CQC logoWaterloo Manor Independent Hospital in Garforth, Leeds, has been formally warned by the Care Quality Commission (CQC) that it must make urgent improvements to standards of care after concerns over the safety of patients were identified. 

The warning follows an announced visit by inspectors to the hospital in February carried out as part of CQC’s scheduled programme of inspections for 2015/16.

Waterloo Manor provides low secure and rehabilitation services for women with mental health needs and was inspected over a period of 4 days by a team which included CQC inspectors, a Mental Health Act specialist, a consultant psychiatrist, 2 nurses and an expert by experience.

Following the inspection, the CQC issued 4 warning notices requiring the provider, Waterloo Manor Ltd, to take action to protect the health, safety and welfare of its patients. The hospital has been given an overall rating of Inadequate.

Inspectors identified serious concerns regarding the safety and cleanliness of the hospital. Between January 7, 2014 and January 2, 2015 there had been 56 serious untoward incidents identified by the service. Eight of these related to incidents of self-harm and 24 to patient-on-patient abuse. 

Patients were not effectively safeguarded from abuse or the possible risk of abuse occurring and the overall leadership and management of wards was poor. There were limited systems to audit the quality of care or to listen to patients' concerns and complaints, and insufficient action was taken to improve the overall quality of care as a result of patient feedback.

Inspectors also found there were not always enough members of staff to care for people safely and staff were not being supported by appropriate training and supervision. Inspectors raised concerns that this was impacting on their ability to provide high quality care. 

Additionally, on some wards, inspectors found potential risks from fixtures that could be used by patients to harm themselves. Although staff were aware of these risks, management did not have clear plans in place in order to address the issue. 

Staff did not always recognise or respond to concerns or incidents and there was limited evidence of any learning from events or actions being taken to improve safety. 

Finally, the inspectors reported that wards were visibly dirty and poorly maintained, and the layout of some wards meant patients had access to areas which could not always be observed by staff.

Jenny Wilkes, head of hospital inspection (Mental Health), said: “Following the inspection we told Waterloo Manor Ltd that they must take action to protect the health, safety and welfare of the people in their care.

“Some patients told inspectors that they were not well cared for and that they had experienced bullying by staff and other patients. 

“The safety issues we found required urgent attention. High staff vacancies, inadequate care planning and the failure to address safety risks posed by ligature points and broken furniture were all areas in need of attention. The number of incidents of patient on patient abuse was disturbing - yet we found little evidence that the provider had a system in place to learn from these incidents or prevent them happening in the first place. 

 “All patients are entitled to services which are safe, effective, caring, well led, and responsive to their needs. It is a matter of concern that this hospital did not have systems in place to monitor the quality of the service. 

“We expect the provider to have made the necessary improvements.  We will return imminently to check that it has made all the changes we require to ensure people are safe and well cared for. Otherwise we will consider using our legal powers further to protect the people who depend on this service.”

In response, Inmind Healthcare, Waterloo Manor's parent company, said in a statement on its website: "We are focused on making the necessary changes as a matter of urgency to ensure our care remains at the very highest standard possible and have developed and implemented a robust action plan to ensure all improvements needed are made. 

"We would like to thank the inspectors for also highlighting in their report the many good areas of practice and care that they found. The safety and wellbeing of those who use our services is always our top priority and we will continue to work with the CQC to ensure our service provides the very best standards of care possible."