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, with 100% compliance in incident reporting training across both wards. In the current year leading up to our inspection, New Dawn Ward reported 625 incidents and Upping Ward 651. The leading cause of incidents related to deliberate self-harm. All physical restraints and administration of rapid tranquilisation (RT), including ‘when required’ (PRN) medicines, were reported as incidents.

Managers monitored themes and trends closely and implemented actions to prevent reoccurrence. The safeguarding team provided feedback on safeguarding incidents. Managers carried out after action reviews (AAR) following serious incidents. Staff we spoke with shared examples of learning from recent incidents, and what changed as a result. For example, managers were planning sensory improvements on Upping Ward because they had identified that noise contributed to an increase in incidents. On New Dawn, we heard about learning implemented around crisis planning and relational security.

We reviewed a sample of incident records across the wards which demonstrated an appropriate level of detail and actions taken. Managers reviewed all incidents in line with the provider’s policy. Feedback was provided to staff through the incident reporting form.

Support was available to patients and staff following incidents, including debriefs with psychology staff and coaching support. For example, a patient we spoke with on New Dawn Ward told us they were offered debriefs with familiar staff, who discussed what had happened and how to prevent it from happening again.

Staff reported a positive learning culture within the service. Staff and managers discussed incidents and learning arising in daily huddles, supervision, and weekly and monthly meetings. Learning from the wider hospital and the provider group was shared in newsletters, meetings and induction. Folders with learning bulletins were also available for staff to read in the nursing offices.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when patients moved between different services.

The service received referrals from NHS commissioners through the provider’s referral hub. The referral and admission processes aimed to ensure that all essential information about the patient was received to determine if their needs could be met safely. Staff discussed upcoming admissions and discharges in daily huddles, handovers and monthly meetings.

Local clinical teams reviewed referral information and made decisions about the most appropriate pathway and ward. Both wards followed their inclusion and exclusion criteria, and the service had declined some referrals for patients whose needs it could not meet safely. New Dawn Ward was separated into 2 areas, New Dawn 1 (12 beds) and New Dawn 2 (6 beds). Patients were allocated to each area in line with their needs, with New Dawn 2 providing more intensive support during crises or increased distress.

At our last inspection, most patients were admitted out of area, which meant they were away from their home areas, families and friends. At this inspection, more admissions were now local, from London and the home counties. The service recently declined some referrals that were very far out of area. The service could also redirect referrals to other Cygnet hospitals closer to the patient’s local area.

Staff involved relevant health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. These included commissioners, acute hospitals, GP and community teams. There was an informal buddy system for new patients on admission, promoting peer support. Staff supported patients to prepare for discharge safely, for example with Care Programme Approach (CPA) support, overnight leave to future placements, and activities of daily living (ADL) assessments.

At the time of our inspection, the needs of a small number of patients admitted to Upping Ward exceeded those the service was able to meet safely. Managers explained that the presentations of these patients had evolved significantly since initial assessment. This had an impact on safety, resulting in increased incidents. Staff were proactively working with the patients’ home teams to identify more appropriate placements for them. We heard that one of these patients had been successfully transferred to a more suitable placement shortly after our site visit.

Staff planned for patients’ safe discharge. In a ward round we attended, staff discussed and agreed plans with a patient who was due to be discharged shortly, including crisis planning and family involvement.

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.

The service had robust safeguarding systems in place. Over 93% of staff on both wards were trained in safeguarding to the level in line with their role. Safeguarding was discussed as part of supervision and team meetings, and staff received quarterly safeguarding supervision. Learning was shared internally through email newsletters, meetings and individual supervision, and shared externally with the local authority team.

Patients and carers we spoke with reported that they, or their relatives, felt safe on the wards. However, 2 patients and 1 carer said they (or their relative) sometimes felt less safe during incidents involving other patients.

The service had a safeguarding lead who was embedded in the multidisciplinary team and easily accessible to staff. The lead supported managers in reviewing incidents and attended weekly meetings involving all managers. Staff we spoke with were positive about the input of the social work team, describing it as very responsive. For example, we heard how the social work team had helped develop a coordinated approach for a patient with complex needs in response to an increase in incidents.

We heard that the service had built good working relationships and effective mechanisms to link with the local authority. In the care and treatment records we viewed, safeguarding referrals had been completed where relevant.

Due to increasingly complex needs of patients, there was a dedicated social worker on each ward. At the time of our inspection, Upping Ward had a vacancy for a social worker which had been recruited to.

The hospital admitted female patients only. Patients could request to work with a female primary nurse, if preferred. Referrals for transgender patients were subject to an individual risk assessment in line with the provider’s policy.

There was a protocol in place for visitors to the hospital. The multidisciplinary team (MDT) screened visits, and the social work team risk assessed children’s visits. Visits with children took place in the dedicated visitors’ room.

The provider’s central team led on and oversaw safeguarding audits. Further training was planned to upskill staff on making safeguarding referrals. The service was in the process of developing its electronic safeguarding dashboard to enable integration with the incident reporting system.

The hospital maintained a blanket restriction register and reviewed it quarterly. There were some restrictions in place which were proportionate to maintain a healthy and safe environment. For example, staff risk assessed and supervised patient access to the kitchen. Patients did not raise concerns about blanket restrictions. Patients were involved in these discussions through community meetings, and we heard that patients recently raised 2 restrictions which were due to be reviewed.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint only after attempts at de-escalation had failed. Staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet patients’ needs that was safe, supportive and enabled them to do the things that mattered to them.

Staff we spoke with demonstrated a good understanding of patients and their individual risks. The risks, and any changes to those, were discussed in daily huddles and handovers. We spoke with 5 patients, who told us they felt safe at the hospital. Patients said that staff supported them to understand their own risks better. However, 2 patients said they felt less safe during incidents involving other patients.

We viewed 8 care and treatment records. Records included a safety summary, providing a clear, at-a-glance crisis management plan. Individual crisis management plans were displayed in each patient’s bedroom. Care plans were holistic, with clear evidence of patient and carer involvement, and were reviewed monthly during ward rounds with patient input. Risk assessments were up to date and reflected recent multidisciplinary team (MDT) discussions and current risks. The hospital recently adopted a safety formulation approach, reflecting current best practice guidance. This meant the wards had moved from older risk assessment models. For example, for one patient there was a discussion about how best to support them during self-harm episodes, including consideration of alternatives to restraint.

Staff demonstrated commitment to reducing restrictive practices and using restraint only as the last resort. Managers monitored and reviewed every incident requiring restraint. In the current year leading up to our inspection, New Dawn Ward reported 33 incidents of rapid tranquilisation (RT) and Upping Ward 36. There were 8 instances of prone restraint on Upping Ward during the same time, and 7 on New Dawn. These related to a small number of patients, one of whom had since been transferred to a more appropriate placement. Incident records detailed the reason for restraint, including whether it was patient or staff-led. Each restraint followed unsuccessful de-escalation attempts in response to significant risks and was typically of very short duration. Managers met with staff individually after each instance. There was no use of seclusion or long-term segregation during the same period.

Two dedicated Prevention and Management of Violence and Aggression (PMVA) leads supported staff and patients. PMVA leads and managers completed joint reviews of restraints using CCTV. Staff compliance with PMVA and relational security training was over 97% on both wards, and all new starters were trained in PMVA prior to starting work. Safety pods were available on each ward.

Most patients who had been restrained told us they understood the reason for this, and said that staff had done so safely and considerately. Patients received debriefs following incidents of restraint. However, one patient was less happy with how their restraint had been carried out, and said they had not received a debrief.

Staff carried out different levels of observations and reviewed these based on individual need and risk. All eligible staff had completed training in observation and engagement. We viewed a sample of observation records, which had been completed consistently, with details of patients’ presentation at each observation point. Patients we spoke with knew what level of observations they were on, and the rationale for this. One patient told us how staff had worked jointly with them to reduce their observation levels. The occupational therapy (OT) team had introduced an engagement resource box containing low-risk games, hot chocolate, and sensory items to help nursing staff build rapport with patients on close observations.

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

Staff assessed and managed environmental risks well. There were daily and weekly security checks and safety huddles. Staff had access to alarms, and bedrooms had nurse call systems. Staff completed risk assessments for potential ligature anchor points and mitigated the risks adequately. Staff completed relevant mandatory training, with 100% compliance in ligature risk reduction, fire warden and health & safety training.

Fire safety arrangements were robust, with regular testing and evidence of learning from evacuation drills. Detailed personal emergency evacuation plans (PEEPs) were in place for patients. The hospital fire alarm system was due to be upgraded in June 2026.

Staff followed procedures to keep patients safe from harm by completing room and personal searches as needed. There were 2 storage areas to manage personal effects and restricted items safely. A security nurse was allocated daily to carry out health and safety checks, and each ward had security champions. CCTV was in operation in communal areas and its records were used to review incidents.

The service environment was well-maintained and recovery focused. Patients had access to enclosed outdoor areas, activity room, indoor gym, and a social hub. The social hub was a welcoming area away from the ward environment. It was equipped with massage chairs, interactive games, a nail bar, and sensory resources. The kitchen and laundry room were accessible with staff supervision, in line with individual risk assessments. However, the activities of daily living (ADL) kitchen lacked sufficient ventilation. Staff continued accessing the social hub while it was used by patients, which resulted in interruptions and potential impact on its therapeutic value.

Staff recognised that the hospital environment could be improved to support the needs of neurodivergent patients better. The service had developed sensory heat maps. There was work planned to make the wards more autism-friendly, for example dimmable lights and sound absorbing sheets. The hospital-wide alarm system was noisy. It was due to be replaced in July 2026, and staff expected this to improve.

The service had access to a seclusion room within the hospital, although the use of seclusion was rare.

Patients had had personalised their bedrooms which they could access throughout the day. Patients were not provided with their own bedroom keys, as identical locks were used throughout the hospital. Each bedroom had an ensuite toilet and sink, and there were shared shower and bath facilities on each ward. Patients could raise maintenance issues in weekly community meetings.

Clinic rooms had appropriate equipment that was checked and calibrated regularly. Emergency equipment including ligature cutters and clinic room grab bags were stored appropriately and were easily accessible. However, on Upping Ward the procedure for checking ligature cutting equipment needed updating to record the contents more accurately.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met patients’ individual needs.

The service was fully staffed to safely meet the needs of patients. We saw staff always present in communal areas and engaging with patients. Patients we spoke with told us they had weekly one-to-one sessions with their primary nurse. Most did not report concerns about staff availability for escorted leave.

There was a small number of vacancies on each ward, in various stages of recruitment and onboarding. These were covered with cross-cover arrangements or locum staff.

Managers had calculated the safe staffing levels for each ward, which were reviewed daily and adjusted according to the changing needs. The service could deploy their own bank and agency staff who were familiar with the wards, or request staff from other Cygnet hospitals.

In the recent months, Upping Ward experienced an increase in safety incidents related to a small number of patients, requiring them to be nursed on enhanced and continuous observations. This had resulted in staffing pressures, which managers identified and mitigated by increasing the staffing levels. Staff we spoke with did not report concerns about present staffing levels. However, some staff reflected on the challenges in supporting patients with high levels of distress, the emotional impact of this and the resulting workload pressures. Although patients did not generally report concerns about staffing, 2 patients on Upping Ward thought that more staff would be beneficial due to the intensive support required for some peers and resulting incidents.

There was adequate medical cover day and night and a doctor could attend quickly in an emergency. Staff received training in responding to emergencies and basic and immediate life support, and staff on both wards were compliant with this training. Unannounced emergency simulation drills took place weekly.

Staff participated in regular training, appraisal and supervision, and managers monitored the completion rates. These were now consistently high. On New Dawn Ward, 89% of staff were compliant with mandatory training and 92% with clinical supervision. On Upping Ward, 98% were up-to-date with mandatory training and 92% with clinical supervision. Compliance with appraisal was 90% across both wards. All staff on both wards had now completed the Oliver McGowan mandatory training on learning disability and autism.

The service had now implemented a robust process to monitor bank staff compliance with training and supervision. Mandatory training compliance was at 95% and clinical supervision 93% for bank support workers. Mandatory training for bank nurses was at 90%, however clinical supervision compliance was lower at 52% at the time of our inspection. Managers ensured that shift allocation was put on hold for staff until compliance had been achieved. Shortly after our site visit, managers provided evidence of bank nursing staff supervision being completed, achieving 90% compliance.

The service followed procedures for safe recruitment of staff. This included criminal record and right to work checks, and where relevant, evidence of continued professional registration. Managers had now implemented additional audits to monitor continuous compliance with employment checks.

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.

The ward environment was visibly clean, with appropriate well-maintained furnishings. Staff maintained clinical equipment well and kept it clean.

Staff adhered to infection control principles, with 100% of staff across both wards up-to-date with the mandatory infection control (IPC) and food safety training. The hospital’s physical health lead was also the IPC lead, and there were IPC leads on each ward.

Cleaning records were completed daily and demonstrated that all ward areas were cleaned regularly. Communal areas were cleaned throughout the week, and routine bedroom cleaning was undertaken during weekdays. Patients we spoke with did not report concerns about cleanliness.

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.

The service had improved its medicines management since our last inspection, and patients now received their medicines safely as prescribed. Staff told us the external pharmacy provider now worked more reliably. There were also contingency plans in place to obtain medicines from a local pharmacy if needed. A new electronic prescribing and medicines administration (ePMA) system had just been launched within the hospital, reducing reliance on paper records.

Staff regularly reviewed the effects of medicines on each person's mental and physical health. Staff told us the pharmacist visited the unit weekly, and we saw evidence that pharmacists checked the legality of prescriptions and informed prescribers if there were any issues. We saw evidence that Mental Health Act consent to treatment forms were in place and verified by the pharmacist.

Rapid tranquilisation (RT), the process of administering a medicine intramuscularly for rapid sedation, was used as a last resort. Staff actively worked to use alternative person-centred ways to de-escalate without the need to administer RT. We saw evidence that when patients were given RT, they were appropriately monitored. When PRN (‘when required’) medicines were used the reason for their use and what else had been tried first was clearly recorded on the daily electronic care records.

Staff monitored the side effects patients experienced from their medicines using the Glasgow antipsychotic side effect scale (GASS) monitoring scales and made adjustments where needed.

Patients we spoke with confirmed they had enough information about their medicines. One patient said they had been informed about the side effects, and another told us how changes to their medicines were discussed and agreed with them in every ward round.

Medicines were stored safely and securely within the locked treatment room. Staff had access to controlled drugs storage facilities that met legal requirements. Temperature readings for medicines storage areas were appropriately monitored and within recommended range. Emergency medicines and equipment were in place and checked regularly. The external pharmacy service provided a TTA (to take away) supply service, and dispensing for unplanned discharges or overnight leave could be undertaken in-house by nursing staff. We saw a sample of TTA medicines labels and instructions staff used when preparing discharge medicines, and these did not include cautionary labels.

The provider had a system in place to ensure staff knew about safety alerts. Staff told us that medicines-related incidents were reported and investigated. The pharmacist produced a medicines report on themes, trends and incidents for the monthly governance committee meeting.