CQC calls for improvements at Huntercombe Hospital Maidenhead

Published: 20 May 2022 Page last updated: 20 May 2022

The Care Quality Commission (CQC) has suspended the ratings for Huntercombe Hospital Maidenhead, and told the provider it must make urgent improvements, following inspections in February and March.

Huntercombe Hospital Maidenhead is a specialist child and adolescent mental health inpatient service (CAMHS), including psychiatric intensive care units (PICU) for young people.

On 5 March 2021, Huntercombe Young People Ltd took over the running of the hospital from Huntercombe (No.12) Ltd. Under the previous provider, the hospital was rated as inadequate overall and CQC imposed conditions limiting the number of young people they could admit to the PICU.

Following an inspection in July 2021, CQC found that some improvements had been made and the hospital was rated requires improvement overall. However, the conditions remained in place to allow the new provider sufficient time to continue to make, and fully embed, the improvements.

In February 2022, inspectors returned to the hospital to check on the progress of the improvements.  They found improvements had been made to the environment, and staff training in relation to eating disorders had improved, as had the supervision of staff. Staff morale had also improved.

Following this inspection, a serious incident then took place at the hospital which resulted in the tragic death of a young person. This is currently under investigation by the police.

CQC then undertook a further unannounced, focused inspection of the hospital in March 2022, specifically to check that young people in the PICU were being cared for safely. Due to concerns about how observations were being carried out, CQC served the provider with a warning notice which required it to take urgent action to ensure staff received the training needed to enable them to understand the importance of undertaking observations conscientiously, to ensure young people are kept safe.

Following the inspection in February, CQC found some further improvements were needed. These included improving the environment on Tamar ward and ensuring all staff treated young people with respect. The previous conditions, restricting the provider to only admitting a maximum of 22 young people across the PICUs, remained in place. 

Due to the concerns found in the March 2022 inspection, CQC took the decision to suspend the ratings of the service until further notice.

Karen Bennett-Wilson, CQC’s head of hospital inspection, said:

“When we inspected Huntercombe Hospital Maidenhead, we found some improvements had been made and staff morale has improved as a result. Changes have been made to the environment to make it more suitable for the delivery of safe, good quality care. However, we still have a number of serious concerns about the safety and quality of care being provided.

“Fundamentally, the hospital did not have enough competent, skilled staff who knew the young people and how to care for them. Staff need proper training to ensure they can undertake observations robustly to ensure young people are kept safe. We saw that new and temporary staff were being asked to carry out observations of young people without adequate training, or a proper understanding of what they were being asked to do and why observations were so important. As a result, staff sometimes left young people unobserved and at times had to ask the young person how they should support them and what observations needed to be carried out. This is completely unacceptable.

“We have now told the provider they need to address our concerns as a matter of urgency, and we will continue to work with our external partners and monitor the service very closely to ensure that the improvements are made and fully embedded. If we are not satisfied, we will not hesitate to take further enforcement action to keep people safe.”

Inspectors found the following:

  • Not all staff understood young people’s needs, and some staff made unhelpful comments about their mental health crises. Young people on the wards said that staff did not follow the care plans in relation to their level of observations. If there was an incident staff stopped doing intermittent observations.
  • Some young people said they felt that the hospital should be shut down. Others acknowledged there were some skilled staff and some enjoyable activities for them to take part in.


  • The number of therapy staff had been increased. For example, there were now two occupational therapists working across the hospital and each ward had a dedicated occupational assistant.
  • The provider had increased the number of communal spaces available on wards and refurbished the main dining room.
  • The provider had also started building work on Severn and Thames ward to remodel them into four smaller wards. The provider had made a planning application to build a replacement ward for Tamar ward.
  • The provider had updated their work on ligature risks, and staff now use observation and CCTV to manage identified risks.
  • Improvements have been made to the area used for people who need to be fed by a tube through their nose (the nasogastric feeding room), to make it a less stressful environment. Further environmental changes to the PICUs are underway.
  • Staff supporting young people who needed to be restrained to receive nasogastric feeds received appropriate supervision and debriefs.

Full details of the inspection are given in the report published on our website.

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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.