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HomeHealthCQC finds 'inadequate' care being provided at Harrow psychiatric hospital

CQC finds ‘inadequate’ care being provided at Harrow psychiatric hospital

The Care Quality Commission (CQC), has rated Cygnet Hospital Harrow, run by Cygnet Health Care Limited ‘Inadequate’ following an inspection that took place in May and June.

CQC looked at the below four services and how well-led the organisation was overall as part of this inspection, which took place as part of CQC’s regular monitoring of services:

The CQC conducted an inspection of four services: a long stay rehabilitation ward for autistic individuals (Springs Wing), acute wards for working-age adults and psychiatric intensive care (Byron Ward), wards for people with autism (Springs Centre), and forensic inpatient wards for autistic individuals (Springs Unit).


The inspection evaluated the overall leadership of the organisation as part of CQC’s routine monitoring of services.

CQC has told Cygnet Hospital Harrow where it must improve and expects to see rapid and widespread improvements. CQC will continue to monitor them during this time to keep people safe and return to check these improvements have been made.

Rob Assall, CQC’s director of operations in London said: “When we inspected Cygnet Hospital Harrow, we saw a service that wasn’t being well-led. Our experience tells us that if services aren’t well-led, it makes it difficult for them to provide a good quality service, which is what we found here.

“This is particularly true in organisations providing specialist services for autistic people, whose very individual needs should be considered at the heart of their care and treatment.

“Three of the services we visited were specialist services for autistic people, who often have very individualised communication needs. Staff weren’t adequately trained to communicate effectively with people using the service, which had a negative impact on how they interacted with them.

“People using the service told us that as a result, they didn’t always feel like staff treated them with compassion and kindness.

“On two of the wards, leaders hadn’t created ward environments that were suitable for autistic people on a really basic level. They were institutional, and noisy with alarms frequently going off, and the lighting was very harsh.

“This is important as autistic people often have additional sensory needs and can find this sort of stimulus distressing. Leaders weren’t able to show they had a clear plan in place to address this. It’s also concerning as the fire alarm routinely going off had become normalised, meaning people may ignore it in a real emergency.

“We found that autistic people who were staying at the hospital for longer periods of time, weren’t having their physical needs met with all routine appointments such as optician, dentist and annual GP health checks. Autistic people have a shorter life expectancy as their physical health needs aren’t always met so it’s important that these are taking place regularly.

“On Byron Ward and the Springs Unit we didn’t always see evidence that people who were given rapid tranquilisation medicines had their physical health monitored afterwards. This treatment can result in serious side effects so people need to be monitored closely.

“It was however reassuring to see that in general across all of the services we saw, that staff used physical restraint as a last resort, using verbal de-escalation techniques first, and that discharges were well planned and tailored to people’s individual needs.

“Cygnet Hospital Harrow still haven’t fully addressed some issues which we found at our previous inspection despite being told where we needed to see improvements. We expect leaders to use our report to make rapid and widespread improvements, and will continue to monitor the service closely during this time to make sure people are safe.”

A spokesperson for Cygnet Hospital Harrow said: “Although we are disappointed with the outcome of the inspection at Cygnet Hospital Harrow, we have already begun working hard to address the issues raised to ensure improvements are made quickly and implemented effectively.

“Since the inspection in May, we have appointed a new hospital manager who is already overseeing the rollout of an enhanced specialist autism training programme for all staff, a new protocol to support patients’ physical health, as well as strengthening governance processes and regular checks of all medical equipment. Improvements are also being made to the ward environments to enhance our service user experience and ensure they meet their individual sensory needs.

“The inspectors did highlight that the ward teams across the hospital had access to the full range of professional staff required and patients had access to a range of therapeutic activities to meet their needs. It also stated that staff had a good understanding of safeguarding processes, however we are not complacent and providing compassionate, personalised care is our absolute priority.

“We are committed to making the required improvements so that our service users receive the standards of care they deserve and we all expect.

“We look forward to demonstrating the improvements we have made at the next inspection.”

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