Cygnet Hospital Beckton

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question as good. At this inspection, the rating has changed to requires improvement. The service was in breach of regulation in relation to safe care and treatment and staffing. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 62 (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 proactive and positive culture of safety in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons learned to identify and embed good practices.

The provider had a policy on reporting and managing incidents. Most staff had completed incident reporting training. Staff we spoke with could describe what incidents were and knew how to report them. Staff reported incidents in line with the policy and leaders monitored the incident data. There was one severe incident during the 6 months preceding our site visit.

Staff could give examples of changes implemented as a result of learning from safety incidents. For example, modifications were made to the bedroom doors after a ligature risk was identified. Staff told us that the risk was rectified promptly, learning shared and the ligature risk assessment updated.

Staff discussed incidents and lessons learnt in a number of forums, including supervision, daily huddles, team meetings and reflective practice. Staff were informed about learning from the wider organisation through the provider’s newsletters. This information was shared with bank staff through group supervision. Staff were debriefed after incidents by managers and psychologists, and an employee helpline was available for additional support.

Patients were able to raise concerns, provide and receive feedback on issues that impacted them. The weekly community meeting included an update on actions, “you said, we did” feedback, safety concerns and environmental issues. A patient we spoke with told us they received a debrief with staff after an incident.

Most carers said they felt reassured that staff took their safety concerns seriously and took actions promptly. One carer said that staff “always answered questions, investigated CCTV or went through what safety precautions and protocols they were putting in place following an incident”. However, another carer said they felt it took “for family members to raise the issues for things to be done”.

Incidents were reported promptly and investigated by managers in line with the policy, with learning documented and relevant actions updated in care records. However, some staff felt that incidents could occur due to not enough staff on the wards. They told us they had raised this through the Freedom to Speak Up Champion but felt no action had been taken.

The service worked with people and partners to establish and maintain safe systems of care and to ensure continuity of care when people moved between different services. However, there were some challenges due to circumstances outside of the staff's control.

The majority of patients were admitted to the hospital from other areas across England and Wales. Although the service's referral process was designed to ensure that essential patient information was requested and received to determine if their needs could be met safely, some staff told us it could be challenging to obtain all necessary clinical information for new patients. This was due to the provider not having access to NHS patient record systems. Staff said at times this meant relying on patients' feedback about their medicines and allergies. Staff mitigated this by completing a physical examination on admission and working with local GPs and hospitals to manage health concerns.

Staff involved other healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Care records detailed multidisciplinary input in the care and treatment of individual patients. The daily multidisciplinary meeting included a range of professionals who contributed to discussions and decisions taken. Staff referred patients to external agencies when required, including GP, accident and emergency departments and hospitals. We observed the ward rounds of 3 patients which were attended by the provider's multidisciplinary team and care coordinators from the patients' local areas who joined virtually. One carer told us the staff were always prompt in arranging dentist or doctor appointments for their relative.

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Staff told us there were sometimes challenges in planning discharges, for example due to local funding and accommodation issues or not having community team involvement from the outset. This could cause significant delays to some patients being discharged safely, with a detrimental effect on their wellbeing.

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Five carers shared some concerns around discharge plans for their relatives, which they felt was largely due to being far out of the area. Although most of them felt the staff planned the discharge well, there were still delays due to availability of local placements. One carer told us their relative was informed about a transfer "very last minute" and found it difficult. However, carers said generally the hospital involved them in discussing discharge plans and collaborated well with community mental health teams.

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The service worked with people to understand what being safe means to them as well as with partners on the best way to achieve this. Staff supported people’s right to live in safety, free from avoidable harm and made sure they shared concerns quickly and appropriately.

The service had a number of systems in place to protect people from harm. The service had policies for safeguarding children and adults. Safeguarding was part of induction for new staff and ongoing mandatory training. Most eligible staff had completed mandatory safeguarding training. Staff we spoke with knew who the safeguarding lead was and how to report safeguarding concerns. Safeguarding was discussed in variety of forums, including daily and weekly meetings, ward meetings, handovers and clinical and managerial supervision.

The service had a safeguarding lead who worked closely with staff to improve their understanding of safeguarding. Staff said they felt well supported in this area.

A patient we spoke with told us they felt safe on the ward. Seven of 8 carers felt their relatives were safe and that on occasions when they had some concerns about safety, those were dealt with well by staff. However, one carer told us their relative had shared concerns about other patients’ behaviour and there not being enough staff on the ward to manage this.

Staff followed safe procedures for children visiting the service. The hospital had a designated room for visitors with children.

The service carried out a blanket restrictions audit, completed by staff with the inclusion of patient representatives. However, we found some blanket restrictions in place on both wards which were not reflected in the audits we reviewed. At the time of our inspection, there was a restriction on the availability of snacks and hot drinks, which was related to the risks of one patient. Patients were not provided with their own bedroom keys as identical bedroom locks were used throughout the hospital. Leaders explained this was due to the costs that would be involved in replacing all the locks.

The service worked with people to understand and manage risks so that care met their needs, in a way that was safe and supportive and enabled them to do the things that matter to them. However, staff did not always communicate with people in their preferred way and did not facilitate access to appropriate advocacy provision.

Staff involved patients in care planning and risk assessment. The was evidence of patient involvement in the records we viewed. A patient we spoke with said they were involved in their care plans and treatment and felt supported to understand the risks and keep safe.

Staff described balanced and proportionate approaches to risks that respected patient choices. They could give a number of examples of risks to or posed by individuals and described how they worked to reduce those. For example, staff had created an individualised timetable for a patient who could pose a risk to others.

Staff did not communicate with all patients about their care and treatment in a way they could understand. Although an interpreter service was available, it was not widely utilised and information about it on display was very limited. We met a patient who spoke limited English and required an interpreter, however this had not been arranged. This meant the patient could not be involved in discussions about their care and staff may not have understood their needs sufficiently.

Patients were invited to attend their weekly ward rounds along with staff, carers and others involved in their care and treatment. Patients were able to contribute and make suggestions which were listened and responded to.

Carers’ feedback about their involvement in their relatives’ care and treatment was mixed. Four carers felt they were only updated in the ward rounds but not otherwise if they could not attend those. One told us they would like to attend the ward round but had not been invited. Another carer said that they could not always get their voice heard in the ward round and their questions were not always answered clearly. Other carers however told us they had a positive experience of ward rounds and felt that staff kept them updated about their relatives’ care.

Staff reviewed observation levels regularly and updated patient records when these changed. A patient we spoke with knew what their level of observations was and said they were “happy with that”.

A patient we spoke with told us they knew how to access an advocate. However, although general advocacy was available, the provider did not facilitate access to Independent Mental Health Advocacy (IMHA) for qualifying patients detained under the Mental Health Act 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.

Restraints were reported and investigated in line with the provider’s policy, with actions and learning documented. Least restrictive practice was on the agenda of weekly community meetings. We reviewed the data on use of restraints, rapid tranquilisation, seclusion and long-term segregation on Hooper and Svanna wards for October, November and December 2024. Twenty restraints took place on Hooper Ward and 84 on Svanna Ward during this period. Of those, 5 were in the prone position on Svanna, with none on Hooper Ward. The service had appointed a Prevention and Management of Violence and Aggression (PMVA) lead who delivered training to new staff and demonstrated the correct technique during restraints.

The service detected and controlled most risks in the care environment and made sure that the equipment and facilities supported the delivery of safe care.

Staff carried out regular risk assessments of the care environment. We saw that most of the checks had been completed fully. However, not all weekly safety checks on Svanna Ward were completed consistently in October, November and December 2024.

The layout of both Hooper and Svanna wards allowed staff to observe all areas, with mitigations in place for the blind spots including CCTV and mirrors. Staff knew about ligature risks, how to mitigate these and could give examples of improvements made in response to risks identified and lessons learnt from past incidents. Ligature risks were part of new staff induction and ongoing staff training. Over 96% of eligible staff had completed the mandatory ligature risk reduction training. An annual ligature risk assessment was completed in March 2024. It was comprehensive and described the management of blind spots. However, there was an outstanding action identified on Hooper Ward, requiring the CCTV camera to be adjusted for a blind spot in the dining room. There was no date for its completion and the staff did not know when it was due to be done. We also found a potential ligature point in the Hooper Ward garden that was not identified in the risk assessment. Following our feedback, staff updated the risk assessment and took immediate action to mitigate the risk until it could be rectified.

Patients were able to raise concerns about the safety of the ward environment in the weekly community meeting and staff took actions in response.

The service displayed a list of prohibited items and followed a policy which detailed when routine and exceptional searches were to be conducted. The search area was in a designated room.

The hospital admitted female patients only and there was no mixed sex or shared accommodation. The provider had a policy on sexual safety and supporting safe relationships. The service also supported staff to feel safe working on the wards. Male staff were accompanied by female colleagues if entering patients’ bedrooms and patients could request to work with female staff.

There was a de-escalation room and a sensory room on each ward. The sensory room on Svanna Ward had adjustable mood lighting, however the one on Hooper Ward had basic lighting and seating and the staff we spoke to felt it could be improved. Both wards provided access to a large garden which was open all day.

The seclusion room allowed clear observation and two-way communication, had toilet facilities and a visible clock. Access to fresh air and natural light was limited, however patients could be escorted into the garden for fresh air.

The service previously experienced some issues with staff personal alarms being faulty. The alarm system had been reviewed. At the time of our visit, staff had easy access to personal alarms and told us alarms were working well and were checked daily.

The service managed fire safety well overall. The safety checks we reviewed were in date and all eligible staff completed the fire warden training. The service carried out quarterly fire evacuation drills. Staff completed Personal Emergency Evacuation Plans (PEEP) for patients who required additional support during evacuations. Staff told us one patient who found noises challenging was provided with ear defenders and received individual support from staff during fire drills and alarms.

The service had enough qualified, skilled and experienced staff who received effective support, supervision and development. However, the service did not ensure that all groups of staff were up-to-date with mandatory training and supervision.

Managers calculated the number and grade of nurses and support workers required and a safe staffing matrix had been approved for each ward. Staffing was discussed in daily meetings. The ward managers could adjust staffing levels daily by deploying agency and bank nursing staff to take account of patient needs. Recent levels of bank and agency staff use were high. In November 2024, 44% of nurses working on Hooper Ward and 50% on Svanna Ward were bank and agency. Managers told us most of the agency staff were regular and familiar with the service.

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At the time of our inspection, there was 1 vacancy for a registered nurse on Hooper Ward and 1 on Svanna Ward. Both wards were fully established otherwise. In the 6 months leading up to our inspection, the average turnover rate was 22% on Hooper and 10% on Svanna. The average sickness rate during this period was 1.3% on Hooper and 4.6% on Svanna.

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In December 2024, 17 shifts were short by one or more staff member on Hooper Ward and 12 on Svanna Ward. Leaders told us they had identified an increase in short notice shift cancellations as a risk in November 2024 and put mitigations in place by adding extra staff to the daily rota.

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A patient we spoke with felt there was not enough staff on the ward at times and that staffing could be improved, although they could get support when needed. One carer said their relative had reported to them "there isn't enough staff members around, meaning patients have to calm things down". Another carer said it could be difficult to speak to staff due to them being very busy.

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Some staff we spoke with said the wards were short staffed at times, especially when many patients were on enhanced observations, when acuity increased or at weekends. Two staff members said this had been raised through Freedom to Speak Up but felt no action had been taken. Some staff told us that staffing could interrupt or delay patient leave. Team meetings minutes showed that staff had reported wards feeling understaffed. However, we saw staff present in communal areas at all times.

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The medical staff we spoke with said there was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. A patient told us doctors always seemed available if they needed to speak to them.

Staff received training appropriate to their roles to enable them to support the patient group using the hospital and most were up to date with their training. Managers monitored training compliance rates in supervision and team meetings. However, the completion rate of several mandatory training courses was low. On Svanna Ward, choking awareness training completion was 74% for eligible staff, with only 64% of support workers having completed the training. On the same ward, 38% of nurses had not completed observation and engagement training. Completion rates of mandatory Learning Disabilities and Autism Tier 2 training were consistently low, at just over 50% for all staff. Leaders told us this was due to unavailability of face-to-face training. This meant some staff may not have been trained on how to best support the autistic patients and patients with learning disabilities who were admitted to the hospital. However, most staff had completed The Oliver McGowan Mandatory Training on Learning Disability and Autism.

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Most staff participated in supervision and appraisal, however this was significantly lower for the bank staff who worked across all wards at the hospital. Only 26% of bank staff were up to date with clinical supervision and 43% with managerial supervision.

Staff could access reflective practice sessions, supervision, debriefs and said that learning was shared well following incidents. New starters received a role-specific induction and managers used a checklist to ensure they had completed it prior to starting work. Prior to Svanna Ward opening, all staff received an induction specific to the ward environment. Staff were positive about the provider's induction, training and development programmes.

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Leaders explained their processes to ensure staff were suitably qualified and had appropriate employment checks, but they were unable to demonstrate a robust system. This will be explored further within the well-led key question.

The service assessed and managed the risk of infection appropriately.

The care environment on both wards was visibly clean, mostly well-maintained and appropriately furnished. A patient we spoke with told us they found the ward clean. Patients were able to give feedback on the environment and raise any issues in weekly community meetings. Cleaning records were up to date and demonstrated that all areas of the ward were cleaned regularly. Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. Clinical equipment was cleaned regularly and after each use.

Staff adhered to infection control principles, including handwashing. Staff completed mandatory training in infection prevention control and personal protective equipment. The service carried out regular hand hygiene and infection control audits.

The service did not always make sure that medicines and treatments were administered safely, in a timely way or in line with national recommendations or legal authorisations. Monitoring was not completed to ensure patients were kept safe following use of rapid tranquilisation medicines.

Patients did not always receive their medicines safely and as prescribed. There were gaps in administration records where it was not clear if a prescribed medicine had been given. Medicines weren’t always available which meant patients missed medicines. When critical medicines were missed, staff did not follow guidance to ensure that medicines were re-prescribed safely. For example, a break of more than 48 hours from clozapine (antipsychotic) requires the dose to be re-titrated from a lower dose. This did not happen and can increase risk of adverse effects from clozapine. Care plans for high-risk medicines lacked details about known risks which staff should monitor. Failure to recognise and act upon known risks can lead to avoidable harm.

Patients were given rapid tranquilisation (RT) medicines intramuscularly to help reduce agitation and aggression. However, staff did not always follow the provider’s policy for the use of RT and did not always complete physical health monitoring following RT in line with national guidance or provider policy. This had been identified as an area for improvement in audits, however, there was no evidence of improvement and staff were unclear regarding post-RT processes.

We were not assured that ‘when required’ (PRN) medicines for the management of agitation were used appropriately. Patients’ care records did not always explain the reason patients were given PRN medicines, their effectiveness or any de-escalation techniques used. Where multiple PRN medicines were prescribed for agitation and aggression, there was no guidance for staff on first line and second line medicines or the time interval between PRNs. Staff did not always follow the PRN medicines administration plans correctly.This could lead to adverse events or increased risks of side effects if multiple PRN medicines were given at the same time.

We saw patients detained under the Mental Health Act (MHA) had been administered medicines that were not in line with MHA consent to treatment authorisations. This had been previously highlighted within the service by its pharmacist, however no learning was demonstrated.

Staff told us it was not always possible to identify an accurate list of patients’ current medicines and allergies in a timely manner.

Medicines were stored safely and were in date. Clinic rooms were clean and neat, although the medicines cupboard on Svanna Ward was overfilled. Clinical equipment was maintained and stored appropriately. However, weekly calibration records for the blood glucose monitoring machines on both wards were not up to date. This meant they may not have produced accurate blood glucose readings for the diabetic patients. A first aid box on Hooper Ward had not been checked since August 2024. We found the fridge temperatures on Hooper Ward recorded as out of range on 3 occasions during November 2024. Following our feedback, this was escalated to leaders and a maintenance request raised.

Staff told us about ongoing issues with medicines supply that impacted on care and treatment. Staff reported that ordering medications could be a problem, with delays of over a week or two on occasion. Leaders told us this had been escalated and they were working with the pharmacy supplier to address these concerns.