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CQC warns Waterloo Manor Independent Hospital that it must make urgent improvements to standards of care

18 August 2015
Waterloo Manor Independent Hospital
  • Media,
  • Mental health hospital services

The Care Quality Commission (CQC) has formally warned Waterloo Manor Independent Hospital in Garforth, Leeds that it must make urgent improvements to standards of care.

The warning follows an announced visit by inspectors to the hospital in February carried out as part of CQC’s scheduled programme of inspections for 2015/16.

The hospital provides low secure and rehabilitation services for women with mental health needs and was inspected over a period of four days by a team which included CQC inspectors, a Mental Health Act specialist, a consultant psychiatrist, two nurses and an expert by experience.

Following the inspection, CQC issued four warning notices requiring the provider, Waterloo Manor Limited, to take action to protect the health, safety and welfare of its patients. The hospital has been given an overall rating of Inadequate.

A full report from the inspection has been published today.

Inspectors identified serious concerns regarding the safety and cleanliness of the hospital. Wards were visibly dirty and poorly maintained and the layout of some wards meant that areas which patients had access to could not always be observed by staff.

On some wards inspectors found potential risks from fixtures that could be used by patients to harm themselves. Although staff were aware of these risks, management did not have clear plans in place in order to address the issue.

Staff did not always recognise or respond to concerns or incidents and there was limited evidence of any learning from events or actions being taken to improve safety.

Between the 7 January 2014 and 2 January 2015 there had been 56 serious untoward incidents identified by the service. Eight of these related to incidents of self harm and 24 incidents of patient on patient abuse.

There were not always enough members of staff to care for people safely and staff were not being supported by appropriate training and supervision. Inspectors raised concerns that this was impacting on their ability to provide high quality care.

Patients were not effectively safeguarded from abuse or the possible risk of abuse occurring and the overall leadership and management of wards was poor. There were limited systems to audit the quality of care or to listen to patients' concerns and complaints, and insufficient action was taken to improve the overall quality of care as a result of patient feedback.

Jenny Wilkes, Head of Hospital Inspection (Mental Health), said:

“Following the inspection we told Waterloo Manor Limited that they must take action to protect the health, safety and welfare of the people in their care.

“Some patients told inspectors that they were not well cared for and that they had experienced bullying by staff and other patients.

“The safety issues we found required urgent attention. High staff vacancies, inadequate care planning and the failure to address safety risks posed by ligature points and broken furniture were all areas in need of attention. The number of incidents of patient on patient abuse was disturbing – yet we found little evidence that the provider had a system in place to learn from these incidents or prevent them happening in the first place.

“All patients are entitled to services which are safe, effective, caring, well-led, and responsive to their needs. It is a matter of concern that this hospital did not have systems in place to monitor the quality of the service.

“We expect the provider to have made the necessary improvements.  We will return imminently to check that it has made all the changes we require to ensure people are safe and well cared for. Otherwise we will consider using our legal powers further to protect the people who depend on this service.”


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Last updated:
29 May 2017

Notes to editors

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. Further information on the display of CQC ratings.


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.