The Care Quality Commission
  • Mental Health
  • Independent mental health service

Cygnet Hospital Beckton

Overall: Good read more about inspection ratings

23 Tunnan Leys, Beckton, London, E6 6ZB (020) 7511 2299

Provided and run by:
Cygnet Health Care Limited

All Inspections

During an assessment of Acute wards for adults of working age and psychiatric intensive care units

Date of assessment: 2 to 4 June 2026.

Cygnet Hospital Beckton is a 58-bed specialist hospital for women of working age. It is based in the London Borough of Newham and is run by Cygnet Health Care Limited, an independent provider group. The hospital admits patients funded by NHS England and Integrated Care Boards.

The hospital provides acute wards and psychiatric intensive care units (PICU) and personality disorder services.

This report is specific to acute and PICU wards.

Svanna Ward is a 12-bed PICU service. Hooper Ward is a 13-bed acute service. At the time of our inspection, Svanna Ward had 6 patients, and Hooper Ward had 9 patients.

We carried out an unannounced site visit as part of our inspection on 2-4 June 2026 and visited both wards. We previously inspected the service in December 2024 and rated it requires improvement. At that time, we identified breaches of regulations in relation to safe care and treatment, staffing and governance.

This current inspection was comprehensive and covered all key questions and quality statements.

Following this inspection, the overall rating has improved to good. The service was no longer in breach of regulations.

We found several areas of good practice. We found significant progress had been made in the areas for improvement identified at the last inspection. These included medicines management, physical health monitoring, staff training and supervision, patient access to independent advocacy and governance processes. The hospital had recently moved to a risk formulation model. Staff spoke positively about the use of the risk formulation model, reporting that it improved their understanding of patients’ presentation and how to support them.

Staff felt respected, supported, valued and described leaders as having an ‘open door’ policy. The Acute and PICU wards were well resourced with multidisciplinary team (MDT) staff. The multidisciplinary team demonstrated an inclusive, person-centred approach. Patient feedback about staff was positive. We observed calm, supportive, and respectful interactions between staff and patients, and heard about patient involvement and co-production.

We also found some areas where best practice could be improved, most of which the managers were already aware of, and subsequent actions taken following our visit.

Current out of hours arrangements meant that the on-call doctor, who would form part of the independent reviewing team for patients nursed in seclusion, may also be the established ward doctor. The hospital manager subsequently told us that updated procedures that addressed out of hours had been introduced.

At the time of our inspection insufficient staff had completed mandatory training in administering buccal midazolam. The hospital took steps to ensure that over the hospital an appropriately trained staff member was available on each shift. The provider since advised us, additional training has been provided to ensure a suitably qualified member of staff is present on each ward.

We raised concerns regarding the move on plan for a patient whose needs exceeded those the service was able to safely and appropriately meet. Actions had been taken to escalate and identify a suitable placement. We were notified shortly after the inspection that this patient had transferred to a suitable placement.

Patient cohorts with complex needs and multiple co-morbidities were associated with significant increases in incidents on the wards. We recommended that the service keep its referral criteria under review, to ensure a consistently safe, therapeutic environment for all patients.

Staffing records for Hooper ward showed that, over a six-day period in May 2026 (26 to 31 May), staffing fell below safe levels. Actions were taken to mitigate the associated risks.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

At the time of our inspection, the hospital provided care to both informal patients and those detained under the Mental Health Act.

Staff received and kept up to date with the Mental Health Act and the Mental Health Act mandatory training, and most staff could describe the Code of Practice and the guiding principles.

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff reviewed section due dates for patients detained under the Mental Health Act in daily huddle meetings and carried out any action required.

The service had relevant policies and procedures that reflected current guidance. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done so

Staff made sure patients could take Section 17 leave (permission for patients to leave hospital) when granted by the Responsible Clinician.

Staff requested an opinion from a Second Opinion Appointed Doctor (SOAD) when necessary.

Mental Capacity Act

Staff received and kept up to date with Mental Capacity Act mandatory training and had a good understanding of the five statutory principles.

The service had a policy on the Mental Capacity Act, including deprivation of liberty safeguards, which staff could describe and knew how to access.

Staff knew where to get accurate advice on the Mental Capacity Act, including deprivation of liberty safeguards.

During an assessment of Personality disorder services

Date of assessment: 2 to 24 June 2026.

Cygnet Hospital Beckton is a 58-bed specialist hospital for women of working age. It is based in the London Borough of Newham and is run by Cygnet Health Care Limited, an independent provider group. The hospital admits patients funded by NHS England and Integrated Care Boards.

The hospital provides acute wards and psychiatric intensive care units and personality disorder services.

This report is specific to personality disorder services, which comprise New Dawn Ward and Upping Ward. This service is for female patients with primary diagnoses of personality disorders, many of whom have complex presentations with co-occurring mental health conditions. Both wards provide care to informal patients and those detained under the Mental Health Act 1983.

New Dawn Ward is an 18-bed Tier 4 personality disorder service. Upping Ward is a 15-bed complex personality disorder unit. At the time of our inspection, New Dawn was fully occupied, and Upping Ward had 12 patients admitted.

We carried out an unannounced site visit as part of our inspection on 2-4 June 2026 and visited both wards. We previously inspected the service in December 2024 and rated it requires improvement. At that time, we identified breaches of regulations in relation to safe care and treatment, staffing and governance.

This current inspection was comprehensive and covered all key questions and quality statements. We have combined the scores for these to achieve the overall rating. Following this inspection, the overall rating has improved to good. The service was no longer in breach of regulations.

We found several areas of good practice. We found significant improvements in the areas of concern identified in our previous inspection. These included medicines management, physical health monitoring, staff training and supervision, patient access to independent advocacy and governance processes. The new managers demonstrated commitment to learning and continuous improvement. Staff described a positive and open culture with good support from managers. There was evidence of strong multidisciplinary team (MDT) working, and the wards were well-resourced with MDT staff. Patient feedback about staff was consistently positive. We saw caring interactions between staff and patients and heard about many examples of patient involvement and co-production.

We also found some areas where best practice could be improved, most of which the managers were already aware of. The needs of a small number of patients on Upping Ward exceeded those the service was able to meet safely, impacting safety and resulting in increased incidents. Managers were working to identify more suitable placements for those patients. Shortly after our visit, we heard that one patient had been successfully transferred to a more appropriate setting. Feedback about the food on offer was mixed. We were told that the service was working on improving the menu. The hospital-wide panic alarm sound was loud and went on for a long time. The alarm system was due to be replaced in July 2026, and staff expected this to improve following the upgrade. We also identified an area for improvement in record keeping related to checking ligature cutting equipment on Upping Ward and NEWS2 documentation, which we discussed with staff during our inspection.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

The service provided care to informal patients and those detained under the Mental Health Act (MHA) 1983. There was a notice to tell informal patients that they were free to leave.

Staff had a good understanding of the MHA, the Code of Practice and the guiding principles. All staff on both wards had completed training in MHA awareness. Staff had access to administrative support and legal advice on implementation of the MHA.

The care and treatment records we viewed demonstrated that when patients were detained under the MHA, staff read and explained their rights and repeated this regularly.

Patients had access to independent mental health advocacy, in line with their statutory rights. The independent advocates visited the wards regularly. Patients knew about independent advocacy and how to access it. Managers told us about implementing an opt out system for independent advocacy, with all detained patients registered for advocacy support on admission.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted.

Staff stored copies of patients' detention papers and associated records appropriately. Staff requested an opinion from a second opinion appointed doctor (SOAD) when necessary.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act (MCA). On both wards, 100% of staff had completed training in the MCA and Deprivation of Liberty Safeguards.

Staff obtained and documented consent from patients appropriately.

In the care and treatment records we reviewed, staff had assessed patients’ capacity to consent on a decision-specific basis and documented the outcome appropriately.

During an assessment of the hospital overall

We assessed Cygnet Hospital Beckton from 2 to 4 June 2026.

Cygnet Hospital Beckton is an independent specialist hospital for women of working age. It provides acute wards and psychiatric intensive care units (Hooper Ward and Svanna Ward), and specialist personality disorder services (New Dawn Ward and Upping Ward).

Cygnet Hospital Beckton is registered with CQC to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of disease, disorder or injury. The service had a Registered Manager in post.

We carried out an unannounced comprehensive inspection to follow up on the areas of concern and breaches of regulation from our previous inspection in December 2024.

We rated the acute service as good. We rated personality disorder services as good. The overall rating of Cygnet Hospital Beckton has improved to good, and it was no longer in breach of regulations.

During an assessment of Acute wards for adults of working age and psychiatric intensive care units

Date of inspection: 10-27 December 2024.

Cygnet Hospital Beckton is a 58-bed mental health hospital for adults of working age located in London Borough of Newham, East London. It is run by Cygnet Health Care Limited. It has a 13 bed ward providing acute mental health services, a 12 bed psychiatric intensive care unit (PICU), and 2 wards providing Tier 4 personality disorder services. The hospital provides care to both informal patients and those detained under the Mental Health Act.

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This report is specific to acute and PICU wards for adults of working age. We undertook this focused, responsive inspection due to concerns about an increase in safety incidents on the wards. We carried out a site visit to the acute (Hooper Ward) and PICU (Svanna Ward) services on 10, 11 and 12 December, followed by offsite activities. This was our first inspection of Svanna Ward which opened in January 2024. We previously inspected the acute and PICU services at Cygnet Hospital Beckton in April 2022. At that time these services comprised Hooper Ward (then PICU) and a learning disability ward which is now closed.

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The acute and PICU services were previously rated good overall. Following this inspection, the rating has changed to requires improvement. We inspected 13 quality statements across the safe, effective and well-led key questions and have combined the scores for these areas with scores from the last inspection to achieve the rating.

During this inspection we found 5 breaches of the regulations in relation to safe care and treatment, good governance and staffing. We identified a number of issues around medicines management. The provider did not always administer medicines safely and did not always monitor patients' physical health appropriately following the use of rapid tranquilisation. The provider did not always assess the risks to the health and safety of patients and do all that was reasonably practicable to mitigate the risks. The provider did not always ensure that patients received their medicines safely due to unavailable supplies. The provider's governance processes were not always effective in identifying areas for improvement or where these were identified, did not always ensure that improvements were made. The provider did not ensure that staff completed all mandatory training.

We have asked the provider for an action plan in response to the concerns found at this inspection.

We found several areas of good practice. There were enough staff to ensure patients' safety and meet their needs. Patients were supported to have choice and control and could give feedback on their care. Staff developed and updated personalised care plans. Staff and leaders reported a supportive and open team culture.

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Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

At the time of our inspection, the hospital provided care to both informal patients and those detained under the Mental Health Act (MHA).

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All staff on Svanna Ward and 94% of staff on Hooper Ward had completed mandatory training in Mental Health Act Awareness. This training was also part of induction for all new clinical staff.

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Staff had easy access to administrative support and legal advice on implementation of the MHA and its Code of Practice. Staff reviewed the section expiry dates for patients detained under the MHA in daily meetings.

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The provider had relevant policies and procedures that reflected the most recent guidance. Staff had access to local MHA policies and procedures and to the Code of Practice.

Staff explained to patients their rights under the MHA in a way that they could understand, repeated it as required and recorded that they had done so. However, we found that one patient did not understand the rights under the MHA read to them on 1 December 2024 and this had not been revisited at the time of our inspection.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted.

Staff carried out monthly audits to ensure that the Mental Health Act was being applied correctly.

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Staff requested review from a second opinion appointed doctor when necessary.

However, patients detained under the MHA did not have access to information about Independent Mental Health Advocacy (IMHA) in line with their statutory rights. Staff and leaders were not clear about the IMHA service and no comprehensive information about it was available. We previously raised a concern about the lack of IMHA provision in September 2024, but found the provider had not taken action to remedy this at the time of our inspection.

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Mental Capacity Act

All staff on Svanna Ward and 94% of staff on Hooper Ward had completed mandatory training in the Mental Capacity Act and the Deprivation of Liberty Safeguards.

Staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

We saw evidence that staff documented patients' capacity to consent to treatment and information sharing. However, we found this had not yet been assessed and documented for one patient whose care record we reviewed at the time of our inspection.

During an assessment of Personality disorder services

Date of Inspection: 10 - 27 December 2024.

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Cygnet Beckton is a 58-bed inpatient independent mental health hospital for adults of working age located in London Borough of Newham, East London. It is run by Cygnet Health Care Limited. It has 2 wards providing personality disorder services, which are New Dawn Ward and Upping Ward. New Dawn is separated into 2 ward areas; New Dawn 1 and New Dawn 2. Patients are allocated to the ward area which best reflects their progress on the treatment pathway.

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The hospital also has an acute ward for adults of working age and psychiatric intensive care services, which were inspected at the same time. This report is specific to the personality disorder services.

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We conducted this responsive inspection following an increase in serious injury and abuse notifications relating to self-harm, including when patients were on one-to-one observations.

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The personality disorder services were last inspected in January 2022 and were rated good overall, with requires improvement under safe. Following this inspection, the rating for this service has changed to requires improvement.

During this inspection we found 5 breaches of the regulations in relation to safe care and treatment, staffing and governance. We found multiple issues with medicines management. Patients did not always receive their medicines safely as prescribed due to unavailable supplies. Risks to patients were not always mitigated following the administration of rapid tranquilisation. Physical health checks were not always completed for patients on high-risk medicines or in line with care plans. Mandatory training compliance was low in some areas. The services' governance systems were not always robust, and did not always identify and address areas of improvement which we found during this inspection.

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We have asked the provider for an action plan in response to the concerns found at this inspection.

We found several areas of good practice. Patients we spoke with said staff treated them with kindness and respect. Staff met regularly to discuss patient risk and information about the wards. Safeguarding processes had improved. Patients were able to provide regular feedback about the service and were involved in their care and treatment. Staff reported a positive and supportive culture where learning was shared. The service had made improvements in relation to safe staffing numbers and was no longer in breach of this. The number of shifts short staffed by 2 or more staff had decreased, and the vacancy and turnover rates had reduced.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

At the time of our inspection there were 17 patients on New Dawn 1 and 2 and 12 patients on Upping Ward. Some patients were detained under the Mental Health Act 1983 for treatment and some patients were informal. The service displayed a notice to tell informal patients that they could leave the ward freely.

Staff received and kept up to date with training on the Mental Health Act. This training was initially provided as part of the induction process with refreshers as required. All staff on Upping Ward and 94.4% of New Dawn staff had completed their mandatory training on the Mental Health Act.

Staff had easy access to administrative support and legal advice on the implementation of the Mental Health Act and its Code of Practice via the Mental Health Act team based at the hospital. During the daily morning huddle, we saw that staff discussed Mental Health Act matters and actions needed for specific patients on each day. This included flagging when Mental Health Act review paperwork was required.

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Staff working in personality disorder services were expected to complete audits twice a year to ensure that the Mental Health Act was being applied correctly. The most recent audits completed in December 2024 showed 100% compliance.

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Staff explained to each patient their rights under the Mental Health Act in a way that they could understand, repeated as required and recorded this clearly in patients' notes. Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted. Staff requested review from a second opinion appointed doctor when necessary. However, patients did not have easy access to information about independent mental health advocacy.

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Mental Capacity Act

All staff on Upping ward and 97.2% of New Dawn staff had completed their mandatory training in the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff induction processes provided initial training, with subsequent refreshers required.

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We saw evidence that staff assessed mental capacity within patient records. Staff took all practical steps to enable patients to make their own decisions. Staff audited the application of the Mental Capacity Act. The most recent audit was completed in November 2024 and showed 100% compliance for all wards.

During an assessment of the hospital overall

Date of inspection: 10 – 27 December 2024. 

Cygnet Hospital Beckton provides acute wards for adults of working age and psychiatric intensive care units (Hooper Ward and Svanna Ward), and personality disorder services (New Dawn Ward and Upping Ward). This inspection looked at both services following concerns about an increase in safety incidents across the wards. The scores from the quality statements covered during this inspection have been combined with existing scores for any quality statements not covered. Together, these calculate the new key question ratings. We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement. We rated personality disorder services as requires improvement. The overall rating of Cygnet Hospital Beckton has changed to requires improvement. In our inspection of both services, we found concerns in relation to safe care and treatment, staffing and governance which have resulted in breaches of the regulations. However, we also found areas of good practice which included patients being supported to have choice and control of their care and treatment, able to provide feedback on their care, and a supportive and open team culture where learning was shared. The personality disorder services had made improvements in relation to safe staffing numbers and was no longer in breach of this.

11-12 April 2022

During an inspection looking at part of the service

Hooper Ward at Cygnet Hospital Beckton provides psychiatric intensive care for adults of working age. Our rating of this service improved. We rated it as good.

  • The service provided safe care. The ward environments were safe and clean. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. This included prescribing oral antipsychotic medication in conjunction with psychosocial interventions. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards, including nurses, doctors, a clinical psychologist, an occupational therapist and a social work assistant. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged most of their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Some patients said that the care and treatment they received was good and that staff behaved kindly towards them, although others patients found it difficult to express their views about the quality of care.
  • The service managed access to beds well and patients were discharged promptly once their condition warranted this.
  • The service was well-led and the governance processes ensured that ward procedures ran smoothly. Leaders had clear oversight of the safety and quality of care provided.
  • Staff felt respected, supported and valued. They said the service promoted equality and diversity in daily work and provided opportunities for development and career progression. They could raise any concerns without fear.

However:

  • The service did not have enough permanent registered nurses but was in the process of recruiting to vacancies.
  • Staff did not dispose of all out-of-date dressings and saline solutions in accordance with manufacturer's instructions
  • Documents relating to patients’ care and treatment are were stored in different places and on different systems. The meant it could be difficult to access essential information quickly.
  • Assessments of patients’ mental capacity were not complete on all the records.

18 and 19 January 2022

During an inspection looking at part of the service

Our rating of this location improved. We rated it as good because:

We rated both services that were open at the time of the inspection as good overall. Our overall rating for wards for people with learning disabilities or autism improved from requires improvement to good, as we now rated it good for all five key questions. We rated wards for people with a personality disorder as good overall, although it remained requires improvement for the safe question. The hospital’s acute ward for adult of a working age, which we rated inadequate when we previously inspected it in May 2021, was not open at the time of this inspection. We will inspect this ward again when it reopens.

The hospital had made progress in addressing the concerns identified at previous inspections. This included achieving a reduction in the use of restraint and a reduction in safeguarding incidents. The service was recruiting new staff. The hospital had increased training in managing violence and aggression, training in ward specific skills and training in leadership for ward managers.

Managers and staff had a good understanding of the risks and pressures on the wards. Each ward held a multi-disciplinary team meeting each morning to review any concerns or incidents that had arisen on the previous shifts. These concerns were escalated to the daily meeting for senior staff.

Wards were clean and well-maintained.

On Hansa Ward, staff provided safe, person-centred care. Staff were aware of patients’ needs and could easily access information providing instructions on how to engage positively with each patient. The ward employed a specialist speech and language therapist to improve communication with patients.

However,

Over the last year there were times when the staffing on the wards fell significantly below the minimum required for safe nursing. On New Dawn and Upping Wards, a high number of staff vacancies, high turnover of staff and high use of agency staff had led to unfilled shifts, inconsistencies in care and an increased risk of harm to patients.

Incidents of self-harm continued to occur when patients were on one-to-one observations. The service recognised there needed to be better communication and engagement with patients when staff were assigned to close observations.

13 May and 10 and 11 June 2021

During a routine inspection

Cygnet Hospital Beckton provides gender specific hospital for women with complex mental health needs, including those with learning disabilities and personality disorders.

We undertook this unannounced comprehensive inspection following our focused inspection in March 2021. At the inspection in March 2021, we rated this location inadequate, took urgent enforcement action and placed the hospital into special measures. At this inspection, the rating for this location has improved to requires improvement. The location remains in special measures.

During this inspection we found:

  • The ward for people with learning disabilities, Hansa Ward, did not meet the principles of right support, right care, right culture (CQC). This was because the ward environment was institutional and did not meet patients’ sensory needs and preferences and patients did not have care plans they could understand.
  • Staff did not always undertake intermittent observations of patients according to the provider’s policy. Observation records on New Dawn Ward showed that on three occasions staff observed patients at exactly the same intervals for four or five hours consecutively. There were further examples of staff observing patients at the same time for two hours consecutively. Intermittent observations should have been carried out at unpredictable intervals so that patients could not plan risky behaviour when staff were not observing. On Hansa Ward, an incident following the inspection showed that a staff member had recorded intermittent observations of a patient but they had not been carried out. Patients on New Dawn Ward said that staff did not always carry out intermittent observations.
  • Patients with a learning disability on Hansa Ward did not have easy-read care plans. This meant patients may not be able to understand the content of their care plan.
  • The environment on Hansa Ward was not therapeutic. The corridors were long and bare and sounds echoed and carried to other parts of the ward. The environment did not support patients’ sensory needs. However, there were plans to redesign the ward later in 2021.
  • Only some staff on Hansa Ward had knowledge of STOMP (stopping over-medication of people with a learning disability). This meant some staff were unaware of how to ensure minimal prescribing of psychotropic medicines.
  • On New Dawn Ward, patients and the advocate said that the ward manager did not welcome complaints and concerns they raised were not acted upon.
  • Whilst the provider had undertaken a strong recruitment drive and recruited to many vacant nursing posts, there were still a significant number of vacant support worker posts. For example, on Upping Ward there was a 49% vacancy rate for registered nurses. Three of the six vacant posts had been recruited to.
  • Patient's relatives and carers were not consistently contacted by ward staff or involved in patients’ care and treatment.

However:

  • Staff had an exceptional and sustained focus on the physical health care of patients. Physical health interventions exceeded those recommended in best practice guidance. A wide range of actual and potential patient health care needs were addressed, from seizure management and pressure ulcers to incontinence, falls, mouthcare and footcare. Nursing staff were trained to undertake 12-lead electrocardiograms and training on foot care was planned. There were very effective links with primary care, the local mental health trust and other specialists, such as a specialist dentist for people with learning disabilities.
  • Staff communication with patients was supportive and respectful. Staff were compassionate, respected patient choices, and demonstrated a non-judgemental attitude.
  • Patients’ care plans were person-centred and holistic. They addressed all of the patients’ identified needs.
  • The relaunch of the least restrictive practice programme had led to a reduction in incidents of restraint. All staff had been trained in restraint techniques. CCTV showed that staff spent considerable time attempting to defuse incidents without use of restraint. When staff did restrain patients, they used authorised techniques for the shortest time possible.
  • There was a strong focus on learning from incidents. Learning was advertised in a newsletter for staff, discussed at ward business meetings and at hospital clinical governance meetings. Incident reporting had improved in terms of the quality of incident reports and previous under-reporting of incidents had been addressed.
  • Staff had undertaken skills-based training specific to the patient group on the ward they worked. Bank and agency staff also attended this training.
  • There was a robust system to ensure that staff followed the requirements of the Mental Health Act, including regularly informing patients of their rights.
  • There were good systems for infection prevention and control and sufficient stocks of personal protective equipment.
  • There was a strong focus, at hospital management level, on engaging with and supporting patients’ relatives and carers. This included a carers support group, co-production, a carers newsletter, and a carers strategy.
  • There was a strong and effective governance system to monitor safety and the quality of care provided to patients. Patient risk assessments, complaints, safeguarding referrals, staffing and recruitment and incidents were all carefully reviewed at hospital governance meetings.
  • The hospital’s local leadership team had the knowledge, skills and experience to drive improvements in safety and quality.

1, 3 and 8 March 2021

During an inspection looking at part of the service

We undertook this focused inspection of the psychiatric intensive care unit and the ward for patients with learning disabilities, following four incidents of the alleged abuse of patients by staff. The service had informed us about these incidents.

We did not inspect the two wards for patients with a personality disorder during this inspection. Due to the overarching concerns we have about the hospital, we have suspended the ratings for personality disorder services.

Following this inspection, the Care Quality Commission took urgent enforcement action under section 31 of the Health and Social Care Act 2008. This means there are a number of conditions on the provider's registration, including that the hospital cannot admit any patients.

Letter from Professor Ted Baker, Chief Inspector of Hospitals:

'I am placing the service into special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.’

We found:

  • There had been four serious incidents between December 2020 and February 2021 which had raised concerns about the potential abuse and poor care of patients. The service had informed us about these incidents. One incident on the psychiatric intensive care unit and two incidents on the ward for patients with learning disabilities demonstrated unacceptable care practice. We saw evidence of unjustified restraint, the use of unauthorised restraint techniques, seclusion without appropriate safeguards and the apparent physical abuse of a patient by staff.
  • We also randomly reviewed closed circuit television (CCTV) of a further two incidents on each ward. One of these incidents showed staff using unauthorised restraint techniques, which could have caused the patient significant harm. We had also been informed by the provider of a further incident where staff had locked a patient out in the ward garden for at least 20 minutes following an aggressive outburst. This happened in February 2021 when the weather was cold. CCTV footage was not available of this incident.
  • Staff were not reporting serious incidents in line with the providers policies and procedures. Staff had not raised any of the above incidents of the use of unauthorised restraint techniques, seclusion without safeguards or alleged abuse, with managers. Managers learnt of three incidents following complaints from patients. The fourth incident was identified during an investigation into a patient injury. Having heard about the serious incidents described above, the management team had not reviewed CCTV of all other incidents on the wards in order to assure themselves of patient safety.
  • The closed-circuit television system was outdated. It was hard to review CCTV footage and images were not saved for 28 days. This meant that the provider might not be able to check the footage for serious incidents. Random reviews of CCTV footage by ward managers had been introduced but did not always take place as planned.
  • Registered nursing and support worker vacancies led to the high use of agency staff who may not know the individual needs of the patients and how to meet their complex needs. The vacancy rate for registered nurses on the psychiatric intensive care unit was 66%, including two team leader posts. The vacancy rate for support workers on both wards was 50% although the number of support worker posts had recently been significantly increased to provide more permanent staff and consistent care. Also, the hospital manager had ensured there were very few registered nurse vacancies on Hansa Ward which is the ward for people with a learning disability. This was due to the specific needs of patients and the need for consistency of care. The manager also tried to use long-term agency staff where possible.
  • Safe staffing levels were not always maintained on the wards. There were a number of shifts, over a period of three months, when both wards were below their current minimum safe staffing levels. In addition, the current staffing levels at night were not sufficient. Four staff were allocated to each ward at night. This included if one patient required continuous observation by staff. With staff breaks, this meant there were insufficient staff on the wards to keep patients safe at night if, for example, staff needed to restrain a patient.
  • Senior leaders in Cygnet Health Care had not sufficiently addressed the ongoing challenges of the recruitment and retention of registered nurses. The number of vacancies of registered nurses in the hospital had been on the hospital risk register since November 2018. The hospital manager had repeatedly raised this with senior managers, including suggested solutions. The provider’s senior managers had not taken effective action in a timely manner to address this.
  • Ward managers and team leaders had not had access to appropriate leadership training to support them to carry out their roles to a high standard. This had been raised by the hospital manager since November 2019. The hospital manager had not been supported by senior managers to put these learning and development opportunities into place in a timely way.
  • Feedback from patients, the patients' advocate, and relatives was mixed. They said staff could be rude, relatives were not always involved in patients' care and treatment, and some patients felt neglected and ignored. However, approximately half of the patients’ relatives we spoke with were very positive regarding staff and their involvement in patients' care and treatment.

However, we also found:

  • The hospital management team informed the local safeguarding team, CQC and the police, following incidents of alleged abuse.
  • There had been a relaunch of the least restrictive practice programme to ensure patients did not have unnecessary restrictions placed upon them.
  • The hospital manager had identified gaps in the care provided to patients. Regular night visits by hospital managers had been introduced.

Shortly after this inspection we received two further allegations of poor treatment of patients on the psychiatric intensive care unit and the ward for patients with learning disabilities. These allegations were referred to the local authority. One of the allegations was not upheld following a safeguarding investigation. A safeguarding investigation of the other allegation was ongoing when this report was published.

11 and 12 November 2019

During a routine inspection

We rated Cygnet Beckton as good because:

The hospital provides mental health services for females across four wards for psychiatric intensive care, personality disorders, forensic and learning disabilities and autism.

  • Staff worked hard to provide safe care in most areas across the hospital. The ward environments were safe and clean. Hooper (psychiatric intensive care unit), New Dawn (specialist personality disorders) and Hansa (learning disabilities and autism) wards had enough nurses and doctors to meet the needs of patients in their care. Staff across the hospital assessed and managed risk well. Staff participated in the providers reducing restrictive practice initiative that championed the use of anticipating, de-escalating and managing challenging behaviour. Staff followed good practice in protecting patients from abuse after the provider improved the service’s safeguarding system. Staff on Hansa Ward knew about and worked towards achieving the aims of the stop over-medicating people with a learning disability programme.
  • Staff across the hospital developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. This included consultant psychiatrists, occupational therapists and psychologists. Staff worked well together as a multidisciplinary team to provide effective care and treatment to patients.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. Staff participated in patient involvement programmes such as the Peoples Council and ‘Safewards’ to empower patients and staff to collaborate in their care and treatment.
  • Staff involved patients in decisions about the service. Patients co-produced the hospital newsletter, outlining what activities and projects the hospital was hosting.
  • Staff ensured that patients had good access to physical healthcare and supported patients to live healthier lives. Staff supported patients with their social and educational wellbeing. The service had a gym onsite that all patients could access. In addition, patients used the hospital’s recovery college to enrol on courses about mental health and wellbeing.
  • Staff supported patients to make decisions on their care for themselves.Staff understood the principles of the Mental Capacity Act 2005, assessed and supported patients who might have impaired mental capacity. Staff made sure they could explain patients’ rights to them under the Mental Health Act 1983.
  • The service was well-led and the governance processes ensured that ward procedures ran smoothly. Staff engaged actively in local and national quality improvement activities. There was a great commitment towards continual improvement and innovation. The service had been proactive in capturing and responding to patients’ concerns and complaints. There were creative attempts to involve patients in all aspects of the service.

However:

  • Although medicines were stored and administered safely, improvements were required on Hooper Ward to oversee the administration of medicines and the implementation of action to prevent medicines errors. We found staff had made two similar errors in the dispensing of the same patient’s ‘as required’ medicine and given over the prescribed amount in a 24-hour period. This meant the patient had been overmedicated and could lead to physical health complications.
  • Staff did not always ensure that physical health monitoring of patients’ vital signs was undertaken after every use of rapid tranquilisation, record physical health observations accurately for patients, and seek medical advice when indicated.
  • Not all patients had access to an alarm to call for help should they need it in an emergency. The provider had installed some on each ward and patients who were deemed at risk of needing to call for help more than others were given these bedrooms. However, staff did assess the risk for patients on most wards and said they would give alarms to patients if they needed one. Not all patients knew about this.
  • Staff on Hooper Ward imposed a blanket restriction on patients. Staff locked away snacks from patients and this was not based on individual patient risk.
  • Staff did not always respond to complaints in a timely manner. This meant complainants may not know what stage their complaint was at.

14-16 March 2017

During a routine inspection

We rated this service as good because:

  • During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe and effective as requires improvement following the July 2015 inspection.
  • Following the last inspection in July 2015, we also made a number of recommendations for the service to consider improving. At this inspection we found that these improvements had been made.
  • The hospital provided good care in challenging and complex circumstances. Staff sought to minimise incidents of self-harm, aggression, violence and other challenging behaviour in a caring and supportive way.
  • Staff consistently responded to patients with care and compassion. They said that morale within their teams was good and that they felt supported by their managers.
  • Staff knew which patient safety incidents to report and how to report them. Senior managers monitored incidents through the clinical governance process. Through this monitoring, managers looked for trends and ways to reduce the number of incidents.
  • The service had introduced a programme to reduce restrictive practices. As a result, patients had unrestricted access to dining rooms, activity areas and quiet rooms. Patients were also now able to make hot drinks whenever they wished.
  • Senior managers demonstrated a strong culture of seeking improvements to the service.
  • Staff assessed risks to patients using standard risk assessment tools. Staff updated risk assessments during patients’ admission, either at regular multidisciplinary team meetings or after incidents.
  • The services used evidence-based therapies to work with patients across the wards.
  • Cygnet Health Care had appointed an Expert by Experience Lead. At this hospital, they had established meetings to promote the views of patients across and facilitating further service user involvement.
  • The hospital had achieved national quality accreditation for the psychiatric intensive care unit, the forensic ward and the ward for people with learning disabilities.

28-31 July & 25 August 2015

During a routine inspection

We rated Cygnet Hospital Beckton as requires improvement because:

  • The provider had not identified in its risk assessments, all the points where a ligature could be tied. Where it had identified potential ligature points and work was required, the provider had not set dates when this would be completed.
  • For two patients, the assessments completed prior to their admission were either not available, or had not been considered by staff when developing initial risk assessments along with the measures required to manage or mitigate the risks. One patient on Hooper ward did not have areas of the care plan that addressed their holistic needs and two care plans for patients on Bewick ward did not contain their views on their care and treatment.
  • Staff could prevent patients from leaving the de-escalation room on Hooper ward. Staff did not recognise that this constituted seclusion and did not provide patients with the proper safeguards. Staff had not recorded some incidents of restraint properly and had not carried out some of the checks required after rapid tranquilisation of patients. The provider monitored the use of restraint but staff were not able to identify trends in the use of restraint.
  • Staff had not recognised a significant safeguarding concern at the hospital and had not followed appropriate safeguarding procedures. The provider did not have robust systems to share learning about incidents and complaints between wards.
  • Not all staff understood how to apply the Mental Capacity Act or the circumstances when a capacity assessment would be appropriate. The provider did not have robust systems in place to ensure that they were using the Mental Capacity Act appropriately.
  • Staff had not administered all medicine appropriately and within the prescribed guidelines. For some patients, staff had not addressed how they were meeting  physical health care needs in care and treatment records.
  • When some patients received rapid tranquilisation, staff had not appropriately monitored their physical health afterwards. New Dawn one and two shared an emergency grab bag which may have resulted in delays in an emergency.
  • On New Dawn ward not all nursing and support staff had received dialectical behavioural therapy training. The provider did not have figures for the numbers of staff who had completed this training and patients commented that nurses and support staff did not understand their needs or the necessary therapeutic approach.
  • Some patients on Hooper and Hansa wards were not able to access drinks and snacks without having to ask staff to open the dining room.

However:

  • Wards were clean and well maintained. The provider maintained safe staffing levels and staff had access to personal alarms. Staff completed appropriate mandatory training.
  • Patients were able to access a range of psychological therapies and the multidisciplinary team included an appropriate mix of disciplines.
  • We observed positive interactions between patients and staff. Staff were caring and respectful of patients’ needs. Overall, patients spoke positively about staff and felt they were friendly. Staff had a good understanding of patients’ individual needs and projected a caring approach when discussing patients.
  • Staff held regular community meetings on each ward. Patients were also able to participate in staff recruitment and quality improvements within the hospital and feed back on the care and treatment they received.
  • Overall, staff provided appropriate activities on the wards. Patients had unrestricted access to outside areas and a range of communal spaces were available on each ward. A range of meals were available to meet patients’ dietary requirements. Staff could support patients to access spiritual support. Staff could request interpreters, if required.
  • Line managers supported staff appropriately. Managers at different levels had oversight of incidents, complaints, supervision and appraisals. The provider met targets for a range of key performance indicators. Staff undertook audits, with actions identified and followed through.
  • Sickness rates were low and overall staff morale was good. The hospital had developed a values-based recruitment process and recruitment to vacant posts was on-going. The hospital was part of the accreditation for inpatient mental health services (AIMS) and was an “investor in people”, an independent framework to promote leadership, support and good management of staff.

15 May 2013

During an inspection looking at part of the service

People were referred to the hospital from a number of different health trusts and organisations throughout England. We found people's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others.

Staff told us they often do not get enough information in the initial referral and would have to send a follow up email to get more information before a decision could be made. They said dates and times of admittance were agreed in advance.

The hospital manager told us at the time of the last inspection they were piloting a new care plan form titled 'my shared pathway' which allowed for more information to be documented.

The hospital manager told us that all staff including temporary staff received a comprehensive induction. We were told an induction form was completed for all staff which they signed and kept a copy for their records. Staff we spoke to confirmed this.

People had their comments and complaints listened to and acted on, without the fear that they would be discriminated against for making a complaint. One person we spoke to told us they had made numerous complaints and were not always happy with the response or outcome but that did not stop them making other complaints.

19 December 2012

During a routine inspection

Patients had mixed reviews about the service. One patient said, 'the place is ok, sometimes staff just hear, but don't really listen." Another patient said, 'I like it here, Its just one person who makes too much noise and is always picking on everyone." whilst another person said, "on the whole care is ok."

Patients were assessed before they were treated. Care plans were reviewed as people's conditions changed. There was evidence of involvement of patients in planning care. There were advocacy services available and these were accessed by patients regularly. We found that records that related to patient care were not always accurate as they did not reflect the input we observed and the input described by staff. Other records for the management of the service were up to date.

Patients were cared for by staff that were trained and had been recruited appropriately. There was evidence that staff renewed their professional registration and that staff had been asked to do a criminal records bureau check before they were employed.

We found that medicines were stored and administered safely and patients knew when they took their medication. Staff had been trained and were able to administer medication safely.

Equipment was clean and staff were able to use them. There was equipment available to promote the comfort of the patients. One patient said, "this my home for now. I don't mind it as staff are ok. My room is very nice and I brought in my personal items."

9 January 2012

During a routine inspection

Overall people we spoke to told us that they were happy with the arrangements that were in place to meet their needs and that the hospital compared favourably to other hospitals they had experienced. We received comments about the hospital that included: 'The staff explained things to me when I arrived here'. 'The staff are nice and it makes such a difference'. 'The hospital is run properly and the staff do a great job'.

We visited Cygnet Hospital Beckton was a planned routine inspection which was intended as a follow up to the previous inspection where concerns had been identified. We found that improvements had been made in all areas that we followed up.

19 January 2011

During a routine inspection

Please note: Asterisks **** are used throughout this report so that patients cannot be identified from what they told us.

We found that patients had mixed opinions about the hospital and their experiences of the treatment and care that they had received from Cygnet Hospital Beckton. All patients are detained under a section of the Mental Health Act and comments are considered in the context that treatment and care is of a compulsory nature.

On commenting about care planning processes patients said:

'Yes, I am aware of what my aims and goals are. These are worked with by staff and I am moving on soon.'

'I have things to work on but I am struggling with things. I'm not happy with the move on place' ('step down' accommodation).

'I have clear objectives, my CPA is on *** and I will be moving to the other side of (the ward).'

Another patient felt that she knows what she is to work on as she works towards her discharge. 'I don't find it easy to contribute to my care plan. I have ***** issues and feel ashamed, but I'm not given space to say what I think about this. I feel I have become institutionalised.'

'I don't agree with all the areas in my care plan and I signed it to state that'.

On staff attitude and helpfulness patients said:

'Staff are okay. If they're busy they ignore you. They spend a lot of time doing paperwork. Should have 1 more nurse ' 4 instead of 3'. 'Some staff are helpful, some can be a bit rude and abrupt'

'The staff are professional and there are no concerns at all'.

On therapeutic activity patients said:

'I have to wait until my therapist is here so sometimes I don't see him for 2 weeks because he can be busy on the ward. It's a strict regime once we do it.'

'They are going to start groups at the weekend but there haven't been any yet'.

'I found the psychology sessions very helpful', another stated; 'The rehabilitation and recovery group really enabled me to sit by and think carefully ' given my behaviour before'.

One patient told us that she had been to the cinema recently. Another patient told us; 'I enjoy the mental health awareness group, as we discuss medication and the next steps in moving on'.

On the use of restraint patients told us:

'Some staff are rougher than others', the patient went on to name the two ward staff who she said are known for being rough. 'I have never had a meeting after restraint to talk about it.'

Another patient said 'The atmosphere is not good on the ward, it's hostile because of different patients. I don't feel safe anymore. There's violence on the ward, nurses get attacked and one had her head bashed on the wall'.

'They bend my wrists back and my wrists hurt for hours or the day afterwards'. 'It's better here than in other places' she added.

'Once I had calmed down the staff spoke to me about the incident. I think their actions made me safe'.

On the management of physical conditions patients told us:

'The other week I ***** and was so weak that staff had to stop me from ******. The doctor was called but they didn't come to see me. I had to wait until the next day- the ward doctor took ages to come. I suffer from *****, it isn't worked with here.'

'I need a dentist check up. I mentioned it to a doctor, (ward doctor) who said to mention it in the ward round. I spoke to a ward doctor about seeing an optician who said the same as before'.

Another patient said they had **** ***** 'a while ago'. 'Sometimes it plays up, I could hardly move and was taken to hospital. The doctor said she couldn't give me painkillers because she didn't know enough about my antipsychotics. The doctor here didn't give me painkillers because she said it was out of her area of expertise'. 'I am still on my own with this.'

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.