Cygnet Grange

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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, patient-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 and assessment, the rating has changed to requires improvement. This meant leaders did not always support the delivery of safe care for patients. 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.

However, leaders ensured there was a shared vision and strategy, the service fostered a positive culture where patients felt they could speak up and their voice would be heard, the service valued diversity in their workforce and the service focused on continuous learning, innovation and improvement.

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.

Quality Statement Score: 3

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 patients and their communities.

Leaders ensured there was a clear and shared vision and strategy, which staff across the service understood and could describe.

The provider’s purpose was to “make a positive difference to the lives of the individuals they care for, their loved ones and all those who work for them.” The organisation’s values Care, Respect, Empower, Trust and Integrity were prominently displayed within the service.

Staff told us they accessed regular ‘bite‑sized’ learning to support them in embedding these values into their day‑to‑day practice. The provider had also developed a behavioural framework to guide staff in translating values into practice.

This demonstrated that leaders promoted a positive, values‑based culture and supported staff to consistently apply these principles when delivering care.

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 at every level were visible and led by example, modelling inclusive behaviours. Staff told us senior leaders visited at least once a month and were knowledgeable, supportive and knew the names of each patient. Staff told us leaders promoted an open culture that encouraged learning, reflection, and continuous improvement.

The evidence showed a good standard. The service fostered a positive culture where patients felt they could speak up and their voice would be heard.

There was a culture of speaking up where staff actively raised concerns. Staff told us they felt confident to speak up and that raising concerns was encouraged within the service. The provider had a Freedom to Speak up (FTSU) Guardian and speak up champions in services. Senior leaders advised no FTSU concerns had been raised about the service in the past year. Staff had received training and knew when to report things. The FTSU meets with the Operations Director quarterly to discuss any concerns and any learning.

Staff we spoke with were aware of the Freedom to Speak Up Guardian and were able to identify who held this role. They showed this by directing us to the Freedom to Speak Up information displayed on the ward, demonstrating that they knew how to access support if required.

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 patients who work for them.

Leaders took action to improve where there were any disparities in the experience of staff with protected equality characteristics, or those from excluded and marginalised groups. The provider reported 100% of staff completed equality, diversity, and Lesbian, Gay, Bisexual and Transgender (LGBT) training.

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.

The provider’s governance systems and processes were not always effective in identifying and addressing risks relating to patient safety and the quality of care. Cleaning and environmental monitoring processes were not always effective, resulting in some environmental risks not being identified or mitigated promptly and leaving patients insufficiently protected from avoidable harm.

The environmental maintenance concerns identified during the inspection indicated that governance arrangements designed to maintain a safe and well-maintained environment were not operating effectively in all areas. Although remedial action was taken promptly once concerns were highlighted, the findings demonstrated a lack of proactive oversight and insufficient assurance that vacated rooms were cleaned, maintained, and made ready for use in a timely manner.

These findings also demonstrated that cleaning checks were not consistently effective in identifying and addressing IPC risks. As a result, there was an increased risk of avoidable infection and evidence of weaknesses in both day-to-day oversight and the effectiveness of governance and assurance processes.

However, senior leaders described a number of governance arrangements in place to support oversight and quality improvement. A central action plan was developed in response to audit findings and was reviewed through governance processes and discussed at staff meetings. Oversight of on-site action plans are reviewed, followed up and actioned by the on-site Registered Manager. Any issues are then escalated into regional governance. Monthly, clinical governance meetings were held at service level and fed into wider operational and regional governance structures. The provider also had an overarching quality governance framework in place across its services.

The provider identified a number of risks on the risk register, including the use of blanket restrictions (for example, no plastic bags in patient areas following organisational learning and a coroner’s direction), CCTV blind spots within the service, and the implementation of personal emergency evacuation plans (PEEPs) to mitigate risks for patients located in upstairs bedrooms.

The provider shared minutes from six local clinical governance meetings. Agenda items regularly included lessons learned, the Patient and Carer Race Equality Framework (PCREF), incidents, restrictive practices, safeguarding, audit trends, enhanced observations, care planning, meaningful activity, and patient experience.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They share information and learning with partners and collaborate for improvement.

The service shared information and learning with partners and worked collaboratively to support improvement. Staff and leaders were open and transparent, and they worked in partnership with relevant external stakeholders and agencies. We saw evidence of positive feedback from external professionals who had attended patients’ care meetings.

Feedback from people using the service, their relatives, and professionals showed that the service was generally responsive to individual experiences and concerns. Records showed that where concerns had been raised, these had been investigated and addressed, demonstrating a structured approach to listening and responding to feedback. Outcomes following resolution were varied, with some individuals satisfied and others less so, indicating a need for continued focus on improving responsiveness and engagement.

Ongoing positive feedback from patients, relatives, and external health professionals reflected consistent strengths in staff attitude and the quality of care provided. This indicated that the service was meeting people’s needs in a respectful and person-centred way, while also using feedback to inform improvements and maintain quality.

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 patients. They actively contribute to safe, effective practice and research.

Staff and leaders ensured that patients using the service, their families and carers were involved in developing and evaluating improvement and innovation initiatives. Leaders told us about co‑production with staff and patients.

Staff were supported to prioritise time to develop their skills in improvement and innovation. Staff were in the process of embedding Safety Formulation, moving away from Short-Term Assessment of Risk and Treatability (START), risk assessments to support a more holistic and person-centred approach to understanding and managing risk. All staff were expected to complete Safety Formulation training by summer of this year.

Another nurse told us that all staff were required to be trained and assessed as competent in Percutaneous Endoscopic Gastrostomy (PEG) tube care by the end of summer 2026. This procedure involves inserting a tube through the abdomen into the stomach to provide nutrition, fluids, or medication for people who are unable to eat or swallow safely.

The service had well-established external partnerships that supported improvement and innovation. Staff and leaders took part in external initiatives, including research activity. Leaders evidenced collaborative working with external networks and programmes focused on restraint reduction, health and safety, and falls prevention, reflecting a commitment to continuous improvement.

Leaders evidenced that PCREF had been formally implemented, and corporate‑level planning was well advanced, with senior leadership involvement to support effective implementation. The hospital was co‑developing an Anti‑Racism Framework and previously ensured equality and culturally sensitive care for patients from ethnic minority backgrounds. Staff received comprehensive training, developed holistic assessments that captured cultural needs. A co‑produced working party involving staff, patients, and carers was being established to strengthen PCREF evidence, engagement, and data collection.

The service was a member of the Quality Network for Neuropsychiatry Services (QN-Neuro). It had successfully completed both the self-review and peer-review elements of the QN-Neuro developmental cycle, achieving a score of 81% in June 2025.

The report highlighted that the service maintained minimal blanket restrictions for patients and had a clear, well-considered structure that promoted patient autonomy. This supported a positive therapeutic environment, enabling patients to make choices about their daily lives and engage in meaningful activities, including real work opportunities, therapeutic earnings programmes, and annual artwork competitions.