Cygnet Lodge Brighouse

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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 our last inspection we rated this key question good. At this inspection it remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted 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 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 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 Hospital Manager had been at the hospital for two years prior to our inspection and worked across two sites, located very close by. When they were not on site at Cygnet Lodge Brighouse, the Head of Care was in charge in their absence. The Head of Care had been in post since 2021. The leadership team worked with their team of frontline staff to maintain a positive culture, following the visions and values of the organisation. They engaged with staff, people who use services and other stakeholders regularly. Staff felt able to raise concerns and highlight areas for improvement and this was acknowledged and supported.

The team took steps to minimise the risk of closed culture developing to create a safe environment which was free from neglect and abuse. They did this by fostering an open and transparent environment where incidents and safeguarding concerns were reported, CCTV was reviewed and monitored, and lessons learned from these were shared, with all staff, to enable improvements to be made.

Management team members informed us that they were working towards AIMS (Accreditation for Inpatient Mental Health Services). AIMS is a quality improvement programme that recognises good practice and high-quality care whilst supporting services to identify and address areas for improvement.

We spoke with the Regional Facilities Manager about improvements to the service and there were improvement works ongoing to the building at the time of our inspection, such as replacement flooring. Proposed future improvements included replacement of windows, refurbishment of kitchen areas and installation of air conditioning in one of the kitchens, in response to patient feedback.

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.

Staff we spoke with reported that managers and senior managers were visible and personable and would get involved in patient care. We observed that the approach to care from the management was non-hierarchical and there was an open-door policy for both staff and patients.

The leadership team had a good understanding of the hospital and the patient group, demonstrating they had the skills, knowledge and experience to perform their roles to good effect.

Clinical Team Leaders had completed sensory integration training, which enabled the mentoring of other occupational therapists carrying out sensory needs work.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The most recent service user satisfaction survey received 9 responses.

Patients and carers were involved in decision-making about changes to the service and managers and staff had access to feedback given and used it to make improvements to the service. Patients and staff could meet with the leadership team, on an ad hoc basis to give feedback.

In the most recent staff survey, 91% of those who responded felt like they would be listened to if they were to raise a concern. Staff scored 98 % in the category that informed that they were aware of the organisations freedom to speak up guardian. The hospital also had a whistleblowing policy in place.

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.

The hospital had a multicultural lead in post and a multifaith room which could be used by staff and patients.

Staff we spoke with advised they were supported with reasonable adjustments, or flexible working arrangements, to support them to carry out their role and to manage personal circumstances, where this could impact.

Staff survey results indicated that 83% of those who responded felt that the organisation recognised the challenges and inequalities faced by individuals due to their protected characteristics. Also, 85 % of respondents were aware of the organisation’s Equity, Diversity and Inclusion Group. The organisation offered a range of other networks and groups such as staff carers network, multicultural network, LGBTQ+ network, disability network, women’s and men’s health networks.

The Triangle of Care assessment identified that Cygnet has a well-defined strategic approach to meeting the requirements under Patient and Carers Race Equality Framework (PCREF).

All staff meetings were open to staff from all disciplines to promote inclusivity. Where staff were unable to attend these, correspondence was sent which ensured they were kept up to date with any changes.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Governance meetings were held to discuss incidents. Clinical audits took place to ensure compliance with policies and procedures.

There was a clear framework of what must be discussed at a ward round, team level or senior meeting level. Handover meetings, supervision, debriefs and reflective practice gave opportunity for discussion. CCTV was reviewed where incidents had occurred and was seen as a learning experience rather than being punitive.

We observed ward rounds and morning meetings where regular agenda items were discussed, and a clear framework structure was followed.

The service had business continuity plans in place for emergencies.

Risk issues and performance were monitored on a regular basis. Hospital managers maintained and had access to the risk register. We reviewed the register which included 5 current risks these were updated when new risks were identified. Staff told us that risks were well managed and that they could identify these within the environment, which corresponded with those noted on the risk register.

The service used systems to collect data which were integrated into the daily routines of staff and did not impact on their roles. The hospital manager and head of care could access information such as staff and service performance and patient care which supported them in their work.

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

The hospital had good working partnerships with external providers such as safeguarding teams, advocacy services and community teams.

External stakeholders such as the Integrated Care Board were included in the engagement process.

We received feedback from stakeholders who found positives in the open and transparent approach of the management, and how incidents were managed, and found the service responsive and adaptable to individual needs. They referred to a good community presence and links with the acute hospital trust and GPs. There was a positive approach to relationships with placing commissioners and the use of a mobile dentist visiting the site to assist with oral health was very much welcomed in promoting physical health needs.

Individual staff members, such as the substance misuse worker, kept patients connected and completed work that was considered ‘life changing’. The Occupational Therapist ‘went above and beyond for patients, helping them to orient to a new area' when preparing for discharge, and was found to be ‘passionate and worked in a person centred way’.

We scored the service as 3. 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 people. They actively contribute to safe, effective practice and research.

Cygnet Lodge Brighouse has been awarded Triangle of Care Star 1 accreditation from the Carers Trust. This is a maximum award level for an inpatient service. This covers 6 Triangle of Care standards, including current practices, examples and improvement suggestions that should be incorporated into the hospital’s action plan. There was a pilot ongoing for producing draft specialist guidance to incorporate Patient and Carer Race Equality Framework (PCREF) principles into the triangle of care.

The service was looking to run a pilot scheme for care plans, to make them more streamlined. This is currently being discussed at governance level.