25 September 2019
Cygnet Whorlton Hall is an independent hospital which provides assessment and treatment for men and women aged 18 years and over living with a learning disability and complex needs. The hospital also cares for people who have additional mental or physical health needs and behaviours that challenge and patients that are detained under the Mental Health Act. The service has 22 beds and at the time of the inspection there were 7 patients receiving care and treatment.
The hospital has been registered with the CQC since September 2013 and is registered to provide the following regulated activities:
- Assessment or medical treatment for persons detained under the Mental Health Act 1983
- Treatment for disease, disorder or injury
The hospital had a registered manager who was the service manager, as well as an accountable controlled drugs officer who was the regional nurse consultant. At the time of our inspection the registered manager had been suspended and we were not able to meet with them.
The location has been inspected by the CQC on five previous occasions.
CQC undertook a comprehensive inspection in September 2017, when it rated Whorlton Hall as good overall and good in all five key questions. We undertook an unannounced, focused inspection March 2018. This inspection was in response to whistleblowing concerns that we received in relation to staffing, patient safety, culture and incident monitoring. Whilst we did not re-rate Whorlton Hall at this inspection, we found the provider to be in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:
- Regulation 18: staffing. Agency staff were not receiving appropriate training relevant to their roles and there was no system in place to monitor this, and not all staff were receiving individual supervision in line with the policy and supervisory bodies.
- Regulation 17: good governance. There were no systems in place to assess, monitor and mitigate the risks relating to the health and safety of service users and others who may be at risk arising from the carrying on of the regulated activity, specifically associated with the lack of risk assessments related to staff working excessive hours, in some cases 24-hour shifts.
In July 2018, CQC undertook an unannounced Mental Health Act monitoring visit. There were no issues reported as a result of this visit.
At the time of the most recent inspection, there was an ongoing police investigation into alleged abuse of patients at this hospital. A large number of staff had been suspended, including the registered manager and the deputy manager. The hospital was working with commissioners to transfer all the patients to suitable alternatives. The service has been none operational since 22 May 2019.
25 September 2019
We inspected Whorlton Hall due to concerns raised by the Panorama programme into alleged abuse of patients at this hospital.
We have taken enforcement action against the registered provider in relation to our concerns about this location. This limits our rating of safe, effective and well-led to inadequate, and the rating overall for Whorlton Hall to inadequate.
At the time of inspection, there was an ongoing police investigation which meant we were not able to review all documentation, or speak to patients, so whilst we inspected these domains, we were unable to rate the caring and responsive.
- The service did not have effective systems in place for ensuring that staff adhered to the provider’s policies and procedures. This included adherence to safe practice in administering ‘as required medication’ and monitoring patients after rapid tranquilisation, keeping records that demonstrated that staff were suitable to work at the hospital and undertaking the daily environmental risk checks.
- Staff used physical restraint on 1348 occasions in the year leading up to the inspection. They also used rapid tranquilisation on three occasions. The Resuscitation Council (UK) recommends that staff using restraint or rapid tranquilisation should receive training in immediate life support as a minimum standard. Staff at Whorlton hall had not received this training.
- The provider’s restrictive interventions reduction programme had not been effective. Staff continued to use physical restraint frequently and the number of times it was used had increased.
- Staff did not follow best practice with respect to mental capacity and best interests. Rather than undertake mental capacity assessments on a decision-specific basis, staff made over-arching assessments which covered a number of different areas. Staff made decisions in patients’ best interests for patients assessed as lacking capacity. However, a number of the best interest documents failed to record how the patient, family, carer or advocate had been involved in the best interest decision making process.
- We found a number of instances where staff were not following the care plan. These included decisions about the gender of staff carrying out observations on patients and the importance of using Makaton and other communication aids.
- Recruitment procedures established to ensure staff employed in the service were of good character or had the necessary qualifications, competence, skills and experience required to carry out their role were not operated effectively.
- Care plans were personalised, holistic and recovery orientated.
- Staff ensured that patients had access to physical health care services.
- There was access to a well-equipped activity hub at the hospital which enabled a range of educational and social activities to be facilitated.