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 patients were protected from abuse and avoidable harm.

At our last inspection we rated this key question requires improvement for the personality disorder services. At this inspection the rating has remained the same. The service was previously in breach of the regulation in relation to safe staffing. Improvements were found to safe staffing numbers at this inspection, but we found an ongoing breach of this regulation in relation to mandatory training. The service was also in breach of regulations in relation to safe care and treatment.

This meant some aspects of the service were not always safe and there was limited assurance about some aspects of safety.

This service scored 56 (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, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew what incidents to report and how to report them via an electronic incident reporting system. Leaders had recently provided refresher training and reminders to staff about the quality of incident reporting, after they identified some shortfalls. In November 2024, staff reported 55 incidents on Upping ward and 136 incidents on New Dawn wards. From June 2024, incidents on New Dawn wards increased each month, from 59 in June 2024 to 153 in October 2024. Leaders monitored themes and trends and implemented actions with an aim to reduce incidents and identify learning for staff. CCTV was reviewed and individual staff made aware of performance improvements where necessary. Leaders noted a sustained improvement with a decrease in self-harm incidents while on enhanced observations, but recognised actions to reduce self-harm using restricted items were ongoing. Leaders planned to start safe practice workshops from early 2025 which focused on record keeping, searches and least restrictive practices.

Patients and staff were usually debriefed and supported following incidents. Staff received feedback from investigations of incidents. Staff met in several forums to discuss risks and learning, including team meetings, reflective practice and individual supervision sessions. Lessons learnt were also circulated via email and displayed on the wards. All staff we spoke with gave examples of lessons learnt following incidents. There was evidence that changes had been made following safety incidents. For example, the estates team had ordered a new style of hatch door for the property room on New Dawn 1 after an incident.

We spoke with a care manager who commissioned beds on New Dawn wards. They said the service was transparent, acknowledged their strengths and areas for improvement, and were willing to act on constructive criticism and recommendations.

Patients were encouraged and supported to raise concerns via several forums, and these were taken seriously. For example, patients raised concerns about staff using their personal phones on the wards. We saw evidence that managers reminded staff about unacceptable phone use while at work. However, community meetings were not consistently managed across the wards in terms of establishing which patient concerns had been addressed or were ongoing. On Upping Ward, staff noted and reviewed actions, whereas this did not happen on New Dawn wards.

The service worked with people and partners to establish and maintain safe systems of care, in which safety was well managed and monitored. They worked to ensure continuity of care, including when patients moved between different services. However, some challenges with external partners’ working practices and inconsistent engagement with the therapeutic programmes resulted in some lengthy admissions.

The service’s referral and admission processes aimed to ensure that all essential information about a new patient was received to determine if the patients’ needs could be safely met. At the time of our inspection, most patients on the wards were out of area from their usual home address, which meant some were quite a distance away from family and friends. However, patients described positive experiences of their admission to the wards, including planned admissions, orientation to the ward, and allocation of a ‘buddy’ for support. Patients kept in touch with relatives, and most carers felt involved with their relative’s care. Some patients and carers commented that the high levels of acuity of some patients on the wards could cause them distress.

Staff involved all the necessary health and social care professionals to ensure patients had continuity of care, both within the service and after discharge. However, the service often experienced delays to discharge, for reasons outside of their control. For example, some external teams did not allocate care coordinators until the point of discharge. Staff expressed the importance of this to build consistency and cross over of care for patients. The service escalated delays to NHS England for New Dawn patients, who in turn escalated to provider collaboratives and ICBs. Staff supported patients to visit future placements and spend more time off the ward when safe to do so to aid transition into the community.

At the time of inspection, 1 patient’s discharge was delayed. The patient’s local team were working to find an alternative placement more suited to their needs. Staff said identifying alternative placements was sometimes challenging. Ten patients exceeded the average length of stay for the personality disorder wards. The average length of stay for patients on New Dawn wards was 18 – 24 months and 18 months for Upping Ward. Some patients had been at the hospital for 4 or 5 years. Leaders explained that reasons for longer stays mainly included changes to therapeutic needs. This included patients who disengaged and reengaged with therapy, and the need for additional therapy sessions or alternative forms of therapy. Leaders told us they monitored and managed patients’ length of stay via discharge planning meetings and quarterly reviews in conjunction with funding and home teams. Feedback from one care manager was that the referral to treatment pathway would benefit from clearer projections of discharge dates. Most records we reviewed noted an estimated discharge date and some had detailed discharge plans. However, of the 3 patient records we reviewed for New Dawn wards, there was no clear discharge planning for 1 patient who had been admitted in July 2023.

The service worked with people and partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. However, we found some inconsistencies around blanket restrictions related to bedroom searches, and it was unclear how leaders regularly reviewed these restrictions and actions from audits.

Staff and leaders described improvements within the social work and safeguarding team after a new team was created in 2024. The new lead social worker and head of safeguarding had focused on rebuilding the team, the reestablishment of links with the local authority, and had developed service improvement plans which included arranging additional training for staff. The safeguarding lead reviewed all incidents each day to check if any were safeguarding matters. The team maintained a database of safeguarding concerns to monitor themes, the notification of external agencies, and the progress of each case. The lead social worker had an improvement plan starting in early 2025 which aimed to allocate a named social worker to each ward to increase their presence and input.

All staff on Upping Ward and 93% of New Dawn ward staff had completed their mandatory online safeguarding training. All staff on Upping Ward and 87% of New Dawn ward staff had completed their mandatory virtual classroom safeguarding sessions. 92% of staff across both wards were up-to-date with their safeguarding supervision, but only 40% of the social work team were up-to-date with their clinical supervision. Staff knew how to identify adults and children at risk of, or suffering, significant harm. They knew how to make a safeguarding alert and did that when appropriate via the social work team.

Safeguarding was discussed in a range of forums including the daily safety huddle, team meetings, supervision and induction sessions. Upping Ward community meetings had an agenda item for patients to raise any safety concerns, but this did not feature on New Dawn ward agendas. Most patients said they felt safe on the ward, although 1 patient said they felt unsafe if other patients were aggressive towards staff.

Staff followed safe procedures for children visiting the service, with a specific family visiting room located off the wards.

Records we reviewed showed that staff attempted to verbally deescalate situations before using restraint, which was supported by patient feedback. The service completed audits of restraints by viewing CCTV where available, which included whether there were any safeguarding concerns about the restraint.

Staff and patients reviewed blanket restrictions via quarterly audits and during community meetings. Some blanket restrictions were in place due to potential risks posed to patients, for example, plastic cutlery was used on the wards. We found that no patients had access to their own bedroom keys, which patients raised during the July and December 2024 blanket restriction audits. The hospital director said a previous funding bid for patient keys had been rejected due to higher risk priorities.

There were inconsistencies with how bedroom searches were completed across the wards. This was supported by feedback we gathered from some patients, concerns raised by patients via the blanket restrictions audit, differences in practices between the wards, and variations in staff understanding of the processes. Some staff and ward managers said all bedrooms should be searched every week but on random times and days. This was also detailed on the search forms. However, the provider’s policy and hospital manager stated room searches should be based on an individual’s risk assessment, or regularly reviewed by senior leaders if all patients were routinely searched. These inconsistencies meant some bedroom searches may have been completed when this was disproportionate to individual risk. Furthermore, the blanket restrictions audit stated it must be discussed and reviewed at least monthly in forums such as clinical governance meetings. We did not see any evidence of such reviews during these meetings. This meant it was unclear how leaders were assured the restrictions were necessary and proportionate, or how they ensured compliance with action plans to reduce restrictions.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs that was safe, supportive and enabled patients to do the things that mattered to them.

We reviewed 6 electronic care records. Staff completed risk assessments on admission, reviewed them during monthly ward rounds and updated them after incidents. Staff also completed daily risk assessment reviews, which aimed to reflect the current presentation of each patient. Staff discussed incidents during the daily huddle. We noted evidence of strong patient involvement within care plans, but this was more limited within the risk assessment process. The service had recognised that triangulation of risk assessments, care plans and daily risk assessment needed to improve, and we saw evidence that this had been discussed at the New Dawn team meeting.

All patients we spoke with said they felt supported to understand their risks and keep themselves safe. They said they were involved with their care and treatment. We observed that all bedroom doors on New Dawn wards displayed personal crisis management plans which outlined individual triggers and techniques to calm patients during crisis. We spoke with 7 carers of patients on New Dawn and Upping wards. Most carers we spoke with felt involved in care plans and treatment with their relative’s consent, and most said they had been invited to attend ward rounds and other meetings about their relative’s care. Most carers felt staff supported their relative to make decisions for themselves. However, 3 carers of patients on New Dawn wards said they had not been able to give their views about their relative’s care.

Staff enabled patients to give feedback on the service through various methods including surveys and community meetings.

Staff ensured that patients could access general advocacy. The general advocate we spoke with said staff knew patients well and were quick to manage incidents before they escalated. However, the service did not facilitate access to independent mental health advocates (IMHAs) for qualifying detained patients in line with their rights under the Mental Health Act.

Between May 2024 and November 2024, there had been 15 restraints on Upping ward and 132 restraints on New Dawn wards. Of these restraints on New Dawn wards, 25 were in the prone position. This related to the care of a small number of patients and a change in medicine administration had led to a reduction in prone restraints. There were no instances of prone restraint on Upping ward. The hospital had a prevention management of violence and aggression (PMVA) lead who completed regular reviews of restraints using CCTV where available. We reviewed 4 prone restraint audits, all of which detailed learning. For example, 3 incidents detailed improvements required to the documentation of the incidents, and 1 incident shared learning around not using mattresses for prone restraint due to the risk of asphyxia. Restraint figures, findings and learning from the audits were shared with staff via clinical governance meeting minutes. Leaders said they met with staff individually where performance improvements were identified and gave them refresher training on PMVA. Records showed that staff attempted to verbally deescalate situations before using restraint. Patients we spoke with said staff used restraint as a last resort. When restraint was used, patients described these as dignified and said staff debriefed them afterwards.

Staff mostly detected and controlled potential risks in the care environment. They usually made sure equipment, facilities and technology supported the delivery of safe care. However, audits were not always effective at ensuring improvements were made to the environment and we observed some gaps.

Staff on New Dawn 1 and Upping Ward completed regular risk assessments of the care environment. There were daily security checks and weekly environmental checks. We found some gaps with weekly environmental checks on New Dawn 2. For example, staff completed checks on 3 November 2024 but the next did not take place until 30 November 2024. The service conducted 4 fire drills per year, an annual comprehensive fire safety and maintenance check, and weekly fire alarm tests. Patients with additional needs had a personal emergency evacuation plan for them and staff to follow in the event of a fire or other emergency.

Patients had access to their rooms throughout the day and had personalised their bedrooms and doors. Each bedroom had an ensuite toilet and sink. Patients shared shower and bathing facilities on each ward. All wards had a small balcony with a seating area that was always open for patients.

The hospital admitted female patients, but also accepted transgender patients following risk assessment. Patients had the opportunity to raise any concerns. The provider had a sexual safety policy and a transgender policy.

The service assessed and managed ligature risks well. Staff were aware of ligature anchor points on the ward and mitigated the risks to keep people safe. New staff had a session on ligature risks as part of their induction. Rooms with ligature points, such as the activity rooms, remained locked and used with staff supervision. Ligature risk assessments had been completed for each ward in April 2024 and there were heat maps and photographs of ligature points displayed in the nursing offices. However, we noted a delay in completing an action point from Upping Ward’s ligature risk assessment from April 2024, to install CCTV in a blind spot.

The ward layout did not allow staff to observe all parts of the ward, but this was mitigated through convex mirrors and staff observations. Staff we spoke with were aware of blind spots in bedrooms and knew to check inside when completing observations.

Staff had easy access to alarms and patients had access to nurse call systems in their bedrooms. The hospital had started to replace old personal alarm models for staff. Staff said the new alarms were more effective and reliable. Personal alarms were tested before the start of each shift. Staff on New Dawn 2 and Upping Ward completed weekly audits of patient call bell alarms. We found some gaps with these audits on New Dawn 1, for example, one audit was completed on 28 October 2024 and the following audit was completed on 30 November 2024. A faulty bedroom alarm was escalated on 30 November 2024, however, due to the gap between audits it was unclear how long it had been faulty for.

The personality disorder wards did not have a seclusion room.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff usually checked the temperature of the clinic rooms and the medicine fridges daily. There was an examination couch in the clinic room on Upping Ward, but no space for these in the New Dawn ward clinic rooms. Patients on New Dawn had to use the physical healthcare room if they needed use of an examination couch.

The service now made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development and worked together effectively to provide safe care that met patient’s individual needs. However, patients did not always have regular one-to-one sessions with their named nurse and compliance rates for some mandatory training was low.

Staffing had improved since our last inspection. While the service had some shifts that were short by more than one staff member between June and December 2024, the frequency had significantly decreased. Vacancy and turnover rates had reduced. New Dawn wards had 12% vacancy rates for registered nurses and 8% for healthcare support workers while Upping ward had 18% vacancies for registered nurses and 8% for healthcare support workers. Turnover rates were 19% on New Dawn wards and 17% on Upping Ward. There were no vacancies within the medical, occupational therapy, psychology or social work teams. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. Leaders had recognised a recent increase in last minute staff absences, so introduced a short term plan in November 2024 where they added 3 staff to the day and night shifts to mitigate against wards being short staffed.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. We looked at bank and agency use of registered nursing staff for October and November 2024. No bank staff were used, but between 21% and 33% of registered nurses working on the wards during these months were agency staff. Agency staff received an induction and leaders aimed to use agency staff who were familiar with the wards.

Managers had calculated the number and grade of nurses and healthcare support workers required. Ward managers could adjust staffing levels daily to take account of case mix. Most staff we spoke with described challenges with staffing during the earlier part of 2024, but said this had improved in recent months. Two staff we spoke with felt that although the staffing requirements were usually met, there were many tasks required of their roles which could feel overwhelming. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. However, the advocate we spoke with said patients on New Dawn sometimes had to wait to receive escorted leave if staff did not have the capacity at specific times, which affected the atmosphere on the ward. Furthermore, staffing levels did not always allow patients to have regular one-to-one sessions with their named nurse. For example, we spoke with 2 patients on New Dawn ward. One patient said they received this session every 2 to 3 weeks and the other patient said it was over a month between sessions. Shortfalls in these sessions had been recognised by the ward manager prior to our inspection, was raised with staff, and monitored by leaders. Feedback from patients indicated further improvements were needed. Patients on Upping Ward reported regular one-to-one time with staff. All patients we spoke with said staff were kind and supportive.

We observed nursing staff were always present in communal areas of the wards.

Staff compliance with mandatory training was low in some areas. Compliance rates for New Dawn and Upping Wards in START risk assessment training was 35% and 63.3% respectively. Compliance rates for face-to-face learning disability and autism tier 2 training was 30.3% and 56% respectively. The service accepted patients with autism, which meant not all staff were appropriately trained to best support them. Four staff we spoke with said they would benefit from more training on autism. The next tier 2 training was booked for summer 2025.

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. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. However, although audits identified shortfalls, they did not always state the required actions or whether the action had been completed. Staff did not always escalate problems with equipment to service leaders.

All wards were clean, had good furnishings and were well-maintained. Cleaning records were up-to-date and demonstrated that the ward areas were cleaned regularly. Equipment had visible and in date ‘clean’ stickers. Patients we spoke with said the wards were clean.

Patients had the opportunity to raise environmental issues within community meetings. There was a maintenance team on site during the week that staff described as very responsive. An external company was available to respond to urgent requests outside of working hours.

Staff usually checked and maintained equipment in the clinic rooms, although the manual blood pressure machine on New Dawn 1 had not been checked in October 2024 as it should have been.

There was no evidence that staff had escalated issues with the fridges in the nursing office or dining room on Upping Ward. The audit showed 7 occasions within a 9 day period that the fridge temperatures exceeded the maximum of 5 degrees Celsius, but there were no comments or actions noted.

Staff adhered to infection control principles, including handwashing. Upping Ward displayed hand hygiene posters, and hand sanitiser was available by ward entrances. The physical health nurse had facilitated a Flu vaccination clinic in November 2024, which was attended by 26 people.

The service had infection prevention and control (IPC) leads. Audits related to IPC were completed regularly, however, actions and dates of completion were not always clearly specified. For example, a hand hygiene audit from Upping Ward identified that not all staff members were bare below the elbows, but the audit did not outline what action would be taken. On New Dawn and Upping wards, the quarterly infection control audits from October 2024 identified 3 actions in total, but did not state if these had been completed or not.

The service did not always make sure that medicines and treatments were administered safely, in a timely way or in line with national recommendations. Physical health monitoring was not completed to ensure people were kept safe following use of rapid tranquilisation medicines. However, patients felt involved in discussions about their medicines, including when changes happened.

Patients did not always receive their medicines safely as prescribed. We observed instances where people had not received some medicines, due to the supply not being available. One carer we spoke with said the ward was “always running out of medication.” Two carers told us that hospital staff had sent their relatives home with the wrong medicines before. The hospital had changed its pharmacy provider during 2024 which had caused problems with medicines supplies. The operations director was aware of these concerns and leaders had implemented interim solutions, but issues persisted.

The clinic rooms were clean and tidy but not always well organised. For example, the drugs trolleys on New Dawn 1 and Upping wards were disorganised. This made it challenging for staff to locate medicines and caused delays for patients. We observed the impact of this on 2 occasions on Upping Ward.

Prescriptions were not always presented clearly or accurately. For example, we saw an instance where a depot antipsychotic medicine had been missed off the medicines chart and another where a medicine had been prescribed twice on the chart. The provider confirmed the medicine was only administered once, but the prescription errors had not been picked up by staff. Similar errors had been identified by the pharmacist; however we were not assured that lessons had been learnt or shared. We saw an example where Mental Health Act documentation did not match with the current prescription. We brought this to the attention of the prescriber, so this could be promptly addressed.

Medicines self-administration was supported when safe and appropriate, to promote independence. However, risk assessments had not been completed in line with the provider’s policy.

Physical health checks were not always completed in line with care plans and recording of results were inconsistent. Care plans for high-risk medicines lacked details about known physical health risks which staff should monitor. Where people were prescribed medicines requiring additional monitoring, staff didn’t always carry this out. For example, bowel monitoring for patients on clozapine was not always completed. In another instance, 3 monthly lithium levels had not been taken for 8 months which had not been picked up by staff. Failure to recognise and act upon known risks can lead to avoidable harm to people.

Staff used individualised de-escalation techniques before administering ‘when required’ (PRN) medicines. People were given rapid tranquilisation (RT) medicines intramuscularly to help reduce agitation and aggression. However, post dose physical health monitoring was not being completed in line with national guidance. None of the post dose physical health checks we reviewed had been completed in line with local policy. The service completed regular RT audits, however, there was no evidence of improvement and staff were unclear regarding post RT processes. There was lack of oversight of RT processes. This puts people at increased risk of harm. We raised our concerns about physical health checks for high risk medicines and post RT monitoring with leaders. They took some immediate actions in response, and implemented an action plan so improvements could be monitored and sustained.

Patients we spoke with said they had enough information about their medicines and that this was discussed during every ward round. Staff checked that patients had swallowed their medicines. Where there were known risks of hoarding and overdose there were care plans in place to support staff.