Cygnet Newham 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 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.

At our last assessment we rated well-led as good. At this assessment the rating has changed to outstanding. 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.

We scored the service as 4. The evidence showed an exceptional standard. The service had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the 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.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

At the October 2025 Neurological and Complex Care awards, the service was named the best neurological provider, and the registered manager had been shortlisted for the ‘manager of the year’ category. A consultant neuropsychiatrist within the service had received the organisation’s innovator of the year award.

The service had implemented a comprehensive Patient and Carer Race Equality Framework (PCREF) action plan which had been embedded across governance, care delivery, and staff practice. PCREF is a mandatory anti-racism framework launched by NHS England to improve mental health access and outcomes for ethnically diverse communities. Co-produced with patients and carers, it ensures services are culturally appropriate, focusing on leadership, data monitoring, and feedback.

Both ward and hospital-level PCREF overviews had been developed, displayed, and discussed within governance forums, supported by appointed PCREF champions and evidence folders to demonstrate oversight and regulatory compliance. The service had established racialised feedback routes, community partnerships, and regular engagement with faith and community leaders, alongside accessible information in multiple languages and adapted legal documentation.

Ethnicity data quality and monitoring processes had been strengthened, with restraint, incidents, care access, and complaints reviewed through an inequality lens and fed into local governance discussions. People using the service had been supported through communication passports, culturally meaningful activities, advance choice processes, and inclusive feedback mechanisms, while staff had received trauma-informed and cultural competence training, with clear escalation routes for concerns.

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 encouraged staff to take on lead roles such as reducing restrictive practice leads and co-sustainability leads to support both their own development and the service. Senior staff had achieved Chartered Management Institute qualifications in management and leadership, and the clinical lead was completing the course to support succession planning and leadership.

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.

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. 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.

Patients and carers were involved in decision-making about changes to the service. For example, staff enabled patients to be involved in a quality review of the service’s patient pathway, thus allowing them to shape the way they and future patients were treated.

The service introduced an open-day recruitment approach in which staff and patients jointly assessed candidates through communication exercises before their formal interviews. This evolved into monthly onsite interview afternoons facilitated by the clinical team and patients, using games and communication aids to evaluate candidates’ values and suitability. The initiative improved the service’s ability to recruit staff with the right values and contributed to reduced staff turnover.

The hospital manager held a monthly virtual out-of-hours meeting for carers to provide them with a consistent link to the service, and regular carers’ days were also held to encourage their involvement.

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.

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 worked 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, including LGBT+, BAME, men’s health and mental health first aiders.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

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 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 incidents, complaints and safeguarding alerts at the service level.

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 as adverse weather, loss of IT, cyber-attacks, fire and bomb evacuations or a flu outbreak.

The service used systems to collect data 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 was working well against its key performance indicators (KPIs). The service operated on 0–1% agency usage. Three shifts were covered by agency staff in December 2025 due to a short notice increase in required observations. Clinical supervision compliance was 97%. The senior leadership team met weekly to review performance, focussing on KPIs and strategies to achieve them. The ward manager and nurse in charge reviewed KPIs daily and scheduled any required supervisions or appraisals. Eighteen of 20 beds were occupied, with a waiting list of four patients awaiting funding from the integrated care board.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and worked in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborate for improvement.

The service engaged and worked in partnership with external stakeholders.

Local commissioners regularly visited the service for assurance. External assurance and commissioner reviews showed the service provided transparent, person‑centred information, with clear multidisciplinary records and effective sharing of information.

Staff within the service engaged with integrated care boards. Feedback from the integrated care boards and commissioners about patient care and treatment was positive.

The service had a good working relationship with the police. Police had visited the service to speak to patients about racist abuse and had supported patients who had been assaulted by a peer on the ward. Attempts were being made to have a police community officer for more regular engagement.

The service had developed a service level agreement with a local mental health trust in relation to the provision of a chaplaincy service to support patients’ spiritual support.

Staff within the service had a good relationship with the local authority safeguarding teams. The service liaised with integrated care boards and care coordinators.

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

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.

Staff supported patients to access their chosen place of worship within the community.

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

The service also had a service level agreement with a local GP practice to ensure patients were accepted on to the GP register, received routine and responsive medical reviews, and were supported with referrals to community and specialist services where appropriate.

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.

Staff were given the time and support to discuss opportunities for improvements and innovation and this led to changes.

Staff used quality improvement methods and knew how to apply them. The service’s psychology team identified a need to improve the service’s awareness of trauma informed care. An initial survey was developed followed by the whole staff team being supported offsite to engage in training and a further survey was conducted to plot progress.

To aid learning and development, the local clinical governance team developed a quarterly innovation report which the individual therapy teams were asked to complete. This ensured that the team were aware of any innovations and practices the individual departments were working on and then this was updated every quarter. This led to a better acknowledgement and understanding of different professions and awareness of roles.

Following some recruitment concerns, the leadership team developed a shared recruitment process which evolved from utilising a hotel to interview candidates with patients, to monthly recruitment afternoons. These afternoons had all job candidates present with members of the therapy team, leadership team and patients. The candidates and interview panel completed communication games, conversation starters and other ways to get an understanding of the candidate to see if they would be an appropriate staff member based on values. Following this they did a formal interview. This reduced staff turnover and resulted in an increased staff team who knew what the job entailed and were passionate about their role.

The clinical manager completed a plan-do-study-act process on neuropsychiatric induction. This was related to the recruitment concerns as it was noted that some staff did not understand the patient need and were not appropriate for the job for which they were employed. The induction within the organisation had always been based around e-learning. The neuro induction incorporated work with patients, carers and the education department to ensure that the induction for staff was comprehensive within e-learning but also incorporated what neuro services required. The service provided monthly development days on site. These started as a response to staff stating they were unsure of people’s roles, so therapy and nursing staff all had a slot to discuss their roles. Following the 12 months when all staff had received this training, a survey was sent to staff about what they wanted for the next 12 months. The development days were now regarding patient needs and support for neuro care.

Innovations were taking place in the service. In the NHS, a Culture of Care refers to an environment where patients and staff feel safe, supported, and valued, moving away from rigid clinical models toward therapeutic, relationship-based care. The team engaged in a 'Culture of Care' action plan that was devised by the registered manager. This was monitored via local clinical governance meetings and ensured that developments were patient and carer centred, ensuring that their experience was the best experience they could have within the service.

A medication reconciliation quality improvement project was undertaken within the service to address significant discrepancies between patients’ prescribed medications on the service’s medication charts and their GP records. The initial audit identified a 5.3% match rate, with 18 out of 19 patients showing inconsistencies, posing risks of medication errors and compromising patient safety. The service implemented a structured reconciliation process, including a weekly‑updated medication spreadsheet, immediate logging of any medication chart amendments, routine communication of updated medication lists to the GP practice, and joint checks between the GP and speciality doctor during bi‑weekly visits. These measures strengthened governance, improved information accuracy, and enhanced communication pathways with primary care. A follow-up audit demonstrated substantial improvement, with 61.5% of patients (8 of 13) having fully accurate medication records across both the GP system and their medication charts. Remaining discrepancies were linked to very recent medication changes not yet reflected on the GP system or isolated external dispensing errors.

The service participated in accreditation schemes relevant to the service and learned from them. The service had achieved a 1-star accreditation in the Triangle of Care. The Triangle of Care is a quality improvement scheme for health and social care providers that promotes safety, recovery and wellbeing by including and supporting unpaid carers.

The service was officially a member the Independent Neurological Rehabilitation Providers Alliance (INPA). INPA is a group of independent specialist health and social care providers, who share the common goal of ensuring the delivery of excellent care in neurorehabilitation.

The service participated in the Headway Approved Provider scheme, an accreditation process designed to help patients, families and commissioners identify high‑quality brain injury services. The scheme is centred on patient and carer experience, incorporating evidence‑based practice, strong governance and an outcomes‑focused approach. The service was assessed on 26 November 2025 through the Headway Approved Provider accreditation process and achieved an overall rating of outstanding. The service was recognised for delivering high‑quality, person‑centred, trauma‑informed care through a fully integrated multidisciplinary team. The service was rated outstanding for culture, workforce development, service delivery, governance and leadership and quality, and good in systems and processes and environment. Patients and families consistently reported positive experiences, describing care as safe, holistic, compassionate, and respectful, with open communication and meaningful involvement in care planning. As a result of this assessment, the service was granted Headway Approved Provider status for a further two years, reflecting sustained excellence in care delivery and management.

The service had implemented a comprehensive programme of quality improvement actions, the majority of which had been completed, including enhanced staff support measures such as trained trauma risk manager practitioners and mental health first aiders, structured induction and ongoing development days, positive behaviour support and trauma‑informed care training, and autism‑informed practice.

Patients were actively involved in shaping their care through co‑produced timetables, personalised activity programmes, daily reflections, menu planning, and the development of therapeutic, sensory and visiting spaces. Carers were recognised as integral partners in care, supported through dedicated roles, Triangle of Care accreditation and flexible engagement arrangements.

The service had strengthened inclusivity and equality through embedding the Patient and Carer Race Equality Framework (PCREF) and improving access to spiritual, community and voluntary sector support.

The service was a member of the quality network for neuropsychiatry services (QN-Neuro). The service’s QN‑Neuro developmental review in June 2025 found a positive, inclusive and supportive culture with visible leadership, open communication and strong staff support systems. Patients and carers described staff as compassionate and committed staff, with effective engagement forums and feedback processes contributing to continuous learning, psychological safety and positive outcomes.