- Independent mental health service
Cygnet Hospital Beckton
Assessment report published 13 June 2025
Contents
Ratings - Personality disorder services
Our view of the service
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.
People's experience of this service
We spoke with 4 patients on the personality disorder wards and 7 carers. During this inspection we piloted an approach to identifying and improving service culture using extended observations.
All patients we spoke with said they were treated with kindness, respect and dignity by staff. Most patients felt there were enough activities, the wards were clean, and felt their treatment and care was explained clearly to them. One patient said, “it’s the best hospital I’ve been in.” Another said, “if I’d been in a different hospital with different people I probably wouldn’t be where I am now.” Throughout our inspection, we observed kind and supportive interactions between staff and patients. Patients were encouraged to provide regular feedback about their care and the ward environment
However, most patients were negative about the food, and described it as “terrible,” “not amazing,” and “horrible.” Two patients on New Dawn said they did not meet with their named nurses every week as expected.
Feedback from carers was mixed. Most carers were positive about staff attitudes, said their relative felt safe, and that staff were supporting their relatives’ recovery. However, most carers said communication from staff needed to improve, and that they had not been asked to give feedback on the quality of the service. Two carers we spoke with also raised safety concerns and described incidents they were not happy with.