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 inspection we rated this key question Requires Improvement. At this inspection the rating has remained Requires Improvement.

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.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

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.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had no incidents of severe harm in the 12 months prior to the inspection.

All staff knew what incidents to report and how to report them. Staff reported all incidents that they should report.

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

Staff received feedback from investigation of incidents, both internal and external to the service. Staff told us that updates were shared at handover and huddle meetings. Lessons learnt were shared with staff in team meetings and these including learning from other hospitals within the provider. Monthly lessons learnt bulletins were created.

There was evidence that changes had been made as a result of feedback. There had been incidents occurring within the main communal area, a review took place of the layout and a decision made to move the salon to a room upstairs in the building. This had a positive impact on the patients and reduced the number of incidents.

Staff told us they were debriefed and received support following incidents.

We do not always work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We do not always ensure continuity of care, including when people move between different services.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Staff did not always involve all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Stakeholders told us that the service was not always able to provide updates on patient progress and identified plans for discharge.

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. Staff told us that their views were listened to about whether the service could meet their needs. However, stakeholders told us that the service did not always fully consider all of the historical information about patients and whether the service could meet their needs. They gave examples where the service had admitted patients and later said they could not meet the patients' needs, resulting in patients moving again to another service.

We do not always 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.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Training compliance for introduction to safeguarding was 100% and intermediate safeguarding training was 100%.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. They gave examples where they had concerns about the presentation of patients on admission to the service and raised these with the previous placement. There was a safeguarding lead within the service and safeguarding incidents were discussed in the morning meetings.

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

Staff followed safe procedures for children visiting the service. There was a visitor's room off the ward with resources for children visiting the service including toys.

During the tour of the hospital, we saw that there was a sign displayed, dated 15 June 2026 that read “staff to observe patient parcel and post opening.” We raised this with the provider as an overly restrictive practice. The provider responded that the sign was recently updated and that the restriction of staff to observe parcel and post opening was an error. Following the inspection the leaders wrote to each patient to apologise for the displayed restriction and to advise that the restriction was in relation to opening parcels in the reception area to enable plastic packaging to be safely disposed of. We saw individual care plans in place for patients who required staff supervision when opening their post due to individual circumstances.

Mental Capacity Act

95% of staff had had training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles

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 provider 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 with regard to significant decisions. Records showed assessments in relation to capacity to consent to medicines, and another assessment was underway during the inspection regarding capacity for excessive spending and giving items away.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Staff also involved family members who had power of attorney in this process.

The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it. Audits took place quarterly.

We 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 scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 4 risk assessments and risk management plans during the inspection. These were up to date and reviewed following incidents. The provider had recently introduced ‘my safety formulation’ as the risk assessment.

There had been 24 incidents of restraint in the 12 months prior to the inspection, this involved 7 patients. Eleven of these were to administer medicines, 12 were related to managing violence and aggression and 1 was to prevent a patient continuing extreme prolonged activity. There were no incidents of prone (face down) or supine (face up) restraint. Four patients were administered rapid tranquilisation in the 12 months prior to the inspection.

Staff had regard to Mental Health Unit (Use of Force) Act 2018 and its guidance and complied with requirements. Staff participated in the provider’s restrictive interventions reduction programme, which met best practice standards including the requirements of the Mental Health Unit (Use of Force) Act 2018 and its guidance. This included information for patients about their rights in relation to use of force and the information was also available in easy read format.

Staff involved patients in care planning and risk assessment (shown by evidence in care plans, participation in multidisciplinary team reviews, access to a copy of their care plan and so on). Records showed these were reviewed as part of the ward rounds.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. This included easy read documents and communication cards. The service had introduced safe cards and we saw these were available in the communal areas of the service to enable patients to feedback about how safe they felt and ask for support if they didn’t feel able to ask staff directly.

Staff enabled patients to give feedback on the service they received. This included weekly community meetings, people’s council meetings and surveys.

Staff ensured that patients could access advocacy. There were 2 advocacy services available for patients; a generic advocacy service and an IMHA (Independent Mental Health Advocate) which was provided by 2 different organisations.

We do not always detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. However, they did make sure that equipment, facilities and technology supported the delivery of safe care.

Staff did regular risk assessments of the care environment. These included the consideration of the activities that would take place in the environment.

The ligature risk assessment and blind spot risk assessment was a lengthy document at 241 pages. The assessment included areas that patients did not access. A guidance document had been created for staff regarding ligature risks, including items that patients could use, how staff should respond and the location of the ligature cutters. Heat maps were created for each floor of the building, these showed the level of risk within the building and the location of the emergency equipment. The guidance document and heat maps were more succinct and accessible for staff to understand the risks in the environment. However the ligature cutters symbol on the ligature risk assessment was different to the one on the heat maps, this meant that there was not consistency and could be confusing for staff, especially when they were new to the service.

Ward layout mostly allowed staff to observe all parts of ward. Blind spots were identified in the ligature risk assessment and blind spot risk assessment and were mitigated mainly by staff observations. Mirrors had been ordered for a blind spot to mitigate the risk.

Staff had easy access to alarms and patients had easy access to nurse call systems.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The service was not smoke free. Patients smoked in the garden area, however this was clean and more welcoming than at the last inspection. A woodland scene had been installed at the back of the garden and secure metal bins for cigarette disposal. The door to the garden was kept closed and this reduced the smell of smoke in the lounge and kitchen. However, you could still smell smoke if the windows were open. The service had plans to become smoke free.

We do not always 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.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well  to provide safe care that met people’s individual needs.

The service had 2 support worker vacancies (WTE) . The service had 178 days sickness in the last 12 months, including a staff member on long term sickness. The turnover rate at the service had been 35% in June 2025, however this had reduced to 18% in June 2026. Agency staff usage was 13% at August 2025, this had reduced to no agency staff use from April to July 2026. Bank staff use had increased from 5% in August 2025 to 12% in July 2026, this was to support the reduction of agency staff use.

The clinical manager could adjust staffing levels daily to take account of case mix. Increase in bank staff had been partly to accommodate the increased observation levels due to increased acuity within the service.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. At the last inspection, bank and agency staff were not consistently receiving an induction to the service. However, at this inspection this had improved. We reviewed the rota and sampled 10 bank staff who had worked at the service prior to the inspection, and they all had the required induction and observation competencies in place.

A qualified nurse was not present in communal areas of the ward at all times. There was usually a support worker in the communal dining area. However, the nurses station had moved to downstairs since the last inspection and was now based off the dining room and a registered nurse was usually based in there.

Staffing levels allowed patients to have regular one-to-one time with their named nurse.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. Patients told us that activities went ahead.

Staff shift allocation records were not always completed accurately. We reviewed the allocation records for 1 to 20 July 2026 and found on the night allocation records from 1 to 5 and 11 July 2026 it showed a bedroom number where a patient was on one to one observations, however, that room showed as vacant. On day allocation records from 4 to 12 July 2026 staff were allocated to 1 to 1 observations however there was no record of which patient was on enhanced observations. This meant staff may not know which patient required enhanced observations. 

Staff were carrying out enhanced observations for longer than best practice advises without a break. The National Institute for Health and Care Excellence (NICE) NG10 recommends “that an individual staff member does not undertake a continuous period of observation above the general level for longer than 2 hours.” On 9, 17 and 20 July 2026 night shift and 15 July 2026 day shift, a member of staff was allocated to conduct observations for 3 consecutive hours without a break. On 16 July 2026 night shift, a member of staff was allocated to 5 hours continuous observations and another staff member was allocated 4 hours continuous observations. On 19 July 2026 night shift, a staff member was allocated 4 hours continuous observations. The providers ‘Safe and supportive observations policy’ dated May 2026 states “ Staff will be allocated one hour of continuous observation duty, however staff may be required to undertake a maximum of two consecutive hours of observation duty.” This meant the service was not following their policy and best practice guidance.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. On call arrangements were in place.

Staff had not received and were not up to date with all appropriate mandatory training. Learning Disability and Autism Tier 2 training was 28% compliant. Since 1 July 2022, all CQC registered health and social care providers have been required to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people with a learning disability. This should be at a level appropriate to their role. The autism capabilities framework state that " People with responsibility for providing care and support for an autistic person or people, but who could seek support from others for complex management or complex decision-making" require Tier 2 training. This meant the service were not meeting the requirements of the Health and Care Act 2022.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

All ward areas were clean, had good furnishings and were well-maintained. Concerns raised at the last inspection had been addressed. There was new furniture in the lounge areas, they had been decorated and the social hub was a welcoming space for patients that had been co designed by patients.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing. Staff were bare below the elbow, which was a significant improvement from the last inspection.

We 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.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Actions from the last inspection had been met, including ensuring that there was a key for the controlled drugs cupboard. Staff now completed and recorded checks of the emergency medicines. We reviewed 9 prescription cards. All medicines administered were signed for with no gaps in recording.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did so in line with national guidance. Staff were preparing for the introduction of electronic prescribing and medicines administration (EPMA).

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.