Cygnet Sherwood Lodge

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

Well led - 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 and fair culture. At this assessment we rated this key question Good. This meant the service was consistently managed and well-led.

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.

Description: We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 3. The evidence showed a good standard of care.

Staff and leaders demonstrated a clear and shared vision, underpinned by a culture of openness, honesty, equality, diversity, and inclusion. Staff consistently reflected the organisation’s values in their day-to-day practice. Leaders ensured the vision was clearly communicated through a structured induction programme, mandatory training, and ongoing support, enabling staff to understand and align with the service’s objectives and priorities.

Results from the most recent staff survey (2026) indicated high levels of engagement. All respondents reported feeling encouraged and supported to raise concerns, including errors, near misses, and incidents, and were confident in how to do so. The survey found that 91% of staff felt trusted, valued and supported to work independently, 93% enjoyed their roles and working within the service. Additionally, 87% reported receiving the training and support necessary to deliver high-quality care and improve the experience of people using the service.

Staff were given opportunities to contribute to discussions about the service’s strategy and development, particularly during periods of change or transformation. This inclusive approach helped staff feel valued and supported, with a clear understanding of how their roles contributed to maintaining high standards of care and treatment.

Leaders demonstrated a strong commitment to addressing workforce inequalities and promoted an inclusive culture. They modelled behaviours that upheld equality, diversity, and human rights, supporting the delivery of equitable, person-centred care.

The provider’s strategy focused on delivering safe, effective, and compassionate care, with a strong emphasis on equality and partnership working. People remained at the centre of all decision-making. Leaders ensured consistent communication across the service to reinforce shared goals and direction, contributing to a positive, inclusive, and supportive working environment.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. The evidence showed a good standard of care.

Service leaders demonstrated the skills, experience and knowledge required to carry out their roles effectively. Roles and responsibilities were clearly defined, and leaders were accountable, ensuring they maintained oversight of issues, concerns and service priorities.

Leaders showed a comprehensive understanding of the service they managed and consistently supported their teams to deliver high-quality, effective and person-centred care and treatment. They were visible, accessible and approachable to people using the service, their relatives and staff. Leaders promoted inclusive behaviours that aligned with and strengthened the organisation’s values.

Opportunities for career development were available to all staff, with clear examples of progression supported in practice. For example, several care support workers progressed within their roles after completing the organisations apprenticeship scheme. Support workers completing the apprenticeship acquired a level 4 qualification, and leaders encouraged and supported them to apply for their nurse training qualification if they wished to do so.

Leaders recognised and valued their teams and took proactive steps to address any cultural concerns that could affect the quality of care or staff wellbeing.

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

We scored the service as 3. The evidence showed a good standard of care.

A freedom to speak up policy and procedure was in place. Staff had access to the organisation’s freedom to speak up guardian, as well as designated freedom to speak up champions based within the service who were readily available to provide support. Staff knew how to raise concerns and felt encouraged and supported to do so. The most recent staff survey (2026) showed that 98% of staff knew who their freedom to speak up guardian was, and 100% of staff knew how to raise concerns.

Freedom to speak up concerns were discussed at governance meetings, monthly team meetings and were also an agenda item in staff supervision whenever required. Freedom to speak up contacts were subject to monitoring and audited to identify any emerging themes. Where themes were identified, action plans were developed to address these. Staff felt assured that concerns were taken seriously and led to positive change. No freedom to speak up concerns had been raised in the six months prior to our assessment.

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

We scored the service as 3. The evidence showed a good standard of care.

There was a strong organisational commitment to equality, diversity and inclusion (EDI) within the service. The provider’s values were embedded in both care delivery and staff support. Leaders maintained effective oversight of the service and its culture, ensuring staff were treated fairly, with respect and compassion. Any instances of unfair treatment or disparities in experience, particularly for those with protected characteristics or from marginalised groups, were identified and addressed. Reasonable adjustments and flexible working arrangements were facilitated wherever possible to meet individual staff needs.

The service actively participated in a sponsorship programme for international staff. The organisation’s human resources team supported overseas staff throughout their transition into employment and provided ongoing support. Leaders ensured all overseas recruits completed role-specific training and competencies prior to commencing their duties. Staff reported feeling listened to, valued and recognised for their contributions within the service.

Leaders promoted inclusion by recognising and celebrating cultural and religious diversity. The service regularly held themed events to highlight different cultures, including shared activities, such as, celebrating cultural diversity through food. To celebrate cultural awareness week kitchen staff freshly prepared a different cultural meal each day. These initiatives enabled staff and people using the service to share and experience diverse cultural traditions, and provided educational opportunities, offering insight into different cultures and religions from around the world.

Equality, diversity and inclusion principles were embedded through the organisation’s core values—care, respect, empower, trust and integrity and reinforced through mandatory training, including EDI and unconscious bias training. The service contributed to an organisational EDI steering group and had designated EDI champions within the service. A range of staff support networks were promoted, including multicultural, LGBTQ+, women’s, disability and men’s health networks. The organisation was also recognised as a Disability Confident Committed and age-friendly employer. Additional EDI resources and support were available via the employee assistance programme.

Recruitment processes ensured fair, timely and equitable treatment of all applicants in line with the Equality Act and organisational policy, supporting a diverse workforce reflective of the population it served.

Leaders fostered an inclusive culture with a zero-tolerance approach to bullying and harassment. They actively sought to ensure all staff, including those less likely to have their voices heard, were able to contribute to service development. Equality, diversity and inclusion were clearly embedded within the organisation’s values, policies and strategic priorities.

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 3. The evidence showed a good standard of care.

Leaders had well-established governance and management processes in place, which supported the delivery of safe, high-quality and sustainable care. Staff demonstrated a clear understanding of their roles and responsibilities and were held appropriately accountable by leaders.

Staff actively engaged in audits and reviews, used findings to inform practice and developed action plans to address identified areas for improvement. This reflected a culture of continuous learning, improvement and service development.

Leaders maintained an up-to-date risk register, which was accessible, regularly reviewed and updated. Staff escalated concerns promptly, and contingency plans were in place to respond to incidents such as infection outbreaks or service disruption.

Information technology systems were effective and supported staff in delivering clinical care. Robust information governance arrangements ensured personal information was handled securely and confidentially.

Leaders had access to accurate and timely performance data, enabling them to maintain effective oversight of the service. Statutory notifications were submitted promptly to external organisations, including the Care Quality Commission, in line with regulatory requirements.

Leaders adopted recognised quality improvement frameworks and supported innovation through proportionate and effective risk management. This ensured governance systems remained responsive, resilient and sustainable.

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 3. The evidence showed a good standard of care.

Staff and leaders demonstrated openness, transparency and effective engagement with external stakeholders and partner organisations. They worked collaboratively with commissioners and other relevant agencies to support service delivery and promote integrated care.

Leaders shared learning through local and national networks and used these partnerships to drive continuous improvement. For example, the service engaged with the organisation’s national learning disability and autism network, which promoted service improvement through co-production with services, people, families and carers. This approach supported more consistent outcomes and ensured people’s needs were met effectively.

Staff at the service were part of a national learning disability nursing forum for private and NHS learning disability specialist providers and attended quarterly meetings to collaboratively review national policies. All updates and changes were then shared throughout the organisation and used to inform the organisations learning disability and autism steering group of any potential impact on services locally and nationally.

Managers worked closely with local and regional learning disability and autism service providers, commissioning partners and the police force. And attended quality and safe meetings. Quality and safe meetings ensured that learning and practice was shared effectively, incidents and risks were managed through a collaborative approach which provided enhanced oversight and understanding.

The occupational therapy team regularly networked with occupational therapists outside of the organisation locally and nationally to share updates, learning and good practice. The occupational therapy team were also part of the quality network for inpatient learning disability services (QNLD) accreditation committee, which again provided an effective forum for networking, evaluating services and improving care for people using services locally and nationally.

The service and people using it were actively involved in community initiatives and charity fundraising projects. For example, 5 people using the service and numerous members of the multidisciplinary team completed a sponsored 8-mile woodland walk to raise money for a charity that supported children and families across the world. The people who were involved with the walk were supported by staff to create their own t shirts to mark the occasion.

Leaders actively sought and valued feedback from partners and the wider community, using this information to shape service delivery and identify innovative practices to improve outcomes for people using the service.

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 4. The evidence showed an outstanding standard of care.

The organisation promoted a strong culture of continuous learning and improvement. Staff and leaders demonstrated a clear understanding of how to implement and sustain change, using structured quality improvement methodologies to enhance care, support and service delivery. For example, the service implemented an ‘Expert by Experience’ initiative. experts by experience brought lived experience of learning disability and autism services, either through prior service use or as family members or carers. Their involvement ensured the views and experiences of people using services were heard, meaningfully considered and used to inform improvements. This approach strengthened co-production and ensured the contributions of people, families and carers were valued in service development.

The service promoted innovative practice through a qualified art psychotherapy programme, using creative expression to help people explore emotions, build confidence, and develop emotional resilience. One person using the service received a commended art award from a national criminal justice arts scheme, recognising their creativity and supporting their rehabilitation journey.

Staff completed a quality improvement project to reduce noise and sensory overstimulation within the service. Improvements included acoustic panelling, soft-close doors, silent alarms, a sensory heat map, and staff training, creating a calmer environment and supporting better outcomes for people with sensory sensitivities.

The project led to a noted reduction in decibel readings, silent alarms effectively reduced the stimulus and distress throughout the service, the acoustic panelling reduced echo and spikes in sound, the sensory map clearly directed people using the service and staff to low stimulus spaces which included a low stimulus sensory room. There were also reduced reported concerns, and positive feedback from both staff and people regarding the noise levels of the unit.

The service participated in relevant national audits and benchmarking initiatives and was in the final stages of gaining accreditation with the Carers Trust Triangle of Care, a recognised quality improvement programme that promoted effective engagement with families and carers and supported them to be key partners in their loved one’s care. Leaders maintained open and transparent communication with staff, fostering a culture of trust where ideas for improvement were encouraged, valued and acted upon.