Lancashire & South Cumbria NHS Foundation Trust

On this page

• 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 good. At this assessment the rating has remained good.

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

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the trust’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes generally operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 trust’s vision and values and how they were applied in the work of their team. Managers felt that the values of the trust were relevant to their work and that staff often reflected these values when providing care and treatment to the patients.

Staff could explain how they were working to deliver high quality care within the budgets available. Managers reflected on some of the limitations that could be faced within the service, with the most common theme being around awaiting funding for some of the bigger environmental projects.

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.

Ward managers were generally experienced and knowledgeable about their roles. They understood their wards and staff teams well and were open and honest about some of the challenges they faced. Managers had goals which they wished to achieve and described being well supported by the senior leadership team at Guild Lodge.

Staff felt respected, supported and valued within their roles. Staff noted that they could raise any concerns without fear of retribution.

Leaders had a good understanding of the services they managed. They could explain how the teams were working to provide high quality care.

Leaders were visible in the service and approachable for patients and staff.

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

The trust had Freedom to Speak Up Guardians and their contact information was displayed on posters throughout the wards. Staff described that they could raise any concerns that they might have without any fear of retribution. Managers were confident that staff would speak up if they had any concerns.

Staff received freedom to speak up training with an average compliance rate of 99% across the service.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. The trust provided a summary of actions taken in response to October’s Friends and Family test results, including changes being made to menus and healthier drink options being available.

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

The service had equality and diversity champions on the wards. Where staff had particular passions or interests about inclusion or equality they were encouraged to explore these and consider how it could benefit the wards and patients.

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

Managers described how they supported staff within their roles and the actions they would take to ensure they were being supported appropriately in line with their needs.

The service held an annual hate crime event every October for hate crime awareness week to raise awareness for both staff and patients.

Staff received equality and diversity training with an average compliance rate of 95% across the service.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had a governance structure which generally enabled communication from ward level to senior management within the service.

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.

Staff generally 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.

Staff undertook or participated in local clinical audits. The audits were generally sufficient to provide assurance and staff acted on the results when needed. However, there were some minor issues identified in respect of record keeping and ensuring certain processes were being completed, such as in clinic rooms where cleaning records were not always being completed and open liquids and bottles that staff had not labelled and dated appropriately. These concerns had not been identified through audits completed.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

Information governance systems included confidentiality of patient records.

Ward 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.

Team meetings took place on a monthly basis and, for the majority of the 14 wards, these had been completed for the three months prior to the assessment. The minutes of these meetings reflected that staff had the opportunity to reflect on ward specific incidents and considerations, along with enabling ward managers to share key information.

The patient care records and the systems used were difficult to navigate and staff were not using the system in a consistent manner across the 14 wards. Staff supporting the inspection team could not always locate specific documentation or information when requested in a timely manner, although for the most part the information was eventually located. The trust confirmed that work was ongoing in terms of improving patient records and ensuring all documentation could be stored appropriately.

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.

The service engaged and communicated with external stakeholders including commissioners. Stakeholders gave positive feedback about their interactions with the service and how they engaged with them.

The service had a service user council which a nominated representative for each ward could attend to give feedback and ensure patients had a voice within the service. We received feedback that engagement and representation from all wards at the service user council was not always consistent.

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 contribute to safe, effective practice and research.

The trust had an internal ward accreditation programme which had been reviewed and updated in 2025. The trust had agreed that each ward would receive an accreditation visit in 2025. As of the time of the assessment, 9 of the 14 wards had been visited in 2025. The remaining wards were due to be visited in November and December 2025.

Quality improvement work was taking place on the wards, including pieces of work around physical healthcare and healthier lifestyles.

The Acquired Brain Injury (ABI) wards at Guild Lodge, Langden, Bleasdale and Whinfell, were part of the Quality Network for Neuropsychiatry Services (QN-Neuro) accreditation programme. The programme involved self-reviews and peer-reviews to support services in working towards accreditation. The ABI wards at Guild Lodge had been peer reviewed in April 2025.

Guild Lodge was part of the Quality Network for Forensic Mental Health Services (QNFMHS) full review process, which was not an accreditation programme. This process consisted of two stages: a full review followed by a developmental review, during which services would be assessed against QNFMHS standards. Guild Lodge underwent its developmental review in May 2025. The report highlighted four key recommendations for service development, including areas such as monitoring and strengthening the monitoring of phone use and raising awareness of the multifaith room.