Cygnet Elms

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 assessment we rated this key question outstanding. At this assessment the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had 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 felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected 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.

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.

The provider had clear organisational vision, supported by a five-year strategy that set priorities for workforce development and service delivery. Staff understood the provider’s vision and values and were able to demonstrate to us how these were reflected in their day-to-day practice.

The occupational therapy team had a structured development plan for January 2026 to January 2027. Priorities included developing sensory-friendly environments, promoting evidence-based practice.

Patients told us they were actively involved in co-producing improvements to the service, including the refurbishment of the sensory room and communication room.

The ward manager described an open and supportive culture, where staff were encouraged to speak openly about any concerns they may have as well as contributing to service improvements. The ward manager also told us they felt respected, supported and valued in their role.

The provider promoted equality, diversity and inclusion throughout the organisation. Staff demonstrated a good understanding of equality and human rights, describing how these were implemented in their practice. Policies and training supported an inclusive culture. Leaders promoted equality for both staff and patients.

Staff told us communication from leaders was clear and regular, helping them to understand the organisations priorities and shared goals. Staff also told us they felt valued and included, speaking positively about the culture within the service.

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 demonstrated effective oversight of the service. The ward manager demonstrated a good understanding of the service, including patients’ needs, staffing arrangements, risk and governance processes.

During our unannounced assessment, the service was also undergoing a Quality Network for Learning Disability (QNLD) peer review. Staff and leaders managed the demands of both their visit and our assessment process effectively. Following our assessment and the QNLD visit, the QNLD team commended the service on how well it managed both their peer review and the CQC unannounced inspection on the same day.

Leaders were visible, approachable and well known to both patients and staff. Staff told us they felt supported by the leadership team, describing how the service has an open culture. The Head of Care provided operational oversight of the service and supported the ward manager with governance, quality assurance and staff development.

Staff received regular supervision every three months and annual appraisals. Supervision and appraisals included discussions around career development. Leadership development opportunities were also available.

Staff told us senior leaders visited the service frequently and maintained oversight of quality and performance.

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 ward manager described an open and supportive culture, where staff were encouraged to raise concerns without fear of consequence. Staff demonstrated a good understanding of safeguarding and whistleblowing processes and told us they felt confident in reporting concerns raised.

The provider had a Freedom to Speak Up (FTSU) policy and procedure in place. Staff also had access to the organisations FTSU guardian.

Safeguarding audits demonstrated effective reporting and monitoring. Patients told us they felt safe and knew how to raise concerns if they needed to.

Patients and their relatives were regularly encouraged to provide feedback through community meetings. Managers reviewed feedback from patients, relatives and staff and used this information to make service improvements.

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.

The organisation had an Equality, Diversity and Inclusion Strategy and an active LGBTQ+ staff network. We saw regular communication promoting these through provider newsletters.

Leaders demonstrated a clear commitment to equality, diversity and inclusion. Staff told us they felt respected and valued, regardless of their background.

The service supported staff through regular supervision, annual appraisals and opportunities for professional development.

Managers made reasonable adjustments for staff where required and supported flexible working arrangements to accommodate staff needs.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders had clear governance processes in place. Staff understood their roles and responsibilities and were supported to raise concerns. Staff told us their concerns reflected those recorded on the risk register and they knew how to escalate risks when required.

Morning meetings, handovers and regular teem meetings provided effective oversight of incidents, risks, safeguarding concerns, complaints and care. Staff told us learning from incidents, complaints and safeguarding concerns were shared through team meetings and meeting minutes.

We reviewed governance systems, including medicines and safeguarding audits, which identified no concerns. There were no Section 42 safeguarding enquiries over the previous 12 months.

Staff worked collaboratively with colleagues and external agencies to ensure patients received coordinated care.

Staff told us they felt they had adequate access to the equipment and information technology they needed to carry out their roles. Although most clinical records remained paper based, they were stored securely and the electronic systems they did have in place supported safe management.

Leaders used recognised quality assurance processes to monitor performance, manage risks and support 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.

Staff and leaders worked with commissioners, health professionals and other external organisations to support patients integrated care experience. Leaders maintained effective relationships with stakeholders and engaged openly with them. Stakeholder feedback was positive, reinforcing the good working relationship they had with the service leaders.

External professionals spoke positively about the service, highlighting the effective multidisciplinary team working and communication.

Patients were supported to engage with their local community through community activities with staff and their peers, as well as local projects and charity fundraising.

The service developed a comprehensive letter from the physical health nurse that was included within patients’ hospital passports. The letter explained the health inequalities experienced by people with a learning disability and autistic people and reminded external healthcare professionals of their legal responsibilities under the MHA, Human Rights Act 1998, Health and Care Act 2022 and Care Act 2014. It also highlighted the importance of making reasonable adjustments to meet peoples individual needs, avoiding diagnostic overshadowing (where symptoms are wrongly attributed to an existing diagnosis), providing timely access to assessment and treatment and ensuring everyone receives fair, person-centred care. The supported the external healthcare providers to understand patients’ individual needs and promoted more equitable care for their patients who may need to access acute services.

The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always 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 provider had a central lessons learnt hub, which shared learning from incidents, quality improvement projects and good practice across the organisation. Staff had access to this information to support learning and improvement in practice.

The service demonstrated innovation through a quality improvement project to develop a dedicated low-stimulus regulation space within the service environment. The environment was designed using principles from the psychology and speech and language team, to provide support to patients experiencing distress or sensory overload. The room included low-stimulus décor, accessible information, Talking Mats, easy-read information and visual grounding techniques to support emotional regulation. During our assessment, patients and staff told us they were currently working together to make further improvements on the space, to suit the patient group’s wants and needs more.

The service continued to improve the environment in response to feedback. Following our assessment, leaders confirmed that further improvements, including the instillation of dimmable light switches in communal areas, had been planned to enhance patient experience.

Staff contributed to learning beyond their immediate roles. Staff told us they supported student nurses to develop their knowledge and understanding of learning disability services, whilst with them. They delivered bespoke training in the following, communication, dysphagia and therapeutic approaches.

The service participated in external accreditation programmes relevant to the care they provided and used feedback from these reviews to make further improvements on the service. Leaders demonstrated a commitment to continually developing the quality of care the patients received.