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 inspection we rated this key question Requires Improvement. At this inspection the rating has changed to Good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

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. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their 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.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Team meeting minutes showed discussions about changes in the service and culture, acknowledgement of the impact of change on staff and how to promote their wellbeing.

Staff could explain how they were working to deliver high quality care within the budgets available. This included training one of the staff team to be a physical interventions trainer who could deliver the training, respond to queries and offer bespoke support and guidance on site.

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. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. The hospital manager had been in change and development roles previously and used their skills to implement the changes since the last inspection.

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. Staff told us and we saw that the operations director visited the service.

Leadership development opportunities were available, including opportunities for staff. Cygnet Masterclasses had been introduced and were available for all staff to book on. Ward manager training was available and staff in acting roles could access this too. Leader in care apprenticeships were available for managers. The service had joined with the University College Birmingham to offer nurse apprenticeships too.

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. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. This included community meetings, with a community meeting notice board showing actions and asking for patients ideas for meals to cook at the cooking groups and ideas for day trips. There was also feedback surveys for both patients and carers, and the patient council. Carers could also give feedback through the carers advocacy service which Cygnet had commissioned. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. An example of an improvement was the introduction of weekly update calls with a parent who was not always able to attend the ward rounds and wanted to be involved in their daughter's care.

Patients and carers were involved in decision-making about changes to the service. This was done through the community meetings, patients’ council meetings and in individual consultation projects, for example the relocation of the salon. Patients had decided which room the salon would be in and on the redecoration and repurposing of the lounge to a social hub, choosing the décor of the room.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. The consultant and hospital manager were facilitating drop in sessions for staff. The freedom to speak up guardian and ambassadors were promoted through the service.

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. The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were equality and diversity champions within the service. Champions included equality, diversity and inclusion, and a staff relations group (a staff representative to share staffs views and experiences at a provider wide meeting). Staff had access to a LGBT+ network, multicultural network and a multicultural mentorship.

Staff were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

Managers put reasonable adjustments in place for staff members to help them carry out their role. This included for pregnant staff.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group.

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 act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was not always 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 and complaints, was shared and discussed. We reviewed minutes of the regional clinical governance meetings and found there was a standard agenda which included safety, incidents, training, care plans, staffing and complaints. The regional operational governance meeting had a standard agenda. However, the team meeting minutes reviewed did not consistently include the agenda items of complaints, incidents and lessons learnt. From March 2026 the minutes showed lessons learnt were included in the meeting and from May 2026 complaints were included in the meeting. This meant team meetings had only recently included information on lessons learnt and complaints.

Staff had implemented recommendations from reviews of incidents, complaints and safeguarding alerts at the service level together with learning identified from reviews of deaths and incidents of severe harm across the wider provider organisation. A change had included moving the nurses office to downstairs in the communal area so that staff were closer to respond to patients needs. The salon had moved upstairs too which provided a larger quieter space for patients and meant that activities were distributed throughout the building rather than all taking place in one area, which caused conflict at times.

Staff undertook or participated in local clinical audits. When issues were identified through audits, staff acted to resolve these.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Stakeholders confirmed that staff were responsive to their requests.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register. Risks aligned with what leaders told us, this included the previous enforcement action from CQC, a block contract with one trust and the number of staff on maternity leave.

The service had plans for emergencies – for example, adverse weather or a flu outbreak.

The service used systems to collect data from wards and directorates 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. Carers told us that the service was responsive to their contact, if when the called the service they staff member was not available, the returned their call promptly.

Information governance systems included confidentiality of patient records. The patient at a glance board was located in the nurses office around a corner so that this information couldn’t not been seen from outside the office. Access to the electronic care records required an individual staff member log in and password.

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. The hospital manager and clinical manager had access to the required performance information and this was reviewed at the governance meetings.

Information was in an accessible format, and was timely, accurate and identified areas for improvement. Although the service were aware of the low training levels for learning disability and autism tier 2 training, the provider had not supported the completion of this.

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. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders engaged with external stakeholders – such as commissioners. Stakeholders told us the service was responsive to their requests. Stakeholders told us the service was open and transparent.

Stakeholders told us how the service incorporated the model of care into reviews for patients to help them understand their progress and areas to continue to work on for their recovery.

The service had demonstrated improvement and stakeholders told us their review showed the improvements embedded into routine practice. They felt the service was willing to act on feedback to improve patient experience and quality of care.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. We saw senior leaders visiting the service. Commissioners visited the service to review the care being provided and how the service were meeting the contract they were commissioning.

However, stakeholders told us the service could improve its links with the Integrated Care Boards and enhance their understanding of the commissioning structure to support both parties.

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 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were given the time, support and opportunities for improvements and innovation and this led to changes. This included streamlining the assessment tool that occupational therapists used to capture progress/decline in a variety of functional areas including shopping, sleep, personal hygiene and kitchen skills.

Staff had opportunities to participate in research. Staff were involved in the creation of the long stay sensory pathway, which was in draft at the time of the inspection.

Innovations were taking place in the service. There were connections with the local community, including the canal and river trust to enable patients to have vocational experience of a canal clean.

Patients were involved in chairing their ward rounds.

Staff did not participate in national audits.

The service was a member of the Quality Network for Mental Health Rehabilitation Services.