- Independent mental health service
Cygnet Hospital Beckton
Assessment report published 13 June 2025
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
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.
People's experience of this service
We spoke with 2 patients and 8 carers of patients on the acute and PICU wards. Patients we spoke with were generally happy with the care received from staff. One patient said there was not enough staff at times, but they could get support when needed.
Feedback from carers was mixed. Some carers said communication with staff varied and some found it challenging to get information. However, most carers said that staff had the skills required to meet the needs of their relative.
Some patients and carers we spoke with described staff as kind and respectful, and most carers said their relative reported feeling safe on the ward.
Most carers said they did not know the process to raise concerns or complaints. Patients were able to provide regular feedback about their care and the ward environment, and we saw evidence of changes being made in response to this.
Patients could access general advocacy and staff informed them of their rights under the Mental Health Act (MHA), however the provider did not facilitate access to Independent Mental Health Advocacy (IMHA) for qualifying patients detained under the MHA.