• Mental Health
  • Independent mental health service

Cygnet Lodge Salford

Overall: Requires improvement read more about inspection ratings

Radcliffe Park Crescent, Salford, Greater Manchester, M6 7WQ (0161) 696 4930

Provided and run by:
Cygnet NW Limited

All Inspections

During an assessment of Long stay or rehabilitation mental health wards for working age adults

Mental Health Act

Ninety-seven per cent of staff including nurses and health care support workers had received training in the Mental Health Act (MHA) including bank staff that was 83% compliant. Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice, and the guiding principles. However, some support worker staff we spoke to told us they had not received any training in the Mental Health Act.

Staff had access to administrative support and legal advice on the implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were. The provider had relevant policies and procedures that reflected the most recent guidance. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had easy access to information about independent mental health advocacy. Staff usually explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it. Audits showed Section 132 rights had not always been completed as outlined in paragraph's 4.28 and 4.29 of the MHA Code of Practice.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted. Staff requested an opinion from a second opinion appointed doctor when necessary.

Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly so that they were available to all staff that needed access to them. Audits showed there were gaps in the Section 17 leave forms and risk assessment in place that had not been signed and dated by the patient's responsible clinician. The service displayed a notice to tell informal patients that they could leave the ward freely.

Care plans referred to identified Section 117 aftercare services to be provided for those who had been subject to section 3 or equivalent Part 3 powers authorising admission to hospital for treatment. Staff did regular audits to ensure that the Mental Health Act was being applied correctly.

Mental Capacity Act

Ninety-seven per cent of substantive staff had received training in the Mental Capacity Act (MCA) With 83% of bank staff having received training. Some staff had a good understanding of the Mental Capacity Act. However, some support worker staff we spoke to told us they had not received any training in the Mental Capacity Act.

There were no Deprivation of Liberty Safeguards (DoLS) applications made in the last 6 months to protect people without capacity to make decisions about their own care. The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were aware of the policy and had access to it. Staff knew where to get advice from within the service regarding the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff took all practical steps to enable patients to make their own decisions.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis regarding significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture, and history. The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and acted on any learning that resulted from it.

During an assessment of the hospital overall

The date of the onsite assessment to Cygnet Lodge Salford was 6 February 2025. We assessed Cygnet Lodge Salford, long stay or rehabilitation (rehab) mental health wards for working age adults as they had not been inspected since 2021. The service provides inpatient rehabilitation for 24 women with a primary diagnosis of mental illness for individuals detained under the Mental Health Act (1983) or informally. It can also provide community rehabilitation support in 3 step down flats to enable individuals to build on their living skills before being discharged into the community. All rooms provided ensuite accommodation. The hospital is based in Salford, Manchester. 

We assessed 31 quality statements across the safe, effective, caring, responsive, and well led key questions.  

The last comprehensive assessment of the long stay or rehabilitation mental health wards for working age adults was in 2021 and the service was rated as requires improvement. The provider had not taken action in relation to concerns raised in relation to staff receiving an induction, supervision and governance raised in 2021.These are the same concerns we found on this assessment.  

We identified 5 breaches of the legal regulations in relation to person-centred care; safe care and treatment; premises and equipment, staffing and governance.  

Our overall rating is requires improvement. 

However, patients and carers reported positive feedback about their care and told us that they were treated with dignity and respect. There were enough staff to ensure people’s safety and meet their needs. People were supported to have choice and control and could give feedback on their care. 

7, 8 and 13 September 2021.

During a routine inspection

We rated this location as requires improvement because:

The service did not provide safe care. Some staff were not following government guidance in relation to infection control and use of PPE. Some staff including bank and agency staff did not receive a thorough induction into the service.

The service was not well led; the governance processes were not effective as they did not identify that staff had not received a thorough service induction. Managers had not ensured that staff were following government guidance in relation to infection control and use of PPE. Areas for improvement identified by the manager had not been fully embedded.

However:

The ward environments were safe and clean. The ward had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national best practice guidance. Staff engaged in clinical audit to evaluate the quality of care they provided.

The service included the full range of specialists required to meet the needs of patients in the service. Managers ensured that these staff received training and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients in care decisions.

Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

The service worked to a recognised model of mental health rehabilitation.