Cygnet Churchill

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

We rated well-led as requires improvement. We assessed 6 quality statements and found 1 breach of Regulation 17 in relation to shortfalls in the effectiveness of governance processes. For example, existing governance processes did not always ensure learning from incidents or quality reviews were completed, or that the environment was adequately cleaned and maintained. Care plan audits assessed if care plans were present but did not assess the quality of care plan content, and we found shortfalls with physical healthcare and risks being updated following incidents. Clinical governance meeting minutes did not demonstrate that leaders monitored themes and trends in relation to complaints, safeguarding matters, or restraints. This meant it was unclear how leaders had oversight of this information, or how they discussed ways to reduce occurrences. However, staff and leaders reported a positive team culture where people could speak up without fear. They said staff were supported to develop their skills and within their roles, and staff were awarded for good work. The service demonstrated ways they actively promoted equality and diversity, and staff had access to staff networks through the provider. Leaders sought feedback from staff and completed actions to address areas of dissatisfaction.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff said there was a positive and compassionate listening culture involving staff and patients where learning was shared. They said the service empowered patients to be involved in their care and treatment, and to provide feedback on improvements for the ward. Some carers we spoke with described challenges with involvement in their relative’s care. Leaders had recently started a carers group and aimed to improve relationships between carers and the service in future. Staff and leaders were able to give examples of how equality and diversity was actively promoted within the service. However, as outlined elsewhere in the report, staff did not always act in line with the provider’s vision and values. For example, we observed 2 interactions between staff and patients while onsite that did not demonstrate the provider’s values of respect or care.

Staff received communications about the provider’s strategy and vision through newsletters, briefings, and on the intranet. We saw evidence of leaders taking actions that aligned with the strategic goals, such as developing staff and partnership working. However, further work was needed to ensure patients were always provided safe and high quality care. Staff had access to equality networks, and organised events which celebrated diversity. There were policies in relation to equality and diversity, and most staff had completed their equality, diversity and human rights training.

There had been some changes to the leadership team in the months leading up to our assessment. For example, a new quality and compliance role had been created, and a new clinical services manager had joined the hospital in early 2024. Staff spoke highly of the current leadership team, including the new Juniper ward manager who they said led by example. Most staff we spoke with described their leaders as supportive, fair and visible, and were pleased with how teamwork was instilled and implemented in the service. Most staff said there was a no blame culture, and felt they received the training required to deliver care and lead effectively. Leaders we spoke with were knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their roles. Leaders were alert to concerns around poor culture, and we saw evidence they had taken steps to address this while acknowledging further work was required.

Leaders had made some changes where they identified quality issues that may have an impact on staff or affect patient care. However, as mentioned elsewhere in this report, there were some shortfalls in the governance processes around recommendations identified to make improvements to the culture on the ward.

We spoke to 9 members of staff and 5 leaders, including the freedom to speak up representative. We also reviewed minutes of staff meetings and staff survey results. Most staff we spoke with said that they felt safe to raise concerns and demonstrated awareness about the process and who to contact. Staff felt there was mostly an open and transparent culture, where their voices and suggestions were heard and acted upon. Leaders told us about initiatives to better engage with staff and to implement changes based on their views. According to the latest staff survey completed in 2023, there had been an improvement in the staff members' awareness of the freedom to speak up process and most staff felt encouraged to report errors, near misses or incidents. This was also reflected in the interviews we had with members of staff.

There were reliable policies and processes in place to ensure that staff were provided with confidential and supportive ways of raising concerns. There had been no formal grievances raised in the 12 months leading up to the assessment. However, the methods of raising concerns were not always made available in an accessible format for staff. We will bring this to the attention of the provider independently of this assessment.

Staff we spoke with said they felt supported by their leaders and peers, and felt there was a diverse, fair and inclusive culture. The staffing and leadership teams were diverse, and staff told us career progression was not hindered by any of the protected characteristics members of staff may have. Some staff gave examples of inclusive practice and ways in which staff with protected characteristics had been supported by leaders and managers, and benefited from the relevant internal policies. One staff member we spoke with said they had received training after a transgender man was admitted to the ward. They welcomed this and felt better able to support transgender patients as a result.

Leaders obtained feedback from staff at the hospital through surveys and monitored progress of actions identified, some of which related to equality, diversity and inclusion. Job advertisements stated the provider was an equal opportunities employer and celebrated diversity. Staff survey results at a provider level identified challenges faced by some disabled and ethnic minority staff, which we are addressing with the provider independently of this assessment. Through the provider’s workforce disability equality standard (WDES) and workforce race equality standard (WRES) reports, it was identified that a significant proportion of staff did not complete the section of their HR record which detailed disability or ethnic background information. This meant it was unclear how leaders at Cygnet Churchill could make action plans in relation to addressing any workplace inequalities if they did not have baseline equality and diversity information for their staff. We did not see this information was obtained via the hospital’s staff surveys either. It was also unclear how leaders addressed actions identified within the WDES and WRES reports. We did not see evidence of discussions or actions when reviewing governance documentation.

There was a range of data and information available to leaders to understand performance and quality. However, despite this data we identified a number of shortfalls during the assessment which we spoke with leaders about. For example, it was unclear from the evidence provided how actions identified from audits were monitored for completion. The service had recently recruited a quality and compliance manager and new clinical services manager who planned to add actions from audits to the OLAP, but at the time of the assessment this was not happening. They said the actions were discussed in morning meetings but ongoing oversight of these was unclear. Clinical governance meeting minutes appeared to be incomplete. For example, leaders said they monitored the numbers of restraints, rapid tranquilisation, complaints, and discussed themes/trends of safeguarding matters, but the meeting minutes did not reflect this. We observed blank spaces in the dedicated sections, which made it unclear how leaders had oversight of these areas or identified themes and trends to inform improvement work. However, staff and leaders we spoke with reported improvements to effective governance and management arrangements. They described regular meetings they attended in which information about the service and lessons learnt were discussed. Managers could account for the performance of staff via dashboards, for example, to check training compliance figures. Leaders sought feedback from patients and staff for the purpose of improving patient and staff experience and monitored progress of actions via the OLAP.

While some governance processes operated effectively within the service, we identified several regulatory breaches that indicated this was not always the case. For example, existing processes had not identified shortfalls with physical healthcare management, complaints, and staff training compliance. Care plans were not always updated following incidents on the ward, care plan audits did not include a method to identify quality issues, and the ward was not clean or well-maintained. Leaders were aware of some environmental issues on Juniper Ward and acknowledged complaints about the temperature had been received. Leaders explained this was to do with the age of the building, and confirmed receipt of significant financial investment for hospital refurbishments throughout 2024. We recognise this as a positive action in the long-term, but we were concerned at the poor levels of cleanliness and disrepair we observed on the ward. When we raised our concerns, leaders took immediate steps by hiring a new housekeeper and maintenance manager. Furthermore, governance processes that related to implementing improvements following reviews and incidents were not effective in ensuring the necessary actions were always monitored or completed. This meant leaders were not always implementing changes that would lead to improvements in patient care. The service had a risk register, but this did not capture some of the risks we found during the assessment, such as the high turnover of staff, the findings from the cultural assessment, and the risk of patients going AWOL from the ward. However, there were also a range of well-functioning processes in place including emergency equipment checks and meetings to discuss risks and performance matters. The service had made improvements to their systems for oversight of safeguarding and incident management. Governance processes had ensured that previous breaches from our 2022 inspection had been improved upon.

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.

Most staff said they felt able to speak up with ideas for improvement. Leaders supported staff to improve their skills. For example, two staff members were supported to become nurse associates each year. Furthermore, in response to staff survey results where some staff did not feel they had access to non-mandatory or CPD training, the medical director was starting role play and simulation learning sessions. Staff we spoke with were positive about learning opportunities within the service. Leaders had recently recognised the importance of input from carers, and recently achieved the carers triangle of care accreditation. A new carers group had been started at the time of assessment. Staff said patient voices were listened to via clinical governance meetings and ward community meetings. Leaders informed us of quality improvement initiatives that had begun on the ward, including one led by the psychology team aiming to improve attendance to group psychology sessions, and another on staff burnout and addressing pressures. However, 2 regular agency staff said they were unaware or uninvolved with improvement plans for the ward.

Learning was shared at ward level and with the wider provider. Reflection and collective problem solving were encouraged via team meetings and reflective practice. Leaders had identified boredom on weekends as a factor in AWOL incidents. In response they opened a new social hub area and employed an additional activity coordinator for the weekend. This meant patients had access to new activities such as games, cooking groups and boxercise classes. Good work by staff was celebrated with awards. The service aimed to improve based on feedback received, for example, the OLAP contained actions from staff and patient surveys, ligature risk audits, some complaints, and the previous CQC inspection. The progress of actions was monitored via leadership meetings. Patients were invited to attend clinical governance meetings and weekly community meetings. We saw evidence that patient requests were acted on promptly. For example, patients asked for more tables and different cutlery which was actioned quickly. However, as mentioned in other quality statements, we found some identified actions for improvement were not always completed promptly or at all. This included the creation of a standard operating procedure following an incident, recommendations following the cultural assessment, and failures to address environmental issues on the ward while awaiting the longer term refurbishment work. This meant the service’s approach to improvement work was not always consistent. Furthermore, team meeting minutes were not recorded on a standardised agenda, which meant learning and incidents were not always discussed. Clinical governance meeting minutes had blank spaces for topics such as numbers of restraints, RT administration, and complaints. This meant we did not see evidence that leaders monitored themes or trends or used this information for learning and improvement ideas. Following feedback, leaders explained ways they planned to make improvements on identified shortfalls.