Contract Failures in Mental Health Services

Mental health services are very unlikely to see any of the £15 billion in funding announced by the government in the first week of September 2021, despite NHS England’s estimates of around 10 million people who would benefit from these services. The money is earmarked for reducing the backlog in elective surgery, so once again mental health services takes second place to physical health.

Not only do mental health services lag behind in funding, it is probably the area most reliant on private companies to provide services. As the NHS’s capacity to deal with demand for mental health services, particularly inpatient services, fell over the years, private companies have been given substantial contracts to provide much of the inpatient care needed. So any money mental health services receive is in part paid to private companies in the business of making a profit out of caring for some of the NHS’s most vulnerable patients.

An investigation by the BMA found that the amount private companies receive to provide residential rehabilitation for those with high-level mental health needs rose from £158m in 2016-17 to £181m in 2018-19, although this is likely to be an underestimate. However, in many cases these private providers have failed to provide the standard of care required under the contracts, instead providing inadequate and often unsafe care.

For example, hospitals run by Cygnet Healthcare, which in 2020 received almost all of its £456.3 million in revenue from public organisations – the NHS, clinical commissioning groups, and local authorities, have received numerous damning reports from the CQC (see below).

In September 2019 the CQC published a report on residential mental health, noting that it had found 28 mental health units run by private companies to be “inadequate” in the past three years.  The Royal College of Psychiatrists is so concerned about the poor standards of care that it has written to the secretary of state urging him to commission a public inquiry led by a high court judge.

In November 2017, the Care Quality Commission (CQC) reported that people with drug and alcohol addiction are being put at risk of harm at many independent residential rehabilitation units. The CQC report found that nearly three-quarters of private clinics were failing to hit regulatory standards of care. The report was based on inspections of 68 independent services providing residential detoxification services over the last two years. The CQC required 49 providers (72%) to make improvements because they had breached regulations of the Health and Social Care Act 2012 and failed to meet fundamental standards of care. The CQC took enforcement action against eight providers.

Over the past years there has been a steady number of reports of appalling treatment of patients at private mental health facilities. For example, in October 2021, the CQC ruled that two Staffordshire hospitals, John Munroe Hospital in Rudyard and Edith Shaw Hospital in Leek, run by the company John Munroe Group, can no longer admit patients without permission from regulators, after inspectors flagged multiple instances of poor care, including patients being pushed and laughed at by staff. The hospitals were rated “inadequate” for a second time.

The move by the CQC comes six months after the hospitals were first downgraded from “good” to “inadequate”, after several whistleblowing complaints over poor covid-19 infection control and covid deaths.

Private companies and charities that have been reported in the media include the leading companies, The Huntercombe Group, Cygnet Healthcare and The Priory Group.

The Huntercombe Group

Hospitals run by the Huntercombe Group have received particularly critical reports after inspections by the CQC. The company’s hospital in Maidenhead  which provides NHS-funded mental healthcare for children, was put into special measures by the CQC in February 2021 after an inspection raised serious concerns over the apparent over-use of medication to sedate patients, among other issues. It has since received a further warning notice. However, the HSJ reports that multiple concerns were being raised about the hospital for several years before it was rated ‘inadequate’.

Five former patients and four parents have told HSJ of poor care and practices at the unit between 2016 and 2020. Two of the families raised concerns directly to Huntercombe, as well as NHS England, local authorities and the local community provider, Berkshire Healthcare FT.

In December 2018, an inspection by the CQC of the company’s hospital in Norwich found serious concerns. The CQC took immediate action to protect those using the service, including enforcement action to remove the registration for the hospital. The Huntercombe Group then closed the service and the children and adolescents had to be found places elsewhere.

Earlier issues, include in September 2017, Watcombe Hall, was closed indefinitely after the local NHS hospital raised concerns about the number of young patients being admitted from the unit suffering from malnutrition and dehydration and in 2016, the company’s hospital in Stafford was placed in special measures and told to urgently improve in 24 areas.

Cygnet Healthcare

Cygnet, a specialist mental health provider which operates more than 150 facilities across the UK, which between them have more than 1,000 beds, has been repeatedly criticised by the CQC. Such was the level of failures that in April 2021, a letter was sent to Cygnet management by Claire Murdoch, the national mental health director, and John Stewart, national commissioning director, which HSJ reported warned Cygnet that “patients deserve better” and they will “not hesitate to take further action” if improvements are not made. The letter noted their concern and disappointment with regard to the repeated service failures and that they are not decreasing in number. The letter also noted that NHS England had been meeting with senior management in Cygnet since February 2020 to address the issues. Cygnet’s CEO is Tony Romero and the company has an advisory board that includes former Royal College of GPs chair, Clare Gerada, and Lord Patel of Bradford, who chairs England’s social work regulator.

In June 2021, the CQC published a review of how Cygnet Healthcare was performing in terms of management – also known as a ‘well-led assessment’. The review followed-up on a 2019 review triggered by the Whorlton Hall scandal (although Cygnet did not own this hospital at the time of the scandal).

Some of the most damning conclusions to come from the 2021 review once again concerned the management within the company. The CQC found that the company did “not have a longer term strategic plan” and “members of the senior leadership team were not able to articulate which groups of service users they were planning to support in the future and how they would ensure they had the appropriate estate and skilled staff to meet their needs. ” A consequence of this management approach, noted the report, was that “Cygnet had continued to close and ‘repurpose’ services and at times this took place with short notice and in response to serious concerns,” which had an adverse impact on the care of service users and caused distress to patients.

From October 2018 to January 2020, 10 of Cygnet Healthcare’s hospitals were rated “inadequate”. However, in 2021 alone the CQC has rated seven of Cygnet’s facilities as ‘requires improvement’ and three as ‘inadequate’, plus Cygnet Appletree Hospital in Durham, which has not received a rating but was given an urgent enforcement notice and restricted patient admissions.

In September 2021 the CQC rated Cygnet Views, the company’s hospital in Matlock as ‘inadequate’. Earlier in the year in July 2021, Cygnet Hospital Hexham was rated ‘inadequate’ and in August 2021, Cygnet Wast Hills was rated ‘inadequate’.

An unannounced inspection by the CQC at the company’s CAMHS at the Godden Green hospital in Kent in October 2020 identified serious concerns about environmental risks and staff’s ability to keep patients safe from harm and injury. The CQC had received complaints from other professionals and relatives. Inspectors found a culture of negativity had developed among some staff, with patients referred to as ‘difficult’ and ‘troublemakers’ in records. Cygnet has now decided to close this service and focus on adult patients at this hospital.

Following an inspection of Cygnet’s hospital in Colchester in October 2020, the CQC told the hospital must remain in special measures with improvements still needed. The inspection followed reports relating to the safeguarding of patients and the reporting, investigation and management of incidents. Inspectors found an allegation of abuse had not been reported appropriately and that staff did not always follow correct Covid-19 policy or infection prevention and control guidelines.

In September 2020 the CQC carried out an unannounced inspection of Cygnet Yew Trees, a 10 bed facility for women with learning disability. The CQC reviewed 21 episodes of closed-circuit television footage and found nine that showed staff “abusing patients, acting inappropriately or delivering a poor standard of care”. Managers suspended eight permanent members of staff from working at the hospital. Referrals have also been made to the police. The CQC criticised Cygnet’s management for allowing a culture to develop at this hospital which led to people suffering abuse.

In January 2020, the CQC told Cygnet to take “immediate action” to improve its management following an investigation of the company and its hospitals.  The CQC found that Cygnet-run hospitals were more likely to use seclusion and physical restraint on patients than other NHS providers of mental health care. The incidents of self-harm and assaults by other patients were also much higher. The CQC report also found that checks to ensure directors and members of the executive board were “fit and proper” were not carried out. The full-scale review was triggered by a BBC Panorama report in May 2019 into Whorlton Hall, a centre for people with learning disabilities. As a result of the programme ten people were arrested for abusing patients.

From January to September 2019, mental health units run by the company have been found to be inadequate by the CQC six times. In November 2019, the CQC ordered that the Cygnus Acer Clinic in Derbyshire must stop admitting new patients due to serious concerns over patient safety. CQC inspectors found that clinic patients had opportunities to hang themselves, and the unit had escalating levels of patient self harm, and a huge shortage of trained staff. In 2019 there were two serious incidents, one of which resulted in a patient taking their own life by hanging. The report notes that whilst inspectors were at the clinic in August they witnessed patients congregating in a ward near the reception and banging on the windows to get help from staff, but the staff were nowhere to be seen. Three whistleblowers have contacted the CQC, one prior to the visit and two whilst the CQC inspectors were present.

In October 2019 an inspection report on Cygnet’s Newbus Grange hospital in Darlington, noted how the CQC had found a patient with “unexplained injuries”, and there were opportunities for patients to kill themselves and staff asleep while on duty.  The unit was put into special measures and its 10 patients moved elsewhere.

In July 2019,  the CQC downgraded the hospital at Godden Green to “requires improvement”. The CQC also imposed two requirement notices on the hospital in relation to safe medicines management and making sure they have a permanent registered manager. As a result of the visits restrictions on the provider’s registration were imposed by the CQC, saying it could not admit any young person to the ward without prior agreement with the CQC. This remained in place for a month.

In June 2019, HSJ reported that multi-agency investigation had been launched into Cygnet’s 65-bed hospital in Maidstone, whose 15-bed male psychiatric unit had had a “disproportionate” number of safeguarding alerts for patient-on-patient attacks.

The CQC inspected the Knole Ward at the Cygnet Hospital at Godden Green, in Kent, in July and August 2017 after it was informed of concerns about the safe care and treatment of young people.

The Priory Group

The Priory the country’s leading provider of mental health services, owned by Waterland, a Dutch private equity group, has been the subject of several reports of failures in care in recent years, including patient deaths.

In November 2020, the CQC downgraded the company’s hospital in Middleton St George, Darlington from outstanding to inadequate and placed it in special measures. The CQC made an unannounced inspection in September, prompted by whistleblowing and notifications from the service indicating high levels of self-harm among patients.

The CQC found that the service had insufficient levels of permanent staff and was highly dependent on agency workers who did not always have the correct training.  Governance and recordkeeping was also criticised and did not always comply with policies.

An inspection of the company’s Keston Unit, part of Priory Hospital Hayes Grove, in September 2020 led to the CQC telling The Priory that it must make urgent improvements. The unit caters is a specialised mixed gender unit for adults who have a diagnosis of Autistic Spectrum Disorder (ASD) with psychiatric co-morbidities, people with ASD and mild learning disabilities.  Previously in January 2020, a CQC inspection rated the unit inadequate and placed a condition on
the provider’s registration, preventing it from admitting patients to the Keston Unit until improvements had been made. In September, inspectors found that the unit had failed to make sufficient progress since January and that the quality of care and treatment provided remained unsafe and compromised people’s privacy and dignity. The Priory Group has now decided to close the Keston Unit by the end of 2020.

Also in 2020, The Bristol Cable published an expose of The Priory Group’s hospital in Bristol. In July 2020, the Cable reported that Banksy ward in the hospital was closing down less than three years after opening because of staffing problems. The patients had to be transferred to the nearest ward of its kind 100 miles away in Maidenhead.

The Cable conducted a six month investigation looking at testimony from current and former workers and documentary evidence. The publication revealed that the problems on Bansky ward went back over a year, including struggles to keep permanent staff, regular incidents of self-harm and violent attacks on staff by patients.

Allegations from staff and former staff include that staffing levels on the ward were too low to deal with incidents, such as self-harm, and the high needs of the patients. There were physical attacks on staff and the high number who left meant that the hospital had to rely heavily on agency staff.

Admissions to the ward were halted in Autumn 2019 after an internal investigation by the Priory.  The ward was reopened to new patients a few months later, but following discussions with NHS England, has now closed. The police are investigating a serious incident on the ward in June 2020.

In July 2019, the CQC placed two of the company’s hospitals in special measures – Priory Hospital Blandford in Dorset and Kneesworth House in Royston, Hertfordshire. The hospitals were found by the CQC to be unsafe and uncaring and rated them both as inadequate. The hospitals have been given up to six months to show improvement or face closure.

At the Blandford hospital, which caters for children and young people with learning disabilities or autism as well as a mental health disorders, the CQC inspectors found a high level of violence among patients and assaults on staff. Bricks and nails were used as weapons, patients felt unsafe and staff appeared unable to cope, resorting frequently to physical restraint.

Earlier in the year in February, the Priory’s hospital for children with learning disabilities in High Wycombe was closed, following a CQC report that gave the unit an overall rating of ‘inadequate’. The CQC found the hospital “not adequately equipped to care for young people with complex needs”. The hospital had only opened in April 2018 and catered for children aged 13 to 17 with learning disabilities and/or autism.

In July 2018, the company’s hospital in Southgate, North London, was rated “requires improvement” overall by the CQC, following an unannounced inspection. However, the CQC rated it as “inadequate” for safety and noted several concerns across its child and adolescent mental health services, acute adult wards and substance misuse services. In February 2018, the company’s hospital in Roehampton was rated “required improvement” overall.

In 2016, an inquest ruled that the death of a 14 year old Amy El-Keria at a Priory hospital in 2012 was as a result of months of serious failings at the hospital, including staff failing to pass on the fact that she had spoken of wanting to end her life. The inquest also ruled that staff failed to dial 999 quickly enough and failed to call a doctor promptly. Staff were also not trained in cardiopulmonary resuscitation (CPR). Staffing levels were also found to be inadequate and a lack of one-to-one time caused or contributed to Amy’s death in a “significant” way.

Following the death of Amy, the Health and Safety Executive brought a case against The Priory Group under the Health and Safety at Work Act. In January 2019, The Priory Group pleaded guilty; reports state the fine could be unlimited, but the prosecutor suggested it would be at least £2.4 million. Eventually the company was fined only £300,000 in April 2019; the judge reportedly took into account that the firm pleaded guilty to criminal charges and reported that its 2017 turnover was £133 million with an operating profit of £2 million.

Early in 2016, the the family of 17-year-old Sara Green, who died in the Priory Royal in Cheadle in 2014, called for the company to have its NHS contract cancelled. In March 2016, the Priory and Solent NHS Trust admitted liability for the death of 15-year-old George Werb, who had been a patient at the Priory Hospital Southampton.

St Andrew’s Healthcare

St Andrew’s Healthcare is one of the largest charities involved in residential mental health services. The CQC has issued a number of very critical reports on the organisation, its management, staff, governance, and safety and quality of care over recent years.

In November 2021, the CQC criticised the charity’s adult ward in a hospital in Northampton, where it was claimed staff fell asleep during work. The CQC has described the facility as unsafe and restricted admissions. The provider is now banned from admitting new patients to its female-only forensic and rehabilitation units, plus all of its learning disability wards, without the CQC’s permission. Inspectors visited in July and August and expressed concerns about staffing levels, patient observations, and workforce culture.

In June 2019, its Northampton hospital was rated “inadequate” by the CQC. The watchdog had found that adolescents were kept in unsafe seclusion rooms for excessive amounts of time and without beds, blankets or pillows. It was reported that some patients had been in seclusion for years and earlier in 2019 the Victoria Derbyshire programme was given footage of a teenager reaching their arm through a door hatch to enable contact with their parents during a visit to the hospital.

In January 2020, the CQC published a highly critical report on St Andrew’s Healthcare and rated the organisation “requires improvement”. The report contained a number of concerns, including that in previous inspections records had been falsified for the CQC thus covering up allegations of poor care and abusive behaviour.

Inspectors have highlighted a series of failings at an independent provider, including treatment of a patient and children being dragged across the floor. In February 2020, the organisation’s adolescent mental health unit in Northampton was rated “inadequate” for the second time in a year, following a litany of failings found by the CQC. 

The report stated: “Staff did not always use approved restraint techniques, which resulted in staff dragging patients along the floor or physically injuring patients during restraint. Senior staff told us they observed CCTV footage of these incidents and were concerned that other staff present had not acted to intervene.”

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