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Care Quality Commission places Inadequate rated mental health hospital into special measures

11 December 2015
  • Media,
  • Hospitals

The Chief Inspector of Hospitals has placed an independent hospital in Birmingham into special measures following its inspection by the Care Quality Commission.

A team of inspectors found that Harriet Tubman House in Handsworth Wood was Inadequate for being safe, caring, effective, responsive and well led. Overall the hospital has been rated as Inadequate.

Harriet Tubman House provides rehabilitation services for up to 15 women with enduring mental illness, including patients who may be detained under the Mental Health Act.

A full copy of the inspection report will be published on CQC’s website on Friday, 11 December:

During the inspection in August, builders were renovating the hospital. Inspectors were concerned that the managers were not taking proper action to prevent avoidable risks to patients and staff and building work was suspended.

Deputy Chief Inspector of Hospitals (and lead for mental health), Dr Paul Lelliott, said:

"Although Harriet Tubman House is supposed to provide a rehabilitation service, we found that this hospital was failing to protect its patients from the risk of harm.

"Managers were not aware of the regulations they needed to meet to ensure the safety of their patients or to reduce the risks. Staff did not analyse incidents so they could learn from them. Care plans and risk assessments did not show staff how to support patients.

"The hospital environment did not promote patients’ recovery and some staff did not engage with patients in a way which would promote their wellbeing.

"At the time of our inspection we made sure that the provider Options for Care took action to address our immediate concerns. We have placed the hospital into special measures and we now expect Options for Care to meet all the legal requirements which are there to protect people in its care.

“We will return to inspect again within six months, and if we find that there has not been sufficient progress, we will take further action on behalf of the patients."

Inspectors found that there were four vacancies for registered nurses out of the establishment of eight. While agency and bank nurses covered vacancies, they did not receive a comprehensive induction to ensure they knew how to keep patients safe.

Inspectors were concerned that there was no evidence of discharge planning in any of the patients’ care. One patient had lived there for 15 years. Psychological therapies were not offered to patients to promote their recovery.

Although records showed that restraint was used, this was not done in line with any guidance from the provider. Staff had not received training in the use of restraint.

Patients who were not detained under the Mental Health Act were not free to leave when they wanted. The staff failed to recognise that these patients were being deprived of their liberty with no legal safeguards.

The report identifies a number of areas for improvement, including:

  • The provider must ensure that the environment is safe for patients and staff at all times.
  • All staff must receive the appropriate training and supervision to ensure that there is always a sufficient number of skilled and experienced staff on duty.
  • Care plans must show staff how to support the patient to meet their needs.
  • The provider must make arrangements to ensure that all staff and the environment respect the privacy and dignity of patients.
  • The provider must ensure that the independence of patients is promoted to enable their recovery and rehabilitation.
  • All staff must receive training in breakaway and de-escalation.

The CQC has shared its concerns with the clinical commissioning groups who are responsible for placing patients at Harriet Tubman House. All new admissions have been suspended since June 2015.


For further information please contact CQC Regional Engagement Manager Louise Grifferty on 07717 422917. Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here. (Please note: the duty press officer is unable to advise members of the public on health or social care matters).

For general enquiries, please call 03000 61 61 61.

Last updated:
29 May 2017

Notes to editors


Services placed in special measures will be inspected again within six months. If insufficient improvements have been made, we will take action in line with our enforcement procedures to begin the process. This may lead to cancelling their registration or to varying the terms of their registration within six months. The service will be kept under review and, if needed we may take urgent enforcement action. 


The Chief Inspector of Hospitals, Professor Sir Mike Richards, is leading a programme of inspections of all independent hospitals in England by inspection teams which include CQC inspectors, specialist clinical advisors and experts by experience. 


Harriet Tubman House is an independent hospital for up to 15 women with enduring mental illness. On the days of our latest inspections, there were nine patients using the service. 


Since 1 April, providers have been required to display their ratings on their premises and on their websites so that the public can see their rating quickly and easily. For further information on the requirement for providers to prominently display their CQC ratings, please visit:


About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.