You are here

Chief Inspector of Hospitals places Mundesley Hospital into special measures following Care Quality Commission inspection

22 December 2016
Mundesley Hospital
  • Media,
  • Mental health hospital services

England's Chief Inspector of Hospitals has placed Mundesley Hospital into special measures after a Care Quality Commission inspection resulted in it receiving an overall rating of Inadequate.

An inspection was carried out in at the independent mental health hospital in North Norfolk in September 2016 where a number of concerns were found.

CQC inspectors found the hospital, which provides private mental health care for up to 27 adults who require assessment and treatment in an inpatient setting, needed to make a number of improvements to ensure it was consistently delivering care which was safe, effective, caring, responsive and well-led.

The hospital was judged as Inadequate for being safe and well-led, Requires Improvement for being effective and Good for being caring and responsive.

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

“We found a number of serious problems when we inspected the services run by Mundesley Hospital and have subsequently placed the service into special measures.

“All of the care plans examined lacked detail, staff did not always ensure that patients were aware of their rights and not all staff had completed mandatory training required to do their jobs correctly and effectively.

“The hospital did not follow their policies and procedures regarding incident management. For example, inspectors saw examples of serious incidents that had occurred, none of which had been reported to CQC.

“Individual patient freedom was restricted due to the layout of the building and the need for staff to have to escort patients. The hospital had not reviewed their environmental ligature risk assessments since the hospital began admitting patients.

“We were concerned that the monitoring and recording of rapid tranquillisation was incomplete and nurses did not consistently monitor the physical health of patients who received this.

“We have maintained close contact with the service and partner agencies since the inspection and will undertake further inspections, including unannounced visits to check that the necessary improvements have been made.”

The inspection highlighted a number of concerns and areas where the hospital must improve, including:

  • The provider must ensure that all staff are up to date with mandatory training, which includes the safeguarding of adults and children; the Mental Health Act (1983) and the Mental Capacity Act (2005).
  • All qualified staff must receive immediate life support training.
  • Incident forms must be completed in full and signed off by a senior manager.
  • Restraint forms and rapid tranquillisation forms must be fully completed as necessary.
  • The provider must ensure there are appropriate systems in place to learn from incidents and share that learning with all staff.
  • All notifiable incidents must be sent to the CQC in a timely manner.
  • The provider must complete an environmental risk assessment that addresses ligature and other risks. This should be updated regularly and identified risks mitigated.


For further information, please contact Helen Gildersleeve, Regional Engagement Officer on 0191 2333379. Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here.

Please note: the press office 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

The Mundesley hospital is a private mental health care facility in the North Norfolk countryside. The hospital has 27 beds for adults who require assessment and treatment in an inpatient setting.

Patients are either informal or detained under the Mental Health Act (1983).It provides mental health acute care for patients assessed with high-level needs and acuity.

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 of preventing the provider from operating the service. This will lead to cancelling their registration or placing restrictions on their registration.

Whenever CQC inspects it will always ask the following five questions of every service: Is it safe? Is it effective? Is it caring? Is it responsive to people’s needs? Is it well-led? Find out more about CQC’s approach to inspection.

Registered providers of health and social care services are required to display their ratings on their premises and on their websites so that the public can see their rating quickly and easily.

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.