A specialist child and adolescent mental health inpatient service (CAMHS) in Maidenhead, Berkshire, has been rated ‘inadequate’ and placed into special measures following an inspection.
Care Quality Commission (CQC) inspectors visited the Huntercombe Hospital, which was previously rated ‘good’ overall, in November and December 2020 following concerns that had been identified.
Self-harm incidents, complaints from parents of young people at the hospital about the quality of the care, and poor communication from staff were among concerns raised.
Inspectors found on two of the three wards, staff did not follow safe systems and processes to prescribe, administer, record and store medicines.
Staff did not record the reasons why some medicines were prescribed for some young people outside of licensed or best practice guidance, and the hospital lacked the required peer review process to oversee these prescribing practices.
Staff did not robustly assess young people’s mental capacity or Gillick competency, which is the legal framework used to decide whether a child under 16 years of age is able to consent to their own treatment.
The watchdog said inspectors were unable to find evidence that staff routinely reviewed consent during a patient’s admission, and found incomplete or contradictory Mental Health Act 1983 consent to treatment paperwork.
As a result of the inspection, the hospital was issued a letter of intent under Section 31 of the Health and Social Care Act 2008, to warn of possible urgent enforcement action.
The provider was given five days to submit an action plan outlining what immediate improvements would be made to ensure young people received safe, individualised care and that all risks were identified, recorded and appropriately managed.
The letter also stated that the provider must ensure all patients on the psychiatric intensive care unit (PICU) wards have their medicines reviewed by an independent consultant psychiatrist.
In addition, valid consent must be sought, or young people should have their capacity or competence to consent to medication assessed, in line with the Mental Health Act 1983 or Mental Capacity Act 2005.
A warning notice was also issued which required the provider to implement a positive behaviour support approach across the PICU wards and staff should be trained to use these.
‘We found that the service was not ensuring the safety of those in its care. Service leaders had not picked up a number of the issues that had led to the inspection, or several of those identified during our inspection, so had not acted to effectively minimise the risk of harm to young people,’ said Karen Bennett-Wilson, head of hospital inspection (and lead for mental health) at the CQC.
‘However, the new leadership team at Huntercombe Hospital – Maidenhead responded quickly on receipt of the Section 31 letter of intent and the warning notice.
‘The team, led by a new hospital director and overseen by Huntercombe’s new chief executive, had started to implement an improvement plan prior to the inspection that had picked up some of the issues and they have built on this and are working at pace to ensure young people receive the care and treatment they deserve.’
Dr Sylvia Tang, CEO of The Huntercombe Group, said: ‘We take the CQC’s report very seriously and I would like to say sorry to young people and their families who were affected by the unacceptable level of care found in two wards of our hospital in particular.
‘Substantial changes have recently been made to the hospital’s leadership structure and this new team has already made significant improvements that mean our current patients are receiving good care.
‘In addition to the changes made after their appointment, we are implementing an action plan to urgently address some outstanding concerns raised in the report, including even more rigorous reporting and documentation processes, more frequent reviews of patients and clearer processes to hear feedback from patients and their families.
‘We’re determined to make these immediate improvements quickly, so our patients receive the highest standard of care.’