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 assessment we rated this key question requires improvement. The service was previously in breach of regulations in relation to safe care and treatment and staffing. At this assessment the rating has improved to good. We found significant improvements in the previous areas of concern, and the service was no longer in breach of regulations.

This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. They 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. Staff told us that they would report any incident of harm, potential harm or risks to safety.

Staff told us incidents and never events were discussed in supervision, daily huddles, team meetings and reflective practice. Incidents were also discussed at clinical governance meetings with learning from these disseminated to each ward.

Themes and trends identified from incidents were discussed with the staff team.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. Duty of candour incidents were reviewed and discussed at the monthly clinical governance meetings.

Staff were informed about learning through the provider’s lessons learnt newsletters. This information was shared with bank staff through group supervision

Managers debriefed and supported staff after any serious incident. Staff felt well supported and were offered the opportunity to debrief immediately following incidents and also in regular reflective practice sessions. The hospital had introduced Trauma Risk Management (TRiM), a trauma-focused peer support system designed to help staff who have experienced a traumatic, or potentially traumatic, event. Staff could also access Sustaining Resilience at Work (STRaW), a well-being peer support system. One staff member described the support they received from TRiM after being involved in an incident and told us that it had been helpful to their wellbeing.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Some people were placed a long way from where they lived and some people experienced delayed discharge while suitable move on placements were identified.

Staff had easy access to clinical information, and it was easy for them to maintain high quality clinical paper-based and electronic records. Patient notes were comprehensive, and all staff could access them easily. Records were stored securely.

The service’s referral and admission processes ensured that all essential information about a new patient was available to determine if the patients’ needs could be safely and appropriately met. At the time of our inspection, patients on the wards were placed out of area from where they lived. Whilst some patients were from South London, the majority were from farther afield, including Devon and Wales. This impacted upon some patient’s ability to maintain regular, face to face contact with their families and other people who were important to them. One carer reported, due to the distance of the hospital, there could not visit they relative as often as they would like.

The service experienced delays to discharge whilst the placing authority identified appropriate move on placements. During the inspection 2 patients on Hooper Ward and 1 patient Svanna Ward were experiencing delayed discharge. We discussed with managers the delayed discharge of 1 patient whose needs the hospital had identified it could no longer safely or appropriately meet. Managers told us, actions had been taken to escalate concerns, and we were notified shortly after the inspection that this patient had transferred to a suitable placement.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared safeguarding concerns quickly and appropriately.

Staff knew how to recognise adults and children at risk of or suffering, significant harm and worked in partnership with other agencies to protect them. Staff we spoke with knew who the safeguarding lead was and felt confident in reporting safeguarding concerns.

Staff received training on how to recognise and report abuse. All new staff received safeguarding training during induction, with ongoing mandatory refresher training provided in accordance with their role and responsibilities. Patients we spoke with said they felt safe on the ward.

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

Safeguarding was discussed in various forums, including a weekly site safeguarding meeting attended by senior managers. This meeting reviewed safeguarding concerns, actions, and emerging risks. A central safeguarding team had oversight and completed audits in relation to safeguarding actions.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately. Improvements were needed to make sure checks when people were nursed in seclusion complied with the Mental Health Act Code of Practice (2015). The acuity of a small number of people receiving care and treatment had led to spikes in the number of incidents and the use of restrictive interventions to manage these.

We reviewed 8 electronic care records. Staff completed risk assessments for each patient on admission using a recognised tool. Risk assessments were reviewed regularly, including after any incident.

The hospital had recently moved to a risk formulation model. Staff had received training in the new approach. Systems and processes were in place to support the embedding of the new tool. 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 we spoke with had a good understanding of each patient and the risks associated with their care. Patient risk assessment and management was discussed in daily huddle meetings, at handovers and in multidisciplinary meetings. All care records for patients had up-to-date risk assessments.

Patients were invited to attend 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. Patients told us, they felt listened to and that their views were taken into account. One patient told us about their positive experience in requesting a change to their prescribed medicines, in line with their personal preference.

Staff demonstrated a clear understanding of patients’ current needs, risks, and preferences. We observed 2 ward rounds. Information discussed during the meetings was reflected in patients’ care plans, and care delivery. This demonstrated that care was planned and delivered in a person-centred manner. Staff identified and responded to changing risks, for example, observation levels were regularly reviewed and increased when individual patient risk increased.

Staff followed policies and procedures when they needed to search patients or their bedrooms to minimise risk and keep them safe from harm.

The hospital carried out a blanket restrictions audit. At our previous inspection in December 2024, the assessed needs of some patients had led to restrictions in accessing drinks and snacks on both wards. During this inspection we saw improvements. Each patient was individually risk assessed, with some patients on Hooper ward able to access the kitchen independently to make drinks and snacks. Patients who were assessed at risk could request hot drinks and snacks from staff. Patients and staffs reported this was working well.

Patients were not provided with their own bedroom keys as identical bedroom locks were used throughout the hospital. Patients had access to their rooms throughout the day. Patients had a secure place to store personal possessions. Each patient had access to a locker and additional allocated space for larger items to be stored.

Staff supported best practice in implementing a smoke-free policy. The occupational therapy team offered smoking cessation support including vapes, nicotine replacement therapy, and a “quit stop” group programme.

The hospital provided care to both informal patients and those detained under the Mental Health Act. Informal patients were aware of their right to leave the ward; each ward clearly displayed information advising informal patients of their right to leave.

Patients could access general advocacy, and staff informed them of their rights under the Mental Health Act (MHA). At our inspection in December 2024, the provider did not facilitate access to Independent Mental Health Advocacy (IMHA) for qualifying patients detained under the MHA. During this inspection we found improvements. The hospital had strengthened its admission processes. At the point of admission, for qualifying patients, they were assigned an IMHA. If the patient declined this support, this was recorded in their care and treatment records.

Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe. Staff participated in the service's restrictive interventions reduction programme, which was centred on a "No Force First" culture. In partnership with the Crisis Prevention Institute (CPI), staff received Prevention and Management of Violence and Aggression (PMVA) training that focused on proactive de-escalation techniques and aligned with best practice standards.

We reviewed the data on use of restraints, rapid tranquilisation, seclusion and long-term segregation on Hooper and Svanna wards for 5 months leading up to the inspection. There had been 158 incidents of restraint on Svanna ward, and 23 on Hooper ward. Of those, 7 were in the prone position on Svanna ward and none on Hooper ward. Managers told us, these related to a small patient cohort with complex needs and multiple co-morbidities, one of whom had been transferred within the 5-month data period, and another who had since been transferred to an alternative placement.

There had been 64 incidents of rapid tranquilisation on Svanna ward, and 11 on Hooper ward. There had been 6 incidents of seclusion on Svanna ward, with none on Hooper ward. The longest period for a patient being nursed in seclusion was 6 days on Svanna ward, with none on Hooper ward. All incidents of restraint, seclusion and rapid tranquilisation were reviewed at clinical governance meetings. Managers and the security lead were also able to access CCTV footage from communal areas to review incidents of restraint.

Staff used seclusion appropriately and followed best practice when they did so. At the time of our inspection, a patient was being nursed in seclusion. Staff monitored all patients for the first hour of seclusion. Details of the patient in seclusion was displayed and noted on a wipe board, including the time of previous nursing review, time of next nursing review and the items the patient took into seclusion.

We reviewed 3 seclusion records. Staff maintained appropriate records that showed that patients were afforded the appropriate checks and safeguards outlined in the Mental Health Act code of practise. We found that the 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. This had happened recently, which meant that the make-up of the independent review team had not complied with guidance. On another occasion where an independent review was required, this had not occurred. We raised this during our inspection. The hospital manager subsequently told us that updated procedures that addressed out of hours had been introduced. The hospital manager also told us, they had added independent reviews on the ‘Hospital Safety Huddle’ template to improve oversight of this aspect of seclusion governance.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff completed regular risk assessments of the care environment, both on Hooper and Svanna wards. Staff carried out health and safety checks of the wards and reviewed all environment checks in daily oversight meetings.

The layout of both Hooper and Svanna wards allowed staff to observe all parts of the wards, with mitigations in place for the blind spots including mirrors and closed-circuit television (CCTV).

Staff knew about ligature risks on the wards and could describe how these were being mitigated. Ligature risks were addressed as part of staff induction and ongoing training. An annual ligature risk assessment had been completed, reviewed and updated 3 weeks prior to our inspection.

There was no mixed sex accommodation

Staff had easy access to alarms and patients had easy access to nurse call systems in their bedrooms. Staff on Hooper and Svanna wards carried out weekly checks of patient call alarms. Staff told us personal alarms worked well and were checked daily.

The seclusion room allowed clear observation and two-way communication, and temperature control was in place. It had toilet facilities and a visible clock. There was no seclusion garden, but patients could be escorted into the garden for fresh air.

The clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked daily. The clinic rooms were visibly clean and tidy. At our inspection in December 2024, weekly calibration records for blood glucose monitoring machines on both wards were not up to date. During this inspection we saw improvements. Blood glucose and ketone monitoring machine checks were completed weekly.

They worked together well to provide safe care that met people’s individual needs. Staff were suitably qualified, skilled and experienced, but compliance rates for administration of some specialist medicines needed to improve. There were some occasions where safe staffing levels had not been achieved and measures had been taken promptly to ensure people were kept safe.

Overall, the service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.

Managers calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants for each shift. The service used a staffing matrix which determined the numbers of staff required, dependent on the number of patients and their acuity.

Ward managers could adjust staffing levels daily in accordance with the needs of patients. Where bank and agency were used, those staff received an induction and were familiar with the wards.

At the time of our inspection both wards were fully established with additional over recruitment to some roles. The average staff turnover rate across the hospital was 3% in the 3 months leading up to our inspection. The average sickness rate was 2.8% within the same 3 month period.

Staffing records for Hooper ward showed that, over a six-day period in May 2026, staffing fell below minimum safe levels. This was escalated immediately, with action taken to ensure safety including, review of leave, postponed activities, and closing the ward to admissions. Staffing levels in the 3 months preceding were within the hospital’s safe staffing matrix range.

The name of the primary and associate nurse was displayed outside each patient’s room. Patients told us they had regular one-to-one time with their named nurse most of the time, when that could not happen, staff informed them. All patients we spoke with said support was available when needed. Two of 3 patients we spoke with said at times there was not enough staff; one told us this was when they were lots of one-to-one observations happening.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. Some staff told us, short notice cancellation of shifts did sometimes result in delays to escorted leave, and activities could be postponed. Leaders told us, late shift cancellations had been recognised as a challenge, and they were working with staff, with measures in place to reduce the occurrence.

On Hooper and Svanna wards, there was enough staff on each shift to carry out any physical interventions safely, and where needed, additional staff were deployed. The hospital had appointed a Prevention and Management of Violence and Aggression (PMVA) lead who delivered training to new staff.

There was appropriate medical cover day and night and a doctor could attend the ward quickly in an emergency. Patients were seen and monitored in a timely way. The service operated an on-call system out of hours.

At our inspection in December 2024, the provider had not ensured that all eligible staff completed mandatory training appropriate for their role to meet the needs of the patients. During this inspection we saw improvements. Overall compliance for mandatory training was 98% for Svanna Ward and 91% Hooper Ward. However, we found that 66% of staff had completed mandatory training to administer buccal midazolam. We raised this with the hospital manager. They took immediate action to ensure that a member of staff was on duty for each shift who could administer this medication across all wards. Subsequently additional training was provided to increase compliance with this course. We also saw that 25% of staff on Svanna Ward had completed mandatory training in complaints. We raised this with the hospital manager. They subsequently told us that additional training had been arranged and compliance with complaints training for Svanna Ward had risen in excess of 92%.

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.

Ward areas of both Hooper and Svanna were visibly clean, and well-maintained. Patients were able to raise any issues and give feedback on the environment in weekly community meetings, for example, the redesign and decoration of the de-escalation and sensory room, and communal area on Svanna ward.

Staff made sure cleaning records were up to date and that the ward areas were cleaned regularly. A bi monthly national cleaning standards audit had been completed.

Staff adhered to infection control principles, including handwashing. Staff completed mandatory training in infection prevention control and personal protective equipment. The service had infection prevention and control (IPC) leads. Regular infection control and handwashing audits took place. Where any improvements were required, these were shared at team and clinical governance meetings

The service made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. They involved patients in planning, including when changes happened.

At our inspection in December 2024, patients did not always receive their medicines safely and as prescribed. Some patients’ physical health was not monitored appropriately, including venous thromboembolism (VTE) assessments and following rapid tranquilisation (RT). Some patients detained under the Mental Health Act (MHA) had been administered medicines that were not in line with MHA consent to treatment authorisations. During this inspection, we found improvements. The service had strengthened medicines management. Patients received their medicines safely as prescribed. Staff regularly reviewed the effects of medicines on each patient’s mental and physical health in daily safety huddles and multidisciplinary meetings. On the day of inspection, the service was in the process of moving over to a new electronic prescribing and medicines administration (ePMA) system.

A review of care records showed that appropriate checks were carried out for patients administered rapid tranquilisation, lithium and clozapine. Medicines were administered in line with relevant Mental Health Act ‘consent to treatment’ authorisations where needed.

When PRN (‘when required’) medicines were used, the reason for administration and what else had been tried first was clearly recorded on the daily electronic care records. A review of 8 care records demonstrated evidence of physical health reviews completed on admission included VTE screening.

Two of the 3 patients we spoke with confirmed they had enough information about their medicines and side effects. Changes in their medicines was discussed and agreed with them in ward rounds. An external pharmacist from the hospitals medicine suppliers carried out weekly medicine audits. Results of the audits and any shortfalls were discussed at the clinical governance meetings.

Managers had a dedicated company card to purchase medicines if needed from the local pharmacy.

Staff regularly reviewed the effects of medicines on each patient’s mental and physical health in line with guidance from the National Institute of Health and Care Excellence (NICE).