CQC logoAn independent mental health hospital in Birmingham has been assessed as inadequate and placed in special measures by care industry regulator the Care Quality Commission (CQC).

A team of CQC inspectors found that Harriet Tubman House in Handsworth Wood, which provides rehabilitation services for up to 15 women with enduring mental illness, including patients who may be detained under the Mental Health Act, was inadequate in several areas, including providing safe services. 

Inspectors found that there were four vacancies for registered nurses out of the establishment of eight. While agency and bank nurses covered vacancies, they did not receive a comprehensive induction to ensure they knew how to keep patients safe.

Other concerns highlighted by the inspectors were a lack of evidence of discharge planning in any of the patients’ care. One patient had lived there for 15 years. Psychological therapies were not offered to patients to promote their recovery.

Although records showed that restraint was used, this was not done in line with any guidance from the provider. Staff had not received training in the use of restraint.

Patients who were not detained under the Mental Health Act were not free to leave when they wanted. The staff failed to recognise that these patients were being deprived of their liberty with no legal safeguards.

The report identified a number of areas for improvement, including: 

The provider must ensure that the environment is safe for patients and staff at all times

All staff must receive the appropriate training and supervision to ensure that there is always a sufficient number of skilled and experienced staff on duty

Care plans must show staff how to support the patient to meet their needs

The provider must make arrangements to ensure that all staff and the environment respect the privacy and dignity of patients

The provider must ensure that the independence of patients is promoted to enable their recovery and rehabilitation

All staff must receive training in breakaway and de-escalation.

Deputy chief inspector of hospitals (and lead for mental health), Dr Paul Lelliott, said: “Although Harriet Tubman House is supposed to provide a rehabilitation service, we found that this hospital was failing to protect its patients from the risk of harm. 

“Managers were not aware of the regulations they needed to meet to ensure the safety of their patients or to reduce the risks. Staff did not analyse incidents so they could learn from them. Care plans and risk assessments did not show staff how to support patients. 

“The hospital environment did not promote patients’ recovery and some staff did not engage with patients in a way which would promote their wellbeing.

“At the time of our inspection we made sure that the provider Options for Care took action to address our immediate concerns. We have placed the hospital into special measures and we now expect Options for Care to meet all the legal requirements which are there to protect people in its care.   

“We will return to inspect again within six months, and if we find that there has not been sufficient progress, we will take further action on behalf of the patients.”   

The CQC has shared its concerns with the clinical commissioning groups who are responsible for placing patients at Harriet Tubman House. All new admissions have been suspended since June.