Cygnet Lodge Salford

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question as requires improvement. The service was in breach of legal regulation in relation to staffing. At this assessment, the rating continues to be requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to safe care and treatment, staffing, and premises.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Staff knew what incidents to report and how to report them. They reported them in a timely manner. Staff had access to an induction module regarding reporting incidents as well as e learning. Staff reported all incidents that they should report.

Incidents were documented on the monthly local clinical governance report. There were no serious incidents reported in the last 12 months.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong.

Staff received feedback from the investigation of incidents, both internal and external to the service. Staff reviewed incidents in daily risk meeting, lessons learnt were disseminated to staff via clinical governance meetings and shared in team meetings and email communications.

There was evidence that changes had been made because of feedback. For example, door locks had been identified at another service as being a ligature risk and these were checked by the service to ensure they were safe. They shared their learning with other sites in the governance processes informing regional operations managers and hospital managers.

Staff were debriefed and received support after a serious incident. Debriefs usually occurred at handover meetings. Psychology held reflective practice sessions to offer support to staff as well as providing support for patients. Post incident support training for staff had been provided.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored, and assured. We ensure continuity of care, including when people move between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Multi-Disciplinary Teams (MDTs) had discussions before any decisions were made to admit patients. The managers were able to refuse admissions where non suitable referrals had been made. When a patient had been admitted to the service a preadmission care plan and occupational therapy plan was in place. Medicines reconciliation was in place to ensure patients had the necessary medication.

When patients needs changed following admission this was escalated to the commissioners and local Integrated Care Board (ICB) to seek a more appropriate placement. Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

Commissioners’ local authorities and community teams were invited to ward rounds. Discharge planning meetings and aftercare service meetings were in place. Also discharge pathways were in place with weekly discharge meetings for those who were approaching discharge.

Healthcare and social care services were involved to ensure patients had continuity of safe care, both within the service and post-discharge. All patients were registered with individual GPs. Staff onsite supported patients to access physical health care and an identified nurse was in place to facilitate this.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect, and we make sure we share concerns quickly and appropriately.

All staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. There were three safeguarding leads, and they were all trained at level 4 safeguarding training. Staff could make direct referrals to the Local Authority, the head of care, and the manager had oversight of these.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

Staff followed safe procedures for children visiting the service. The service had a policy in place to facilitate children visiting and other people visiting the service.

Restraint and safeguarding were reported in the local and regional operational governance meetings. This included the number and type of restraints and the numbers of safeguarding referrals that were made to the Local Authority. In the 6 months prior to our assessment, 36 safeguarding referrals were made however, not all these met the threshold for the Local Authority to proceed. Restraint data over the last three months indicated this was used 26 times.

These was no written register of blanket restrictions in place at the time of the assessment; this had been recommended in an internal quality inspection on 26 November 2024 and not actioned. The blanket restriction register was provided following the assessment. Patients and staff worked collaboratively to review any restrictions at the morning meetings and within the patient’s council. The blanket restrictions audits were reviewed every three months by the head of care.

The provider did not always work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We looked at 8 risk assessments/risk management plans during the assessment.

In the records we looked at some of the risk assessments and risk management plans had not been updated following incidents and people did not always have risk management plans on their records in relation to a particular risk which was apparent from the incidents they had been involved in including violence toward others and being absent without leave.

Staff we spoke to were not always aware of the risks relating to each patient’s care. One patient had increased choking risks and was on a modified diet and not all staff were aware of this. The way the care records were structured meant that risk information was not always clearly highlighted. For example, although the patient with increased risks of choking did have a risk management plan relating to this it was in the physical health section of their care plan rather than the potential risks section and so could potentially have been overlooked by staff unfamiliar with the individual.

A patient absconded from the unit on the day of the assessment due to tailgating a member of staff through the ward door, this patient did not have a care plan relating to this risk and there had been a previous incident of attempted absconsion.

The number of incidences of restraint over the most recent three-month period was 26, one of these was in the prone position, rapid tranquilisation was used 4 times in this timescale. Post-incident debriefs were recorded within the governance reporting systems. There were 9 rapid tranquilisations, intramuscular within a 6-month period. There was not always evidence that post-monitoring checks were carried out following administration of rapid tranquilisation. e.g. Intramuscular Lorazepam. Incidents were recorded, and this allowed the service to monitor incidents happening monthly. Cygnet incident review forms were used and submitted following any rapid tranquilisation.

Staff involved patients in care planning and risk assessment, this was evidenced in care plans and participation in multidisciplinary team reviews. Patients were offered a copy of their care plans. However, some patients told us they were not always involved in their care planning.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Patients were invited to their ward meetings and staff and patients completed monthly feedback in preparation for their ward meeting if they wanted too. The ward round process did not always facilitate meaningful patient engagement, and some patients told us they were not able to say what they wanted to in their ward rounds. Patients had access to weekly community meetings and newsletters were produced in collaboration with psychology. Staff enabled patients to give feedback on the service they received via patient surveys. Advocacy was available for patients and an expert by experience spent time on the unit to support patients and share information. There was a patient’s council where they gathered feedback from the wards and management to ensure that the service users and staff were heard at all levels of the organisation. A co production strategy was in place to ensure people who were using services were equal partners in the service design.

The provider did not always detect and control potential risks in the care environment to make sure that the equipment, facilities, and technology support the delivery of safe care.

We saw instances of the ward and garden environment requiring maintenance to ensure patient safety, including damaged and stained furniture. On the unit the lift had been out of working order for some time. However, this had been reported, and they were awaiting this being repaired. The ward manager said the lift needed replacing and this was on the schedule of works to be completed this year. Following the assessment, evidence provided showed that the lift was being looked at to repair the operation of it. The front door was broken, and this had been reported, but work to make this safe and in working order had not been completed at the time of the assessment. This meant the patients were placed at risk from people entering the unit who should not be there. Following the assessment, this had been escalated, and a date had been arranged to repair the door. The ward environment needed refurbishment, with damaged paintwork in places and the secure courtyard area was very messy, with rubbish and cigarette ends all over the floor and overflowing from plant pots.

The patients’ main lounge area was being used primarily as a cut through to the smoking area which meant it was not inviting for patients. The door was constantly open which meant it was cold and there was a strong smell of smoke.

Staff did regular risk assessments of the care environment. The ward layout allowed staff to observe all parts of ward. Ligature anchor point and blind spot risk assessments had been completed, and this had been updated in June 2024. Where potential ligature anchor points had been identified the risks had been mitigated. The lift was excluded from the ligature risk assessment as it was out of order at the time the assessment was completed. Patients had reported the lift was frequently out of service and this caused difficulties in accessing the upstairs area for patients with limited mobility. Staff had easy access to alarms and patients had easy access to nurse call systems. Clinic rooms were fully equipped, and the resuscitation equipment was checked; however, the emergency drugs had not been checked regularly. Resuscitation simulations had been completed, and fire risk assessments had been completed as well as fire drills. Monthly health and safety audits were in place. Environmental issues including maintenance, risk and health and safety were reported on within the staff morning communication meetings and this was documented.

The provider did not make sure there are enough qualified, skilled, and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

Staffing data provided indicated several bank and agency staff had not completed their induction and therefore may not have been familiar with the unit. Both support workers and nurses received an induction at the start of their employment. Not all bank staff had received and were up to date with appropriate mandatory training. Prevention and management of violence and aggression safety intervention for bank staff was 71%. Personality disorder was mandatory e-learning however no bank staff had completed this. Staff raised concerns about recent changes to the patient cohort, for example admission of patients with primary diagnosis of personality disorder and feeling they had not had adequate training to meet the needs of some of these new patients.  Staff received supervision, appraisals, and safeguarding supervision. However, clinical supervision (every 90 days) for the consultant and doctors was only 50%. The speciality doctor told us he had not received any clinical supervision since June 2024. Following the assessment information reviewed identified that clinical supervision had been completed. The training was appropriate for the patient group using the service. The support workers we spoke with had not had any training on the MHA or MCA and were not familiar with the basic provisions of either Act. 

There were five vacancies for whole time equivalent support workers. The service had increased female staff who were agency workers as it had been incident reported about the number of male agency staff being employed on one shift being very high. This meant the female patients may not have been afforded privacy and dignity. There had been a large increase in agency staff being used because of acuity on the unit and increase in observation levels.

Managers had calculated the number and grade of nurses and healthcare assistants required. The manager was able to increase staffing numbers due to the acuity of the unit. The ward manager could adjust staffing levels daily to take account of case mix. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels.

Staffing levels mostly allowed patients to have regular one-to-one time with their named nurse and this was recorded. The manager reported this can sometimes be inconsistent due to the acuity on the ward.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities and if this did happen then the escorted leave and activities were facilitated as soon as they could.

There were enough staff to carry out physical interventions for example, observations, and restraint safely. There was adequate medical cover day and night, and a doctor could attend the ward usually within an hour in an emergency. If urgent care was required, then emergency services would be contacted.

The provider did not always assess and manage the risk of infection, detect, and control the risk of it spreading and share any concerns with appropriate agencies promptly.

There was some damaged furniture which presented an infection prevention and control risk. However, following the assessment CQC received confirmation that new furniture had been ordered.

The ward area inside was clean and cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Patients we spoke with reported the unit was clean.

We saw staff were not all bare below the elbows. The dress code policy addresses the need for staff to be, where they are providing direct patient care.

The provider did not always make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication.

The service was supported by a pharmacist from an external company. The pharmacist attended the site weekly to review charts and support audits.

People were given rapid tranquilisation medicines intramuscularly to help reduce agitation and aggression. Physical health monitoring post dose was not always completed in line with policy.

People were supported to manage their own medicines when it had been risk assessed that it was appropriate to do so.

People were supported to access over the counter medicines when needed to treat minor ailments.

Although people had risk assessments for venous thromboembolism (VTE) on their care records, it was not always clear if these risk assessments had been completed or when.

Medication records were not always contemporaneous – we saw for 3 people there were gaps on their chart to show if medicines had been administered, and two people had been administered medicines that had not been signed by a prescriber. Therefore, we could not be assured they had received their medicines as prescribed.

Medicines were stored securely and areas used to store medicines had temperatures monitored. However, the key to the controlled drugs cabinet had been lost. This was rectified immediately following our assessment.

Patients had been given statutory doses of medication on the basis of an email from the prescriber, and this was not then subsequently signed for by the prescriber on the patient’s prescription chart. Post-injection monitoring information was not available for the patients who had received rapid tranquilisation (IM lorazepam). The records of checks of the emergency bag did not include any documented checks of the emergency drugs which were also stored in the bag.

Physical health monitoring was completed in line with policy, however bowel monitoring for patients prescribed clozapine was not always documented.