Cygnet Hospital Beckton

Updated 13 June 2025

Date of inspection: 10 – 27 December 2024. 

Cygnet Hospital Beckton provides acute wards for adults of working age and psychiatric intensive care units (Hooper Ward and Svanna Ward), and personality disorder services (New Dawn Ward and Upping Ward). This inspection looked at both services following concerns about an increase in safety incidents across the wards. The scores from the quality statements covered during this inspection have been combined with existing scores for any quality statements not covered. Together, these calculate the new key question ratings. We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement. We rated personality disorder services as requires improvement. The overall rating of Cygnet Hospital Beckton has changed to requires improvement. In our inspection of both services, we found concerns in relation to safe care and treatment, staffing and governance which have resulted in breaches of the regulations. However, we also found areas of good practice which included patients being supported to have choice and control of their care and treatment, able to provide feedback on their care, and a supportive and open team culture where learning was shared. The personality disorder services had made improvements in relation to safe staffing numbers and was no longer in breach of this.

Updated 29 October 2024

Date of inspection: 10-27 December 2024.

Cygnet Hospital Beckton is a 58-bed 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 a 13 bed ward providing acute mental health services, a 12 bed psychiatric intensive care unit (PICU), and 2 wards providing Tier 4 personality disorder services. The hospital provides care to both informal patients and those detained under the Mental Health Act.

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This report is specific to acute and PICU wards for adults of working age. We undertook this focused, responsive inspection due to concerns about an increase in safety incidents on the wards. We carried out a site visit to the acute (Hooper Ward) and PICU (Svanna Ward) services on 10, 11 and 12 December, followed by offsite activities. This was our first inspection of Svanna Ward which opened in January 2024. We previously inspected the acute and PICU services at Cygnet Hospital Beckton in April 2022. At that time these services comprised Hooper Ward (then PICU) and a learning disability ward which is now closed.

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The acute and PICU services were previously rated good overall. Following this inspection, the rating has changed to requires improvement. We inspected 13 quality statements across the safe, effective and well-led key questions and have combined the scores for these areas with scores from the last inspection to achieve the rating.

During this inspection we found 5 breaches of the regulations in relation to safe care and treatment, good governance and staffing. We identified a number of issues around medicines management. The provider did not always administer medicines safely and did not always monitor patients' physical health appropriately following the use of rapid tranquilisation. The provider did not always assess the risks to the health and safety of patients and do all that was reasonably practicable to mitigate the risks. The provider did not always ensure that patients received their medicines safely due to unavailable supplies. The provider's governance processes were not always effective in identifying areas for improvement or where these were identified, did not always ensure that improvements were made. The provider did not ensure that staff completed all mandatory training.

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. There were enough staff to ensure patients' safety and meet their needs. Patients were supported to have choice and control and could give feedback on their care. Staff developed and updated personalised care plans. Staff and leaders reported a supportive and open team culture.

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Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

At the time of our inspection, the hospital provided care to both informal patients and those detained under the Mental Health Act (MHA).

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All staff on Svanna Ward and 94% of staff on Hooper Ward had completed mandatory training in Mental Health Act Awareness. This training was also part of induction for all new clinical staff.

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Staff had easy access to administrative support and legal advice on implementation of the MHA and its Code of Practice. Staff reviewed the section expiry dates for patients detained under the MHA in daily meetings.

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The provider had relevant policies and procedures that reflected the most recent guidance. Staff had access to local MHA policies and procedures and to the Code of Practice.

Staff explained to patients their rights under the MHA in a way that they could understand, repeated it as required and recorded that they had done so. However, we found that one patient did not understand the rights under the MHA read to them on 1 December 2024 and this had not been revisited at the time of our inspection.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted.

Staff carried out monthly audits to ensure that the Mental Health Act was being applied correctly.

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Staff requested review from a second opinion appointed doctor when necessary.

However, patients detained under the MHA did not have access to information about Independent Mental Health Advocacy (IMHA) 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.

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Mental Capacity Act

All staff on Svanna Ward and 94% of staff on Hooper Ward had completed mandatory training in the Mental Capacity Act and the Deprivation of Liberty Safeguards.

Staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

We saw evidence that staff documented patients' capacity to consent to treatment and information sharing. However, we found this had not yet been assessed and documented for one patient whose care record we reviewed at the time of our inspection.

Updated 29 October 2024

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.

Updated 3 March 2022

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.

Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.