CQC takes action to protect people at Doncaster mental health service

Published: 15 December 2023 Page last updated: 15 December 2023
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The Care Quality Commission (CQC) has rated Cheswold Park Hospital, Doncaster inadequate and placed it into special measures to protect people, following an inspection in July.

Cheswold Park Hospital, run by Riverside Healthcare Limited, is an independent mental health hospital which provides accommodation for adults with mental disorders, and autistic people and people with a learning disability. At the time of this inspection there were 86 people living at the hospital.

This unannounced inspection was prompted by a review of information CQC held about the service.

Following this inspection, the overall rating has dropped from requires improvement to inadequate, as have the ratings for being safe, effective and well-led. The ratings for being caring and responsive have declined from good to inadequate.

The service is now in special measures, which means it will be kept under close review by CQC to keep people safe and it will be monitored to check sufficient improvements have been made.

The provider was also issued with two warning notices, to focus their attention on making improvements to their leave policy for people using the service, as well as improving the care and treatment being provided to people.

Additionally, CQC served the provider with a fixed penalty notice of £4000, as the hospital did not have a registered manager in place which is a requirement by CQC. Since the inspection, a registered manager has been appointed.

Jenny Wilkes, CQC deputy director of operations in the north, said:

“When we visited Cheswold Park Hospital, it was shocking to see such a significant shortfall of strong leadership. We found a lack of effective systems and processes to enable staff to deliver high-quality care for people.

“It was concerning that we heard the registered manager, who is responsible for making sure the hospital is complying with regulations, hadn’t visited the wards in the last 18 months, therefore they weren’t aware what was happening or what issues there were. This is totally unacceptable as they must have much better oversight of the service so they can make any necessary improvements to ensure they provide a high standard of care people deserve.

“We saw some worrying behaviour from staff who were ignoring people at the service and weren’t providing the care and support people deserved. During our inspection, we saw two members of staff standing in front of a woman who was upset and crying, while other people were around her having a conversation. They didn’t interact with her and the language they used was disrespectful and showed no care for the woman’s obvious distress.

“We also had concerns around staffing levels which led to some staff telling us they didn’t feel safe working on the wards due to low staffing numbers. The lack of staff also effected people’s escorted leave and activities which were often cancelled when the service was short staffed.

“Due to the poor care, we found at Cheswold Park Hospital, we took enforcement action to ensure the provider makes significant, urgent improvements. We will continue to monitor the hospital closely, to check on the progress of those improvements, so we can be sure people receive the care they have a right to expect.”

Inspectors found:

  • The service did not provide safe care. The wards did not have enough nurses and support staff
  • Staff did not assess and manage risk well or manage medicines safely or follow good practice with respect to safeguarding
  • The service placed people at risk of harm by not ensuring that all staff were up to date on their training
  • Staff did not develop holistic, recovery-oriented care plans informed by a comprehensive assessment and they were not updated including after incidents. The electronic records system was not fit for purpose
  • Managers did not ensure that people had suitable access to activities on and off the ward and people were restricted to the ward for extended periods of time
  • Staff and people using the service did not receive appropriate debriefs following incidents
  • Not all staff understood or discharged their roles and responsibilities under the Mental Health Act 1983 or the Mental Capacity Act 2005
  • Staff did not always treat people with compassion and kindness, respect their privacy and dignity, or understand their individual needs. They did not actively involve people and families and carers in care decisions
  • The service was not well led, and the governance processes did not ensure that ward procedures ran smoothly.

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.