• Cygnet Chesterholme rated “inadequate” by CQC and placed into special measures
  • Inspectors visited hospital following Whorlton Hall scandal in May
  • CQC says it is currently considering additional enforcement action

A mental health hospital has been placed into special measures by the Care Quality Commission after inspectors found more than 500 instances of restraint in a year and dozens of unexplained serious incidents.

CQC inspectors rated Cygnet Chesterholme, in Northumberland, “inadequate” overall and added it could face further unspecified enforcement action.

The home, which cares for up to 26 NHS and private patients with learning disabilities and autism, was owned by the Danshell Group – the same owner of Whorlton Hall hospital, where widespread abuse and alleged neglect was exposed by an undercover BBC Panorama investigation earlier this year.

The CQC conducted an unannounced inspection of Cygnet Chesterholme during four days in May after the BBC programme raised “significant concerns” about the Danshell Group’s safety and culture.

Inspectors downgraded Chesterholme from its previous “requires improvement” rating following the inspection in May this year.

The CQC found staff turnover at the hospital was 45 per cent and an “increasingly high” number of unqualified and untrained staff were working with patients with complex needs.

There was also a “significant increase” in the use of restraint since the previous visit in November 2018. Despite a restrictive intervention programme being in place, there were 581 incidents of restraint between April 2018 and May 2019.

The report, published today, said: “At our last inspection, we found that there were 124 restraints in a six-month period, and in our 2015 inspection there were 22 restraints in six months. These figures show an increasing number of restraints between inspections.”

Inspectors also highlighted how hospital staff were not trained in epilepsy, or did not receive refresher training if needed, and the provider “was unable to explain” 27 serious incidents which had occurred over the past 12 months.

Brian Cranna, the CQC’s head of mental health inspection, said: “We found the service had deteriorated significantly and there was a lot of confusion regarding the direction and governance of that care and support.

“Also, some staff did not have the right skills, experience or managerial support to care for people with complex needs.”

Mr Cranna said, although some of their findings were addressed following the inspection, inspectors continue to have “serious concerns” about the quality of care. He added: “We are keeping this service under close review, alongside our partner agencies, and will return to inspect it again in due course.”

Inspectors also found:

  • Two policies used by the previous owner, Danshell, were still in use and overdue for a review by 18 months;
  • Risk assessments were “not consistently updated or reviewed” following incidents;
  • Medication for use after rapid tranquillisation emergencies was not available; and
  • Staff were not trained to provide immediate life support should an emergency occur.

After apologising for failing to identify abuse of patients at Whorlton Hall, the CQC announced an independent inquiry into a whistleblower’s claims that reports of poor care were not acted upon.

Northumberland Clinical Commissioning Group said in a statement it was “deeply disappointed” to learn of the CQC’s findings, adding: “We are fully supportive of these actions and are working closely with the CQC, NHS England and our other partners at this time.”

A Cygnet spokeswoman said: “We acknowledge the findings of the CQC’s report on Cygnet Chesterholme, part of the Danshell Group, which we recently acquired and we are investing significant resources to further enhance the infrastructure and management capability across the group’s facilities.

“Following the CQC’s inspection in May, we took immediate and significant steps to address the issues raised, though we were heartened that the CQC rated the caring and responsive aspects of our service as good and noted positive staff interactions.

“The safety and wellbeing of the people who use our services is of paramount importance. We remain committed to acting upon the report’s recommendations and working closely with the CQC to ensure we provide the highest standard and quality of care that our service users expect and deserve.”

The HSJ Transforming Mental Health Summit, taking place at the Hilton Leeds from 28-29 November, unites 120+ senior figures from across the NHS, local authority and wider mental health service delivery landscape to discuss how to realise the visions of the NHS long-term plan and ensure successful local implementation of national priorities. Held under the Chatham House Rule, attendees will quiz Paul Farmer and other national figures on general policy direction and co-develop solutions to their local challenges with NHS and local government colleagues from across the country. The Summit is free to attend for senior NHS and public sector figures – register your interest here for this free to attend forum on our website: https://mentalhealth.hsj.co.uk/register-2019