Berkshire independent mental health service placed into special measures

Posted February 17, 2021

The Care Quality Commission has rated Huntercombe Hospital – Maidenhead, in Berkshire, as Inadequate and placed it into special measures following an inspection. The service was previously rated Good overall.


Huntercombe Hospital – Maidenhead provides specialist child and adolescent mental health inpatient service (CAMHS), including psychiatric intensive care for young people.

CQC carried out a focused inspection at the service in November and December 2020 following a number of concerns that had been identified, including the number and frequency of incidents of self-harm and the number and content of complaints from parents of young people at the hospital about the quality of the care and poor communication from staff.


The inspection highlighted several concerns. As a result, Huntercombe Hospital -Maidenhead was issued with a letter of intent under Section 31 of the Health and Social Care Act 2008, to warn it of possible urgent enforcement action. The effect of using Section 31 powers is serious and immediate. The provider was given five days to submit an action plan explaining what it would do to make immediate improvements to ensure young people received safe, individualised care and to ensure that all risks to and for each young person were identified, recorded and appropriately managed.


The letter also stated that the provider must ensure that all young people 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.


CQC’s Head of Hospital inspection (and lead for mental health), Karen Bennett-Wilson, said:


“The care provided at Huntercombe Hospital – Maidenhead fell well below the standard that young people should expect to receive. During our inspection, we found a number of serious concerns about the standard of care provided and the risks this posed to young people.


“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.


“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.


“We will continue to monitor the service very closely, and if urgent improvements are not made to ensure people are safe, we will not hesitate to take further action.”


Inspectors found a number of issues including:
• On two of the three wards inspected (Severn and Thames), young people did not receive safe care that met their individual needs. Young people were not receiving person centred care.
• Staff did not effectively monitor young people’s physical health.
• On Thames and Severn wards young people and their families were not involved in care planning or risk assessment. Care plans lacked personalisation. Young people did not have copies of their care plans. Parents said they felt their knowledge of their child’s needs and risks, and their views, were ignored by staff. Parents felt concerned that this had led to less effective and potentially harmful care being provided to their child.
• There was a lack of robust oversight and assurance by Huntercombe senior leaders. They had not picked up poor care at the hospital and acted to make improvements in a timely manner.

Click here or on the image above to open a PDF and read the report.