Cygnet St. Williams Also known as Cygnet Behavioural Health Limited

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 as good. At this assessment the rating has changed to outstanding. This meant service leadership was exceptional and distinctive. Leaders and the service culture they created drove and improved 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 were consistently effective. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements. Managers actively promoted a culture of openness and transparency. There was evidence of innovation and quality improvement taking place within the service. Staff worked in partnership with external services and enabled patients to have access to the community.

This service scored 89 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 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 people and their communities.

The provider’s purpose, vision, mission and values were:

• Purpose - To make a positive difference to the lives of the individuals we care for, their loved ones and all those who work within the organisation
• Vision – To provide high quality, sustainable specialist services that ensure service users and residents feel safe and supported, staff are proud of, commissioners and service users select, and stakeholders trust
• Mission - To work together in a positive culture of openness, honesty and inclusivity, where safe, compassionate, quality care is delivered to service users and staff enjoy a fulfilling, rewarding environment in which to work.
• Values – To care for our service users, staff and visitors, to respect them, to ensure a bond of trust is built among us, to at all times empower those we look after as well as our staff, to deliver quality services with integrity.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.

Staff had the opportunity to contribute to discussions about the strategy for their service in team meetings and during supervision and appraisal sessions.

Staff could explain how they were working to deliver high quality care within the budgets available.

We scored the service as 3. 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 had the skills, knowledge and experience to perform their roles. They 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 for patients and staff.

Leadership development opportunities were available, including opportunities for staff.

Managers planned for the future in terms of succession planning of staff. Staff could undertake leadership apprenticeships. Succession planning was part of the providers quarterly nurse associate programme. The provider’s human resources were responsible for talent management within the service. Supervision sessions included discussion around goals to increase skills and experience. Managers enabled staff to attend external courses such as maths and English to progress to a national vocational qualification.

We scored the service as 4. The evidence showed an exceptional standard. The service was exceptional at fostering a positive culture where people knew they could speak up and their voice would be heard.

There was a freedom to speak up guardian within the organisation. Staff knew who they were and where to find their contact details. There were also 2 freedom to speak up champions within the service who promoted the freedom to speak up process to staff.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs such as community meetings, comments cards and the provider’s complaints process. Survey results conducted over the last year indicated that staff engagement and follow ups were good. Patients felt their suggestions were implemented and their opinions were heard. Patients felt access to advocacy was good and knew how to complain. Feedback indicated that although patients liked the food they were provided, the menu needed to be changed as it was repetitive. This had been addressed at the time of our inspection.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

Patients and carers were involved in decision-making about changes to the service. For example, a patient had shared an idea for a group based on occupational therapy sessions they had done with the occupational therapist. The patient wanted to start a drawing group where an image/word was placed in the middle of the table and then everyone had to draw this in their own style, using paint, clay, colour pencil, shading etc. The occupational therapist suggested to the patient that they could facilitate the group together which was agreed. The new group was added to the activities timetable. Another patient contributed to the provider’s recruitment process by taking part in staff interviews. At the end of the interviews, the patient posed two questions to the candidates and helped inform decisions about those most suitable for the roles.

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

We scored the service as 3. 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.

There were equality and diversity champions within the service. These included a multicultural lead, and a staff relations lead.

The provider had 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.

The equality monitoring of staff within the service was undertaken by the provider's human resources team and via recruitment processes to ensure it was diverse in its make-up and representative of the patient group.

Staff were able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues.

Managers put reasonable adjustments in place for staff members to help them carry out their role. Staff with specific needs had been allowed to take additional breaks. Staff had been provided with specialist equipment following display screen equipment assessments or occupational health recommendations. This included specialist chairs, ergonomic computer mice, wrist supports and laptop and desktop risers.

We scored the service as 4. The evidence showed an exceptional standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Governance systems were effective.

All areas of the service building were safe and clean. There were enough skilled, trained and experienced staff within the service who received supervision and were appraised. Patients were assessed and treated well. Staff adhered to legislation, knew how to deal with complaints and reported incidents and safeguarding concerns. The medicines management arrangements now worked well. Managers shared lessons learned from investigating complaints, incidents and safeguarding issues. Staff participated in audits which were effective in identifying areas for improvement and acted upon. Staff received information governance training and maintained patient confidentiality. Staff worked in partnership with other teams and services to ensure patients received high quality care and treatment.

There was a clear 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.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. For example, following an error with medication administration, nursing staff were required to check every patient’s medication chart at every medication round to ensure patients received correct doses and nursing staff were required to re-familiarise themselves with the provider’s administration of medication guidance to ensure that they were following the correct procedures when completing medication rounds.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed.

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

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register.

The service had a business continuity plan for emergencies such, adverse weather, loss of IT, cyber-attacks, fire and bomb evacuations or a flu outbreak.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff.

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.

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 service’s key performance indicators were included bed occupancy. At the time of our inspection, the service was under budget as there were 8 patients using the service and the budget was for 9 patients. Training compliance was 98% and the outstanding 2% of staff already had their training scheduled. The service had scored 98% compliance in a regional quality audit. This audit covered patient feedback and involvement, reporting and investigating incidents and complaints, staff knowledge of safeguarding, assessing and managing risk, monitoring outcomes, responding to patients’ needs, coordinating care between teams and services, service culture, leadership competency, encouragement of innovation and ensuring best practice was adhered to.

We scored the service as 4. The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

The service engaged and worked in partnership with external stakeholders. Police liaison officers attended the service to support staff and patients following complaints of racist abuse. Staff worked closely with the integrated care board leads, local acute hospital, social services and local authority. Staff sent regular patient updates to commissioners and home teams. Commissioners were invited to ward rounds and care planning approach meetings. The service had good links with PEG and stoma services. The service had a service level agreement with local GPs and a pathology service.

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

The service promoted patient education and work opportunities as part of its weekly programme. Staff enabled patients to engage in volunteering with local charities, including activities such as dog walking, litter picking, assisting at community gardens, and supporting charity shops.

Staff ensured patients had access to dentists, GPs, opticians and other primary healthcare professionals within the community.

Staff gave patients access to activities within the community, including visiting a local reptile shop, swimming and, visits to train museums and seaside resorts. Education and training pathways were facilitated by the service’s occupational therapist, enabling patients to access courses at the local college

Staff supported patients to access a church at the rear of the service building which accommodated all faiths.

When patients were due to be discharged, staff referred them to community mental health teams when required to ensure they received ongoing support.

We scored the service as 4. 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 and effective practice.

Innovations were taking place in the service. Staff were using alternate methods for neuropsychological assessments such as treasure hunts, games, escape rooms and other activities. This has been developed and an article sent for publication summarising this. The service had found this was an effective way of understanding a person’s cognitive strengths and difficulties when they were unable to or did not want to participate in formal assessments. It also helped staff to understand people’s abilities in more “real life situations” which was helpful for considering placements and rehabilitation needs.

An activities coordinator was developing a network for peers to share good practice and group work to enable activities coordinators in different Cygnet services.

The service was seeking to gain a Headway accreditation to recognise and formalise its centres of excellence in brain injury and associated neuropsychiatric care. At the time of our inspection, applications had been submitted, and the service was awaiting dates for an assessment.

Staff used quality improvement methods and knew how to apply them. These included Plan-Do-Study-Act (PDSA) cycles to test small-scale changes before wider rollout, post-incident and learning reviews (noting system-level improvements to prevent recurrence). Staff conducted regular clinical audits to assess adherence to evidence-based protocols such as care documentation, person-centred care plans, health and safety and compliance with legislation and national guidance.

The service had recently undertaken a regional initiative on patient engagement within the unit to improve patient experience, involvement in care planning, and feedback incorporation. This involved a structured patient and carer feedback collection to identify barriers to engagement and involving patients in designing care processes, information materials, and discharge planning tools.

The service participated in the Triangle of Care framework to strengthen safety, engagement, and partnership with families, carers, and people who use mental health services. Staff implemented the principles of the framework into their daily practice, including enhanced family and carer involvement in care planning, patient safety strategies, and communication protocols.