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Archived: Watcombe Hall Inadequate


Inspection carried out on 10, 11 & 18 May 2017

During an inspection looking at part of the service

We are placing Watcombe Hall into special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We rated Watcombe Hall as inadequate overall because:

  • The provider had not undertaken all of the actions that we told them take following our inspection in February 2016. It had not ensured that all staff had access to appropriate and regular supervision and appraisal. The provider had not ensured that staff were following up physical health observations systematically when young people declined physical health checks. There were gaps in recording of physical health observations and lack of monitoring. The provider did not consistently meet its own policy to respond to complaints within 25 days. Although the provider had reviewed what restrictions should be placed on all patients regardless of their individual risk, staff were still being inconsistent in applying these ‘blanket restrictions’. We found issues around section 17 leave, consent and capacity and section 62 urgent treatment orders and delays in requesting second opinion appointed doctors to review the medication of people detained under the Mental Health Act.
  • Following our inspection in February 2016, we had the rated the services as requires improvement overall but with a rating of good for caring, responsive and well led. During our follow up visit in May 2017 we were concerned enough to re-inspect all the key questions. We changed the rating in safe and effective from requires improvement to inadequate and well led and responsive from good to inadequate. The rating for caring was changed from good to requires improvement.
  • The leadership of the service was not robust. The unit manager and clinical manager were both off work and there was confusion and speculation amongst staff and young people about the long term management of the unit.
  • There were a high number of incidents in the service; including 18 serious incidents in the first three months of 2017. This has led to 38 staff injuries in the previous six months, staff feeling overwhelmed and staff leaving the service. Young people said they did not feel safe.
  • New and agency staff had not completed an induction and staff had not had regular supervision and training. Some staff said they did not feel confident to carry out their role. Stakeholders were concerned about staff training and staff consistency.
  • Young people were not attending regular education and therapy sessions. The service was ‘firefighting’ from one incident to another and as a result young people were bored and under stimulated.
  • Governance processes had not alerted the provider in a timely manner that the service was deteriorating.
  • We were concerned that the service was not meeting Regulations of the Health and Social Care Act (Regulated Activities) Regulations 2014. We issued a letter of intent to advise the provider of p
  • The provider sent an action plan within the agreed timescale.
  • The provider voluntarily closed the service to admissions in agreement with us and in liaison with NHS England on 11 May 2017.

The letter of intent identified the following issues:

  • Watcombe Hall was not safe and the impact of multiple issues had affected the safety of the unit for children and young people and the staff.

  • There were 354 incidents involving restraint in the last six months.

  • Patients were at risk when staff responded to incidents and had been left unobserved or had attended the incident with the member of staff.

  • There were 38 staff injuries in the last six months.

  • There was a lack of formal debriefing following incidents

  • Staff turnover impacted on the quality and consistency of the care being delivered to children and young people.

  • New staff were not adequately trained, inducted and supervised.

  • Access to fresh air for young people was overly restricted and some young people were not going outside on a day to day basis. There was also a lack of therapeutic activities.

We asked the service to take immediate action on the following:

  • To deploy sufficient, appropriately trained and competent staff for the safe management of the unit.

  • To ensure sufficient observations of the young people to ensure they were not left unattended or required to accompany staff attending to incidents involving other young people.

  • Ensure that the environment was safe. This included addressing the PICU fence, external doors and access to upstairs bedrooms.

  • Ensure young people had regular access to fresh air and exercise.

  • Ensure all young people to received timely appropriate care and treatment including for their physical health needs.

  • We also required the provider to send us a daily update of any incidents and to provide assurance that any staff on duty had completed an appropriate induction and training.

The provider voluntarily closed the service to admissions in agreement with us and in liaison with NHS England on 11 May 2017. On 19 May, the provider submitted an action plan which confirmed that the provider had taken action to address the immediate safety issues. The provider has submitted regular action plan updates since this inspection.

We made six requirement notices for the provider to address which are detailed later in the report.

Inspection carried out on 23 – 24 February 2016

During a routine inspection

We rated Watcombe Hall as requires improvement because:

  • There were blanket restrictions in place that were not individually assessed. For example, bedrooms doors were kept open at night and wardrobe doors were kept locked regardless of risk of self harm. Parents could not visit children in their rooms and mobile phones were not permitted.
  • Physical health observations, such as vital signs were not always followed up when patients had initially refused to have them taken.
  • Staff were not familiar with the revised Mental Health Act Code of Practice and this was not included in the current Mental Health Act training, although action was being taken to rectify this.
  • Although there were safe staffing levels and ward activities were rarely cancelled, patients told us that they frequently had to wait for care and support when staff were busy attending to other patients. There were gaps in specialist staffing, such as a social worker and family therapist. These roles had been recruited to and staff were due to start. The responsible clinician role was also vacant due to an internal promotion and this was covered by a locum consultant who was familiar with the service while recruitment took place.

  • The service was full and there were three patients whose discharge had been delayed and length of stay was longer than clinically needed due to funding delays with ongoing placements. There were some delays with completing and some complaints within the agreed timescales.

  • Staff were not up to date with completing annual appraisals, although an action plan was in place to fulfil this by the end of the appraisal year. Sickness rates were higher than average and the 2015 staff survey found that staff felt less involved in the overall vision and values of the organisation than the year before.


  • Patients and carers commented positively on the cleanliness. The service was clean and well maintained with up to date cleaning and environmental and maintenance records kept. There were good alarm systems in place to alert staff quickly if help was needed. There had been a number of recent improvements to the hospital, such as a new reception area, purpose built gym and occupational therapy kitchen.
  • Staff were skilled and trained in de-escalation techniques and restraint was only used as a last resort.

  • Staff reported high levels of job satisfaction, despite the pressures that they felt at times. They were supervised and trained and had access to developmental training, shadowing opportunities and reflective practice meetings.
  • There was a range of multidisciplinary staff to provide specialist child and adolescent mental health (CAMHS) support and the service was continuing to actively recruit. There were therapies in place and a therapeutic timetable that patients followed. Young people were supported with individual programmes and were encouraged to attend college and use their local community. There was good interagency working and positive relationships with the local authority, GPs, safeguarding and other services. The provider had developed relationships with external agencies to improve community links and discharge planning. There was regular access to advocacy and patients were familiar with the advocate who visited the service each week.
  • Staff were caring and respectful and this was supported by parents and carers who were very complimentary about the staff. Patients were complimentary about some staff but views from young people were mixed. Patients told us that the hospital was better than others then they had been to and some staff were singled out for praise. However, four patients complained about waiting for care when staff were busy attending to other patients and three patients told us that some staff did not always support them or understood their needs.
  • Response to complaints showed that the hospital fulfilled its duty of candour because complaints were investigated and responded to and there were examples were lessons had been learned.

Inspection carried out on 7 October 2015

During an inspection looking at part of the service

Inspection carried out on 27, 28 August 2013

During an inspection looking at part of the service

In April 2013 we inspected Watcombe Hall Annex and identified concerns in relation to care, records, medication systems, quality assurance and staffing. We issued the hospital with compliance actions, and warning notices in relation to quality assurance and care. We followed these up with another inspection in June 2013. We identified that some improvements had been made and that the hospital was compliant with standards on quality assurance but some work was still needed to become complaint with standards of care.

On this inspection we looked again at the other outstanding areas from the April Inspection. We found that improvements had been made to care, staffing, medication and records.

We found patients were receiving the healthcare they needed. We saw staff supporting patients well. Medication was being managed better and records had improved in general. Care plans and other records were up to date and reflected patients needs and wishes. We saw that action had been taken to ensure staff recruitment was thorough and staff received the training and supervision they needed to fulfil their job role.

One person about to be discharged told us �I am feeling much better now and want to go on and just live my life. The staff here have been very good � better than at xxxxx where I was before. They have helped. I didn�t really want to be here, but I can see how much I have improved.�

Inspection carried out on 17, 18 June 2013

During an inspection looking at part of the service

In April 2013 we inspected Watcombe Hall Annex and found that the hospital was not meeting regulations with regard to people's health and welfare or properly assessing and monitoring the quality of the services provided. We found that patients did not experience care, treatment and support that met their needs, and that their physical healthcare needs were not being assessed and met. Patients at the hospital were under individual safeguarding processes with the local authority as a result of concerns being raised about their welfare.

Following that inspection we issued Four Seasons (Granby One ) Limited with warning notices. The warning notices told Four Seasons (Granby One ) Limited, who operate the hospital, that they had to achieve compliance with the regulations by the 14th June 2013.

This inspection was carried out on the 17th and 18th June to follow up on the warning notices and see what had improved. We looked at the records of care being delivered, spoke with staff and patients and spent time with the management team looking at what had changed since the last inspection.

We found that new systems were in place to manage the quality of the services and that there had been many areas of improvement. We found that new permanent and senior staff had been appointed. However we still had some concerns over the way patient's healthcare needs were being supported.

We will continue to monitor the service to see that improvements are sustained.

Inspection carried out on 26, 28, 30 April 2013

During an inspection in response to concerns

We visited Watcombe Hall Annex to follow up on our last inspection from December 2012, and to look at concerns we had received.

People we spoke with told us they were looked after well, and we saw some improvements had taken place. However we saw that the systems for assessing and planning the health care needs of patients still did not ensure they received safe appropriate or well planned care, and in particular healthcare. This put patients at risk of not having their needs identified or met.

We found that the care records were poorly maintained, incomplete and had not been evaluated or audited. We found that the provider did not have effective governance or quality assurance systems in place. The systems for medication management were not effective in protecting people from risks.

We found that there had been a high turnover of staff and a reliance on agency staff. However, we found that the provider had taken steps to mitigate against the risks this posed,with some agency staff working at the service for a minimum of three months.

We saw that incidents and episodes of restraint were recorded and analysed, however we had concerns over the quality of the information used in this process. We saw some policies and procedures had been updated appropriately.

We saw staff were being supported. However we had some concerns over the information obtained about agency staff and saw staff needed additional training to help them support people effectively.

Inspection carried out on 12, 13 December 2012

During an inspection in response to concerns

This report is based on two visits that were carried out as part of a co-ordinated responsive inspection.

Overall we found that patients at Watcombe Hall were being supported well. We found patients were involved in making decisions around their care, and patients we spoke with told us they were happy with the service provided there. We found the involvement of relatives was inconsistent, both in decisions about the initial admission and in ongoing care planning.

We found that many records or policies and procedures were out of date, inaccurate or not being completed properly. We were told these had been reviewed and new policies and procedures were due to be issued by the company shortly after the inspection.

We did not find evidence of overly restrictive practices at the service. However we did find that some patients were experiencing episodes of seclusion for short periods following restraint. The service was not correctly identifying this as seclusion so were not putting in place proper safeguards in relation to patient's care. We also found records in relation to restraint were not being completed properly. This meant staff may not have identified how to prevent a recurrence. Qualified nursing staffing levels were reduced at weekends and nights, but nursing staff were on call to support if needed.

We found the quality assurance systems were not functioning properly, but recent significant improvements had been made to enable them to do so.

Inspection carried out on 25 July and 6 August 2012

During an inspection in response to concerns

We visited Watcombe Hall Annex over two days. The first visit was unannounced and took place on the 25th July 2012 with a Mental Health Act commissioner. The second visit on 6th August 2012 was announced to ensure that the manager had time to spend with us. Over both of the visits we spoke to all of the people living at the home, talked to the staff on duty and spent time observing care and relationships within the home. We also spoke to a visiting professional.

The mental health act commissioner completed their own report following the inspection. This is not a published report, but may be available upon request.

We visited the service as we wanted to see how the service had responded to compliance actions set following an inspection as part of the learning disability review in January 2012. Prior to the visit we had also received some concerns that people were not being treated with respect for their privacy or dignity and that the regime at the service was punitive. We did not find evidence of this during our visits.

We saw people having opportunities to make choices in their lives and to participate in the running of the home. As an example there was a small kitchen where people could make their own drinks, and one person showed us the fridge where they could store their own food such as yoghurt if they wished. People living at the home were involved in shopping and preparing food, and we saw this in action on the day of the first visit.

We saw that all the care files except one had an advanced statement of wishes on how people wished to be supported in case of their becoming very distressed or in crises. These included information on any medication they did or did not want to take and who they wished to be involved with their support. This helped ensure that people�s wishes about their care when in crises were understood in advance and helped them feel safer.

An activities plan was also on display, along with copies of house rules. This meant that people could be clear about some of the boundaries and responsibilities of living within the service. We saw people being treated respectfully and engaged in conversation with staff throughout the visits.

We saw in one file clear guidelines and techniques for an individual to support them in managing their own anxiety in positive ways. There were also clear admission assessment tools including for risk related behaviours. We saw evidence of staff using de-escalation techniques to minimise an individual's anxiety.

Throughout much of the day on both visits people we saw were engaged in activities with staff. People told us that the availability of staff meant that sometimes they had to wait to carry out an activity, because they needed an escort or additional support to undertake it.

Two people living at the unit worked for a few hours a week in a local shop with staff support. It was hoped to develop new links with services and community facilities outside of the service in the coming months to support people when they were able to leave the service.

A visiting health professional told us that one individual they supported had flourished since being at the service and was learning new skills and ways of managing their mental health issues in a positive fashion.

We saw evidence that people had access to legal support and advocacy.

Inspection carried out on 10, 11 January 2012

During a themed inspection looking at Learning Disability Services

There were three in-patients at Watcombe Hall when we visited. We were able to meet and introduce ourselves to all three of the patients.

We spoke to two patients in more depth to get their views on the service and the care and support they received. Both patients were happy to show us around the unit and also wanted to show us their bedrooms.

Patients we spoke to said they liked staying at the unit. They said that they felt safe and that staff were kind and caring.

The two patients we spoke to said that they had been involved in writing their care plan and that they were able to go to meetings to tell staff if there was anything they were unhappy about.

One patient said that they had a plan that had information just about one of their health needs �The plan says that I am able to take my own medication and I think that is good�

Patients told us about the things they were able to do during the day and at weekends.

One patient said that they were able to go out every day �I go out everyday and sometimes if I get up and I am in a very good mood I get to go out twice�

Another patient said that they liked to go out to the shops and to have a coffee. We were also told by one patient that they liked playing games and that they would sometimes play scrabble with the staff.

One patient said that they get to go out everyday but was unhappy that patients don�t have a computer and that this would be good to use in the unit.