Cygnet Lodge Lewisham

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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 assessment we rated this key question good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew and understood the hospital’s vision and values and how they were applied in the work of their team. Staff could explain to us how they were working together to deliver care to their patients.

Staff had the opportunity to contribute to discussions about changes within the hospital. For example, about changes to the staff room, and the newer multidisciplinary team offices.

Managers had the skills, knowledge and experience to perform their roles. They had a good understanding of the hospital they managed. They could explain clearly how the team was working together to provide care to their patients. At the time of assessment, the hospital manager had been in post for 11 months.

All staff told us managers were visible in the service and approachable. They reported managers were supportive when approached.

Staff were very positive when speaking about their hospital manager. They told us they were making positive changes at the hospital, for example, improving team-working within the nursing team. Carers and patients also told us the manager was helpful and approachable.

Senior staff appeared proactive and responded quickly when areas of improvements were identified.

Leaders recognised success and celebrated their staff, for example, their employee of the month scheme and recognising milestones within the service.

Development opportunities were available. The hospital manager was attending the hospital managers development programme. Apprenticeships were also available to nursing support staff.

Staff we spoke with stated that they felt able to raise concerns and were aware of the whistleblowing policy.

The provider had a freedom to speak up policy and system in place. The hospital had a local lead. This information was displayed for staff to see.

Patients had opportunities to give feedback on the service they received. For example, through community meetings, one-to-ones with staff and the complaints form. However, patients told us they had not been asked for feedback on a regular basis, such as through frequent surveys.

Patients and carers were able to meet with the hospital manager to give feedback if needed.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. For example, patients and staff had requested a multifaith room, which was created. Patients were also able to re-arrange their food menu to suit their needs. Patients were able to raise issues in weekly community meetings. We saw staff were responsive to these requests and actioned them, providing feedback at the next meeting.

The provider valued diversity in the workforce and had several initiatives to promote an inclusive and fair culture for their staff.

Staff were able to access several staff networks through the wider provider. These included, LGBTQ+ network, women’s network, disability network and a multicultural network.

There were also equality and diversity champions at a local level within the hospital, for example LGBT+ and a multicultural lead.

All findings from the other key questions demonstrated that most localised governance processes were effective in identifying issues and driving improvement. We found a small number of areas where further work was needed.

The hospital had a framework of what must be discussed in team and governance meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

The ward team had a monthly meeting where they discussed health and safety, incidents, audits, hospital performance and team goals. The hospital manager chaired this meeting. Staff could join the meeting in person, or remotely via online video calls. There was also a nurses forum, attended by registered nurses where they discussed clinical matters in more detail, such as medicines management and specific audits.

A monthly governance meeting was held jointly with another local Cygnet hospital. They discussed matters such as incidents, safeguarding, training compliance and shared learning across the hospitals.

Managers and senior staff were able to manage performance issues appropriately. Managers and senior staff had access to a range of information about the performance of the service, staffing and patient care.

Staff knew how to report incidents on their internal system. We saw incidents and learning being discussed in team meeting minutes. Meeting minutes contained pictures and details of incidents from within the hospital, as well as incidents that happened at other Cygnet hospitals. Staff were able to tell us examples of recent incidents and the learning that came from the investigations.

The hospital raised safeguarding concerns when needed with the local authority. The hospital’s social worker managed all referrals and followed up areas as needed. They regularly discussed cases with the local authority to support their patients. However, nursing staff did not routinely raise safeguarding concerns themselves with the local authority. Staff told us concerns were raised as an incident, and the social worker or hospital manager sent the safeguarding referral. We did not see any evidence of delayed referrals to the local authority.

The hospital had a local risk register, maintained by the hospital manager. Staff concerns matched those on the risk register, such as, the nurse alarm system being updated.

The hospital had a business continuity recovery plan in place. They had plans for emergency situations, such as, a loss of electricity, a fire or water leakages.

The hospital carried out yearly staff surveys. At the time of assessment, the 2025 staff survey was being completed. The last staff survey was carried out in April 2024. This survey showed 100% of staff said they received the training to do their job well. That 96% of staff felt informed about news and updates from the hospital, and 88% of staff were able to contribute their ideas. However, 56% of staff were satisfied with their working hours and conditions, and 21% were happy with their pay. On this assessment, we did not receive any negative feedback from staff in relation to their working hours, their conditions, or their pay.

We found a few small areas for improvement around some actions plans relating to audits and simulations, and having both a paper and electronic system.

Staff participated in local clinical audits. The audits were sufficient to provide assurance and in most cases, staff acted on the results when needed. We did however see one audit where the same learning around documentation was identified for 3 weeks in a row, meaning an effective action plan had not been created.

The hospital ran scenario-based simulations for emergency events. The type of scenarios in the simulations would reflect the needs of the patients and where they had experienced recent incidents, such as the management of seizures. However, where gaps in staff knowledge were noted, we did not always see specific action plans in place. For example, for 3 consecutive months the simulation training showed staff were not carrying out chest compressions in line with recommendations. There was no specific and detailed action plan to follow up this finding at the hospital.

Staff had access to the equipment and information technology needed to do their work. However, some staff told us there was duplication of information as there was often an online form as well as a paper copy of some documents. Staff told us this took extra time to complete, as well as added confusion as to where the most up to date information was. For example, the spreadsheet for blood tests reviews showed some patients as outstanding, despite other information stating the blood tests had happened. We observed some staff had difficulties in locating some documents, for example, when trying to find incident forms.

Leaders understood who their partners and communities were and engaged with external stakeholders, for example, commissioners.

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

The hospital had a positive approach to quality improvement.Quality improvement projects were ongoing at this hospital. For example, there were projects looking at reducing constipation and promoting physical health.

There were examples of innovative care at this hospital. For example, supporting patients to increase their physical activity by employing a fitness instructor and having events to increase involvement, such as the ‘marathon in a month’ and the ‘national fitness day’ events. They also supported patients to learn how to cook their own meals, and patients were able to have copies of the cookbooks they used on the ward to use once discharged from the hospital. One of these cookbooks had been created by patients.

Staff were offered opportunities to develop and reflect. Mandatory training and supervision was completed by 100% of staff. Team meetings, nursing forums and clinical governance meetings all took place in line with their recommended time frames.

The provider had a green energy initiative in place for all Cygnet services. Their goal was to become a net zero company by 2040. The provider plans was to implement electric vehicles, solar panels, energy efficient lighting upgrades and increase their recycling.

The hospital’s consultant had recently been elected onto the Faculty of Rehabilitation and Social Psychiatry for the Royal College of Psychiatrists.

The hospital had submitted their application to become accredited through the Quality Network for Mental Health Rehabilitation Services.