Cygnet Maple House

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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, person-centred care, supported learning and innovation and promoted an open, fair culture. At the previous inspection, this key question was rated Inadequate. At this assessment, there was insufficient evidence to rate.

The service was in breach of 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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The evidence showed significant shortfalls. The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leaders did not always have the experience, capacity, capability and integrity to ensure that the organisational vision could be delivered, and risks were not always well managed.

For example, leaders were unable to provide assurance that safeguarding concerns had been recognised, escalated and managed appropriately. A senior member of staff was unable to describe the actions required following a safeguarding disclosure despite holding safeguarding responsibilities. This reduced our assurance that leaders understood and fulfilled their safeguarding responsibilities.

We were not assured that senior leaders maintained effective oversight of safeguarding activity, incidents or emerging risks. Important safeguarding concerns had not been referred, investigated or reported until inspectors intervened. This meant leaders could not be assured that safeguarding concerns were identified promptly, managed appropriately or that patients were consistently protected from the risk of harm.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Governance, management and accountability arrangements were not clear. Staff did not understand their role and responsibilities. Leaders did not have effective oversight of safeguarding activity, incident reporting or risk management.

We found inconsistencies between safeguarding records and Datix incident reporting systems, demonstrating a lack of accurate and reliable governance information.

Auditing and monitoring arrangements had not identified concerns relating to safeguarding referrals, reporting obligations, observation practices or risk management documentation. As a result, risks to patients were not always recognised, escalated or addressed.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.