practice confidentially, to raise concerns about a colleague’s conduct, and leaders addressed the matter appropriately.

Leaders acted with openness, honesty, and transparency. When concerns were raised, leaders investigated them sensitively and confidentially, and shared learning where appropriate. When things went wrong, leaders demonstrated a willingness to take accountability, provide explanations, and take action to prevent recurrence. During our inspection, leaders responded positively to feedback, acknowledged shortfalls, and showed motivation to address them.

Leaders actively promoted equality, diversity, and inclusion within the workforce and worked to create an inclusive and fair culture. Staff reported a generally positive experience, and leaders reviewed and improve the organisational culture in relation to Workforce Equality, Diversity and Inclusion (EDI) principles.

Leaders took steps to prevent and address bullying and harassment at all levels and for all staff, including those with protected characteristics under the Equality Act 2010 and those from marginalised groups. The workforce was diverse, and staff from different backgrounds were represented across the service.

Staff were supported to work in an environment that promoted fairness, respect, and inclusivity.

Leaders had defined roles and responsibilities. However, governance systems and accountability processes were still developing and were not yet fully embedded. While oversight of the service had improved, governance arrangements remained in the early stages of implementation.

Leaders used available information about risk, performance, and outcomes to inform decision-making. However, they did not always identify concerns proactively. In several instances, leaders took action in response to concerns raised by external partners rather than identifying issues through internal systems. For example, the Integrated Care Board (ICB), which plans and funds local health services, and the Care Quality Commission (CQC), the independent regulator of health and social care in England, identified some of the initial shortfalls. Leaders then acted to address these concerns.

Staff understood their roles, responsibilities, and legal requirements. Staff submitted statutory notifications to the CQC as required, which are formal reports that providers must send to inform the regulator of significant events such as incidents, safeguarding concerns, or deaths. Managers held staff accountable for their actions, behaviours, and performance. The service also had business continuity plans in place to manage emergencies.

However, systems to monitor risk, performance, and quality were not consistently effective. Audits did not always identify issues in the service before external agencies raised concerns. For example, Mental Health Act 1983 administration was not always robust, and leaders did not have effective auditing processes in place to identify errors. Following findings from another ward, the provider reviewed documentation on this ward and identified similar issues, which they then addressed. This meant leaders had not identified these risks independently.

Staff and leaders understood their responsibility to collaborate and work in partnership with other organisations and services. They worked with relevant external stakeholders and agencies and were open and transparent in their approach. Staff shared information with partners to support patients’ care and treatment and engaged with external services, including community teams, to promote continuity of care.

Leaders had taken steps to strengthen relationships with partners and improve communication. They demonstrated an open and collaborative approach and had begun to use feedback and shared learning to support service improvements.

At the time of our inspection, the service was making improvements to address shortfalls in care and governance. However, many of these changes were in the early stages of implementation and had not yet been fully embedded in practice.

Leaders and staff showed an understanding of the need for improvement and were taking steps to strengthen oversight and quality within the service. Staff described being encouraged to develop their skills and contribute to improvements within the service.

Processes were developing to support learning when things went wrong and to share examples of good practice. However, these processes had not always been robust in the past and required further development to ensure learning was consistently found and implemented.

While the service had begun to focus on strengthening learning and improvement, these systems were still developing and required time to become fully effective and embedded.