CQC inspectors place children’s mental health service into special measures

Published: 21 July 2017 Page last updated: 3 November 2022

England's Chief Inspector of Hospitals has placed Watcombe Hall hospital in Torquay into special measures after an inspection by the Care Quality Commission.  

Watcombe Hall is an independent hospital, providing specialist mental health services for children and adolescents aged 13 to 18 years.  

Overall, the service has been rated as Inadequate. 

Inspectors visited the hospital in May 2017 to check whether the provider, Huntercombe (Granby One) Limited, had made the improvements to the hospital that had been required following the previous inspection in February 2016.

Inspectors found that the provider had not made the improvements required and that there were further significant concerns, which led to inspectors undertaking a full comprehensive inspection of the service.

Immediately after the inspection, CQC told the provider it must make urgent improvements to make the hospital safe for young people. The provider agreed to suspend admissions and NHS England moved young people who were inappropriately placed in the service. 

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

“We are very concerned that Huntercombe (Granby One) Ltd. has not made the improvements required following our last inspection (February 2016) - and that further and more serious quality and safety concerns were found."

“Young people told us that they did not feel safe. In the previous six months, there had been 38 significant incidents were staff were injured in the course of their work. Staff felt overwhelmed and several members of the team had left recently."

“There was a lack of robust leadership. Some staff said they did not feel confident to carry out their role. New and agency staff had not completed an induction and staff had not had regular supervision and training. There was a lack of a consistent approach in caring for young people, including the application of blanket restrictions applied to all young people regardless of individual risk. For example, staff prevented young people from accessing their bedrooms and did not give them access to fresh air."

“There were worrying gaps in the monitoring and recording of physical health observations."

“We also had concerns about how the provider managed patient leave, how staff obtained consent and assessed the patients’ mental capacity, and delays in requesting Second Opinion Appointed doctors to review the medication of people detained under the Mental Health Act."

“Since the inspection CQC has been working closely with NHS England and the provider to make sure that our concerns are appropriately addressed and monitored."

“Due to the significant nature of the concerns about the safety of young people CQC has placed Watcombe Hall placed into special measures. Our inspection team will continue to monitor this service closely and will return in due course to undertake further inspections, including unannounced visits, to check that the necessary improvements have been made." 

The inspection identified a number of areas where the service must take immediate action, including:

  • The service must deploy sufficient, appropriately trained and competent staff for the safe management of the unit.
  • The services must ensure that staff undertake sufficient observations of the young people to ensure they are not left unattended.
  • The provider must ensure that the ward environment is safe. This included improving the psychiatric intensive care unit fence, external doors and access to upstairs bedrooms.
  • The service must ensure that the young people in its care have regular access to fresh air and exercise.
  • The service must ensure that all young people receive timely appropriate care and treatment including for their physical health needs.
  • CQC has also required the provider to send a daily update of any incidents and to provide assurance that all staff had completed appropriate induction and training. 

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We are very concerned that Huntercombe (Granby One) Ltd. has not made the improvements required following our last inspection

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

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.