The CQC carried out an inspection of Cygnet Health Care between July 2 and August 2 2019, after a BBC Panorama programme identified serious concerns around the safety and culture at Whorlton Hall.
The NHS-funded and privately run site was shut down after the documentary, which claimed that care staff deliberately harmed patients, restrained them for longer than needed, made threats and used offensive language towards them, was aired on May 22.
A spokesman for the CQC said, during the review, inspectors found there was a high use of physical restraint and seclusion across services compared to similar services in other mental health providers.
While the number of patient assaults by other patients and self-harm recorded were also higher in Cygnet Health Care compared with NHS providers of similar services.
The review found that care and treatment did not always include best practice and that training for intermediate life support was not provided to all relevant staff across services where physical intervention or rapid tranquillisation was used.
Inspectors said that a clear line of accountability could not be established across all of Cygnet Health Care’s locations and the executive team did not ensure all locations had a registered manager in post.
However, the review found that there was a stable senior executive and leadership team in place with a range of skills, who worked together to support the delivery of care and senior leaders took steps to improve the quality of patient care once concerns were identified.
Dr Kevin Cleary CQC’s deputy chief inspector for mental health and community services, said:
‘All patients must receive safe, effective and person-centred care. During the review, we identified serious concerns about Cygnet Health Care’s governance and leadership and the impact of this on the quality of care being provided to vulnerable people in some services.
‘Cygnet must now take immediate action to address our concerns. They must ensure that effective governance systems and processes are embedded across all services and that policies and procedures are consistent across all services to support staff to provide high-quality care and treatment.
‘Clinical and corporate risks must be identified and effectively managed at every level in the organisation including a clear risk escalation process. All checks required by fit and proper persons regulations must be carried out and a freedom to speak up guardian be appointed in all services commissioned by the NHS.
‘Since our review Cygnet have commissioned a corporate governance review from an independent person and are taking action to make improvements at a number of locations.
‘We will be closely monitoring the provider to ensure the necessary improvements continue to be made to ensure patients are receiving safe care.’
A spokesman for Cygnet said it is ‘not complacent’ and is taking on the CQC’s recommendations and taking steps to improve services.
‘The report documents that this review was a response to Whorlton Hall and we cannot stress enough that we were horrified and shocked by the footage shown in the Panorama programme.
‘We have a zero-tolerance approach to abusive behaviour and took immediate steps to minimise any risk across our portfolio well in advance of this review, including transferring residents to appropriate alternative placements, closing the facility and cooperating fully with external agencies, which we continue to do.
‘This inspection happened in July 2019, since when a number of the services highlighted in the report have improved. However we are not complacent and take on board recommendations where we must improve and are already doing so.
‘At Cygnet, we treat some of the most acute patients that other providers may not be able or willing to support. We always aim to de-escalate and advocate the least restrictive practices in line with current good practice guidelines.
‘Our priority is to deliver safe, effective and person-centred care across all of our services to some of the most vulnerable people in society. We are pleased this report has recognised that Cygnet’s vision and values support a person-centred approach to providing services.’
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