Cygnet Lodge Salford

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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 requires improvement. At this assessment, the rating stayed the same requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation relating to governance and quality monitoring.

This service scored 61 (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 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.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. Appraisals reflected Cygnets vision and values.

Information was available on their website and a rehabilitation pathway document and model of care was also available. A five-year strategy was in place, and this was communicated to patients and an easy read format had been produced.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Awaydays for staff had been arranged to discuss issues about the service as well as team meetings, supervisions, appraisals, and daily handover meetings.

Staff told us they were able to speak out about any concerns they had within the service. There are equality and diversity and inclusion champions within the service. They had a LGBTQ+ network, women’s network a disability and multi-cultural network.

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.

Leaders had the skills, knowledge, and experience to perform their roles. Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Leaders were visible in the service and approachable for patients and staff. Leadership development opportunities were available, including opportunities for staff. Leaders in the service were open and honest as well as being compassionate with patients in the service.

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

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Carers we spoke with said staff were respectful and polite and they could speak up and give feedback about their relative’s care. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

The provider had a raising concerns freedom to speak up whistleblowing policy for staff. The policy was to support staff to feel empowered and safe to raise concerns in the workplace. Concerns raised were investigated with findings which were used to improve the services. The service had freedom to speak up guardians for staff to raise any concerns if they did not wish to discuss with their managers. They held monthly drop-in sessions and could be contacted remotely.

Patients and carers were involved in decision-making about changes to the service. Patients and staff could meet with members of the provider’s senior leadership team to give feedback. The Operations Director visited regularly and completed a walk round speaking to patients and staff. Carers, family, and friends could meet with the psychiatrist to discuss their relatives care with consent from the patient that they wanted this to happen. Carers had access to advocacy support provided by the same company the patients received support from.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We do not always have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment, and support. We do not always act on the best information about risk, performance, and outcomes.

From the information we reviewed, we were not assured that the provider had the appropriate governance structures and systems of accountability in place to assure them that good quality care, treatment and support was being delivered.

Care plans were not always being reviewed in a timely manner and not consistently reflecting collaborative working with patients. This reflected what patients told us on the assessment. There were no records available to demonstrate that bank and agency staff, including staff who were working on the ward on the day of our assessment, had received an induction when they first started work on the ward. The specialty doctor had not received any clinical supervision since June 2024.

Some Black and Minority Ethnic staff members described experiences of racism at work both in terms of verbal abuse from patients and feeling held back in their career development as a person of colour.

Staff undertook or participated in local clinical audits. The audits were insufficient to provide assurance. Audits did not highlight the environmental and infection control issues we saw on assessment. Patient risks were not always recorded in a way for staff awareness.

However, the unit had a risk register and staff had access to this. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register. For example, the front door not locking. Risks were not always mitigated in a timely manner for example the front door being broken and the lift not working. Risks were shared in morning meetings and any actions were disseminated. Risks were also highlighted in team meetings, governance meetings, regional and locally.

There was a clear framework of what must be discussed at a ward, team, or directorate level in team meetings to ensure that essential information, such as learning from incidents, complaints, and complements, was shared, and discussed. The clinical leadership nurse provided feedback to staff.

Staff had implemented recommendations following incidents, complaints, and safeguarding alerts at the service level. Due to the acuity of patients on the unit, the number of incidents had risen in the last month. The nature of some of these incidents being personally hurtful both physically and emotionally to staff. The manager acknowledged this and provided links and forms of support to all staff.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Management of risk, issues, and performance were reported by the governance meetings.

The service used systems to collect data from the unit that were not over-burdensome for frontline staff.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well, and helped to improve the quality of care.

Information governance systems included confidentiality of patient records.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing, and patient care. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

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.

Directorate leaders engaged with external stakeholders – such as commissioners and Integrated Care Boards (ICBs). Feedback received from commissioners confirmed the management were open and transparent and they kept them updated about patients. Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. Where any investigations had been completed by the service, they shared the outcomes with partner organisations where needed.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.