Unstimulating ward environment
Mental health wards having dreary, unstimulating environments that contribute to patient boredom and impact recovery.
Source spread
Where this theme appears
This theme appears across 16 independent accountability sources, so the source mix matters as much as the headline total.
4 inquiry recs
8 PFD reports
5 committee recs
8 HSSIB recs
64 CQC actions
1 IOPC rec
26 IMB recs
4 detention investigation recs
1 DHR rec
1 PHSO decision
2 LGO/SPSO decisions
4 CJINI reports
6 CQC enforcement actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(4)
27 — Co-ordinate occupational services
Recommendation: All occupational services, including industrial therapy, should be effectively co-ordinated under the aegis of a professional Resocialisation Group. They should be expanded, with the emphasis on industrial therapy, to provide activities for all patients who can make use of them.
Unknown
R100 — Person-centred day activities and supported employment
Recommendation: Trusts, private and 3rd sector care providers must ensure that person-centred day activities (including supported employment where appropriate) should be available and offered to all people with learning disabilities and autistic people. This should be monitored through Trust delivery plans.
No response yet
R11 — Meaningful daily activities
Recommendation: Like anyone else, people with learning disabilities and autistic people require a variety of meaningful activities on a daily basis to enhance their quality of life. Every person should have an individualised activity schedule, including leisure activities and skill-building activities, …
No response yet
BAHA-13 — Segregation and Sight Deprivation
Recommendation: In dealing with segregation, JDP 1-10 should make clear that sight deprivation should not be used as a means of segregating CPERS to prevent them communicating with each other.
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
Prevention of Future Deaths reports(8)
Dominic Travis
Concerns: The coroner identified a lack of specialist inpatient mental health provision for young adults in general adult psychiatric wards. Additionally, Pennine Care NHS Foundation Trust's internal investigation was inadequate, lacking independence and transparency, being conducted by directly involved staff.
Overdue
Kelly Campbell
Concerns: The coroner sought assurance regarding rigorous trust policies surrounding clinical decisions, such as returning shoelaces to patients. Concerns were also raised about the dreary physical environment of the rooms, which contributed to patient boredom.
Overdue
Billie Lord
Concerns: The coroner noted that three-bedded dormitory accommodation at the Campbell Centre was inappropriate for mental health patients, causing additional stress, and recommended a review of the facilities to meet modern standards.
Response (Milton Keynes Clinical Commissioning Group): • CNWL Mental Health Trust is commissioning a study to assess the feasibility of creating a new inpatient campus in Milton Keynes. • The Milton Keynes CCG stated it offers … (AI summary)
Responded
Matthew Arkle
Concerns: The report identifies gaps in the risk assessment for unescorted leave and the recording of family requests. Delays occurred in reporting a patient missing due to inaccurate departure times and the absence of a CCTV review policy.
Response (Norfolk and Suffolk NHS Trust): • The Trust issued an internal alert to inpatient wards to prompt reflection on processes for capturing information from external sources, with wards to address any identified gaps and share … (AI summary)
Responded
Katharine Dowling
Concerns: The coroner noted a lack of clear national guidance, consistent support, and appropriate environments for patients with Autism Spectrum Disorder and co-existing mental health diagnoses. There were also concerns regarding the inconsistent implementation and monitoring of ASD training for staff across the UK.
Response (NHS Engalnd2): • NHS England stated it would support the production of 'Good Practice Guidance' on autism and co-existing mental health conditions. • A Core Capabilities Framework for Supporting Autistic People is … (AI summary)
Responded
Roy Campbell
Concerns: The coroner noted delays in implementing an electronic system to prevent detained patients from absconding, and that environmental checks to identify means for patients to leave a ward were not consistently carried out or enshrined in Trust policy with mandatory staff training.
Response (Worcestershire Health and Care NHS Trust): • The trust ordered 10 electronic visitor tracking systems for installation across all relevant wards and units. • Environmental check forms were amended, distributed, and staff were instructed to use … (AI summary)
Responded
Joy Burgess
Concerns: The coroner noted that mental health ward environments could be chaotic and unsuitable for patient recovery due to resource constraints, alongside lengthy waits for psychological therapies, averaging one year locally.
Response (Department of Health and Social Care): • The government stated it is investing over £400 million up to 2024/25 to eradicate dormitory accommodation and £150 million for improvements to the mental health estate. • An extra … (AI summary)
Responded
Sapphire Bernard
Concerns: The coroner raised concerns regarding the lack of inpatient psychiatric beds, leading to unacceptable wait times in A&E for mental health patients. The A&E environment was noted as unsuitable for those awaiting mental health beds, especially individuals with Autism or who are neurodiverse, as it can exacerbate their condition.
Response (NHS England): • NHS England introduced national monitoring of patients waiting over 72 hours for mental health placements in emergency departments. • Action cards were introduced from Winter 2024/25 for trusts and … (AI summary)
Response (NHS Sussex Integrated Care Board): • NHS Sussex and Sussex Partnership NHS Foundation Trust commissioned an additional 14 beds, which have been extended for Quarter one 2025/26, and SPFT will reopen a redesigned ward in … (AI summary)
Responded
Select committee recommendations(5)
#21 —
Recommendation: The self-harm rates at HMP Eastwood Park and HMP Styal, which hold the vast majority of Welsh women offenders, are deeply concerning. While we recognise that the self-harm rates are higher in the women’s estate than the men’s estate generally, …
Response status not verified
#6 —
Recommendation: There needs to be greater recognition across the prison estate that some older prisoners will be unable to engage with the normal regime. Suitable activities and forums should be available to older prisoners to support their welfare and rehabilitation. We …
Response attribution not verified
#21 — Severe overcrowding in adult male prisons increases violence and reduces prisoner wellbeing
Recommendation: The adult male estate was operating at 98.0% to 99.7% occupancy between October 2022 and August 2024, with many prisons severely overcrowded.71 HMPPS confirmed that around a quarter (23.6%) of prisoners are sharing cells designed for one person, often with …
Response attribution not verified
#11 —
Recommendation: Inpatient facilities do not consistently meet the needs of autistic people and people with learning disabilities and too often this is because of factors such as the unnecessary use of restrictive practices; inpatient facilities being unable to accommodate individuals’ needs …
Response attribution not verified
#10 —
Recommendation: Research commissioned by HMPPS found that the prison environment, including the condition of accommodation, played a role in how prisoners behave.20 Between 2015 and 2018, among adult prisoners, key indicators of poor safety in prisons reached all- time highs. This …
Response attribution not verified
HSSIB safety recommendations(8)
Keeping children and young people with mental health needs safe: the design of the paediatric …
HSSIB recommends that NHS England, in collaboration with key stakeholders, updates ‘Health Building Note 23: Hospital accommodation for children and young people’ to include the therapeutic environment for supporting children and young people with mental health needs.
Safety Recommendation
Keeping children and young people with mental health needs safe: the design of the paediatric …
HSSIB recommends that NHS England, in collaboration with key stakeholders, including young people with lived experience and their families, develops guidance on how acute paediatric wards could be adapted to support children and young people with mental health needs. This …
Safety Recommendation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
Those involved in healthcare research can improve patient safety by seeking to understand the design principles for mental health inpatient settings that underpin safe and therapeutic care. Research should include consideration of sensory environments, the role of technology, and the …
Safety Observation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
HSSIB recommends that the Department of Health and Social Care undertakes assessment of the capital requirements of the built environments across high-secure services in England and develops plans to ensure the long-term safety of patients, staff and the public. Social …
Safety Recommendation
Medicine omissions in learning disability secure units
HSIB recommends that NHS England and NHS Improvement reviews and updates all health building guidance relating to learning disability secure units to reflect current clinical guidance on ensuring the design and layout provides a suitable environment for patients and staff.
Safety Recommendation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
HSSIB recommends that the Department of Health and Social Care, with input from stakeholders including NHS England, identifies the short-, medium- and long-term requirements of NHS mental health built environments to ensure they enable delivery of safe and therapeutic care …
Safety Recommendation
Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for …
National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and …
Safety Observation
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services …
Organisations that provide mental health care can improve patient safety by adopting a comprehensive person-centred care approach that prioritises the individual needs, preferences and rights of each patient. This approach should ensure consistent access to meaningful therapeutic activities, actively involve …
Safety Observation
CQC inspection actions(64)— showing 50 strongest matches
Salford Royal Hospital
The service should ensure it takes action to implement a more dementia-friendly environment across the surgical wards and theatre area.
Should Do
Rochdale Infirmary
The service should ensure it takes action to implement a more dementia-friendly environment across the surgical wards and theatre area.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that the layout of the ward is reviewed to support patients living with dementia.
Should Do
Fleetwood Hospital
The trust should ensure that there is a room available for child and adolescent mental health patients within the paediatric area which meets the Royal College of Paediatrics and Child Health standards.
Should Do
Fairfield General Hospital
The service should ensure it takes action to implement a more dementia-friendly environment across the surgical wards and theatre area.
Should Do
Wycombe Hospital
The trust should consider improving the environment to meet the needs of people living with dementia.
Should Do
Windsor Dialysis Unit
Considerre-decoratingthe‘quietroom’andprovidinginformationforpatientstotakeaway.
Should Do
West Berkshire Community Hospital
Considerre-decoratingthe‘quietroom’andprovidinginformationforpatientstotakeaway.
Should Do
Poole Hospital
De-clutter the lounge on Portland ward and address the damp and mould issues to make it a pleasant environment for patients to use.
Should Do
Clifton Hospital
The trust should ensure that there is a room available for child and adolescent mental health patients within the paediatric area which meets the Royal College of Paediatrics and Child Health standards.
Should Do
Bushey Fields Hospital
Ensure that the environment on Holyrood ward at Bushey Fields Hospital reflects national guidance to safely meet the care needs of peoples suffering with dementia.
Should Do
The Princess Royal Hospital
The service should continue to improve the care provided to patients living with dementia which includes improving the environment.
Should Do
Royal Shrewsbury Hospital
The service should continue to improve the care provided to patients living with dementia which includes improving the environment.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust should consider introducing education facilities for children staying on wards.
Should Do
Mount Vernon Cancer Centre
The trust should consider the provision of appropriate waiting areas to allow patients with complex needs to wait in quiet environment.
Should Do
Clatterbridge Hospital
The service should review the two wards and where appropriate set out a plan to improve the environment, equipment and space for rehabilitation services being delivered.
Should Do
Birmingham Children's Hospital
The trust should consider having play areas for children with complex needs.
Should Do
Birmingham Children's Hospital
The trust must ensure there is a suitable mental health room including toilet facilities which complies with statutory requirement.
Must Do
Wavertree Bungalow
We recommend the provider seek advice and guidance from a reputable source about adapting a suitable environment for people using the service.
Should Do
The York Hospital
The service must ensure their new ED environment does not compromise the fundamental standards of care staff can provide to patients, protects their privacy and dignity, and ensures staff can offer them emotional support.
Must Do
Royal Victoria Infirmary
The service must ensure that there is timely review of dementia friendly environments, ensuring that premises used by the service provider are safe to use for their intended purpose.
Must Do
Royal Preston Hospital
The trust should consider reviewing the environment where paediatrics are treated to be more child friendly.
Should Do
Rochdale Infirmary
The service must ensure all areas of the department are suitable and properly maintained. This includes but is not limited to the size and design of the department and rooms used for assessing a patient’s mental health.
Must Do
Rochdale Infirmary
The service must ensure all areas of the department are clean and staff have access to enough equipment that is secure, suitable and properly maintained. This includes but is not limited to checks of specialist equipment and rooms used for …
Must Do
Rochdale Infirmary
The service must ensure all areas of the department are clean and staff have access to enough equipment that is secure, suitable and properly maintained. This includes but is not limited to checks of specialist equipment and rooms used for …
Must Do
Lister Hospital
The service should ensure that all patients with dementia have their needs assessed and recorded as per policy to allow safe care in the absence of regular staff and the premises are suitable to meet these needs.
Should Do
Kidderminster Hospital and Treatment Centre
Ensure all patients are cared for in a suitable environment.
Should Do
Kidderminster Hospital and Treatment Centre
The service must ensure that patients are assessed and treated in appropriate environments.
Must Do
Glenfield Hospital
The trust should consider improving entertainment and communication facilities for patients.
Should Do
Fleetwood Hospital
The trust must ensure the trust follows national guidance and ensures that the environment and facilities are suitable
Must Do
Clatterbridge Hospital
The services should consider ways to make the surgical wards more dementia friendly.
Should Do
Chorley and South Ribble Hospital
The trust should consider reviewing the environment where paediatrics are treated to be more child friendly.
Should Do
St Benedict's Hospice
The service should review the resources available for the occupational therapy department and explore options for improving the environment at Palmer Community Hospital to ensure they meet the needs of children accessing the service.
Should Do
Fairfield General Hospital
The trust should consider provisions for children for example access to a child friendly area and play specialist to provide distraction and coping skills for children waiting for surgery.
Should Do
The Royal Orthopaedic Hospital
The trust should ensure wards are adapted to the needs of patients living with dementia.
Should Do
Princess Anne Hospital
The trust should consider investment in the estate to help modernise the service and experience of the patients and staff.
Should Do
Durham Diagnostics and Treatment Centre
The service should review the resources available for the occupational therapy department and explore options for improving the environment at Palmer Community Hospital to ensure they meet the needs of children accessing the service.
Should Do
Brook House
We recommend the registered provider enables people to access more individualised meaningful activities to help reduce the risk of social isolation.
Should Do
Cygnet Bury Hudson
The provider should address the issues in relation to a sensor light shining into patients’ bedrooms and the office doors slamming on East Hampton ward so that patients’ sleep is not disturbed.
Should Do
Reside at Southwood
We recommend that action is taken to review the accommodation with regard to best practice guidance about creating dementia friendly environments.
Should Do
Meads House Residential Care Home
We recommend that the provider seeks advice and guidance from a reputable source to make the environment more dementia-friendly, and explore how technology and equipment could help to promote people's independence.
Should Do
Hamilton House
We recommend the provider takes account of dementia research and the Accessible Information Standard (AIS) in the design and decoration of the service.
Should Do
Reside at Southwood
actions continue to be taken to review the accommodation with regard to best practice guidance about creating dementia friendly environments and to meeting people's physical care needs.
Should Do
Mead Lodge Residential Care
The service was not decorated in a way which supported people living with dementia to orientate themselves around the building. Corridors were not decorated individually so people could recognise different areas of the service. People's bedroom doors were not decorated …
Should Do
Salford Royal Hospital
The service must ensure all areas of the department are clean and staff have access to enough equipment that is secure, suitable and properly maintained. This includes but is not limited to checks of specialist equipment and rooms used for …
Must Do
Salford Royal Hospital
The service must ensure all areas of the department are clean and staff have access to enough equipment that is secure, suitable and properly maintained. This includes but is not limited to checks of specialist equipment and rooms used for …
Must Do
Woodlands
We recommend the provide review best practice guidance in relation to dementia friendly environments.
Should Do
Winterton House
We recommend best practice guidelines are sought in relation to creating a dementia friendly environment.
Should Do
Linda Lodge
people's suggestions would be worked with to extend and improve the activities available for people as they were aware that the activities needed to be more stimulating and frequent.
Should Do
Gledhow Lodge
We recommend the provider review their provision of activities and stimulation for people.
Should Do
IOPC learning recommendations(1)
IMB individual recommendations(26)
Norwich (2021)
Are there plans for refurbishment of the healthcare unit and L Wing to provide a more suitable environment for the ill and elderly?
HMPPS
Rejected
North West and Midlands STHF (2025)
A television is not available for persons detained in East Midlands airport (see section 5). Television can have a calming effect and be a distraction for those being detained. The Board recommends that a television is fitted.
Home Office
North East Midlands, Yorkshire & Humber STHF (2025)
We consider that this facility, comprising a windowless room with no natural light or ventilation, is not fit for purpose in the summer months and recommend it not be used for detention in that time of the year.
Home Office
Drake Hall (2020)
The number of mental healthcare staff has increased, and with it the potential to increase the range of therapeutic interventions available. However, there is a lack of private space available in the prison for the team, and to support such interventions. Only approval for building new accommodation will resolve the situation.
HMPPS
In Progress
Cookham Wood (2020)
What will be done to either improve the inhumane Phoenix CSU, or remove it from use?
HMPPS
Implemented
Belmarsh (2020)
Will the prison take steps to remedy the continued poor ventilation in the HSU (see section 5.2.1)?
Governor / Director
Sudbury (2023)
Whilst acknowledging that the Board’s annual reports repeatedly comment on the general poor state of prisoner accommodation at Sudbury, it remains an extremely live issue for prisoners and therefore bears repeating again. The extent to which the prison is able to make any substantial improvements to dormitory accommodation, in particular, is limited. What can be done to make the environment …
HMPPS
Foston Hall (2023)
Clinical and group-work space for physical and mental healthcare and group-work space for mental healthcare is very limited. How can their accommodation be improved?
Governor / Director
Huntercombe (2024)
When will the Governor be able to provide appropriate clinical space for mental health therapeutic work?
Governor / Director
London short term holding facilities (STHF) (2025)
The temperature problems in the holding rooms, both at London Heathrow and London City Airport, need to be resolved. The Board would like to see DCOs be given some form of control, either by being able to directly adjust the temperature or by asking someone to adjust the temperature at their request. The temperature problem in London City Airport was …
Home Office
Five Wells (2025)
What steps will be taken to improve the airflow in houseblocks?
Governor / Director
Five Wells (2025)
What steps will be taken to improve the airflow in houseblocks?
Governor / Director
Buckley Hall (2020)
Provide more suitable dining tables and chairs on the wings (see paragraph 5.1.2)
Governor / Director
Foston Hall (2021)
Are there plans to address: the longstanding problem of the size and layout of the CSU (despite the recent renovation), which mean the regime provided is limited and the environment is poor
HMPPS
In Progress
Wandsworth (2022)
The previous report noted that the new healthcare facility, when it opens, will not include any cell accommodation to relieve pressure on the totally inadequate Jones and Addison units. HMIP recently described the units as ‘not a fit place to care for seriously unwell patients’. Funding was secured for the refurbishment of six cells in Addison, and work began in …
HMPPS
In Progress
Wealstun (2023)
To consider reinstating the mental health sessions in the gym.
Governor / Director
Thorn Cross (2024)
To establish a planned programme of decoration for residential units.
Governor / Director
Nottingham (2025)
As referenced in our previous report, we again raise with the Minister the issue of the wellbeing of prisoners who are severely mentally ill. The Board remains concerned at the length of time it takes for suitable places in secure mental health hospitals to become available. This means that severely unwell prisoners are having to be detained in the care …
Other
In Progress
Belmarsh (2020)
Will the prison take steps to improve the environment of the outpatients holding room (see section 6.2)?
Governor / Director
Cookham Wood (2021)
When will the refurbished Phoenix unit be opened as a functioning integrated care unit?
Governor / Director
Implemented
Wakefield (2022)
Dirty protest additional payments for staff – a number of officers have expressed dissatisfaction with the current policy. The Board is very sympathetic to their concerns, primarily due to the poor natural ventilation on the segregation unit where dirty protest incidents are managed.
Governor / Director
Whitemoor (2023)
Will the Prison Service also give priority to funding works, including showers, that help meet standards of basic decency and safety?
HMPPS
Wealstun (2023)
To consider a complete refurbishment or replacement of the older wings (A and B wings) as it is increasingly apparent that this accommodation, built in the 1960s, needs significant remedial action for a number of reasons and is not a humane environment for prisoners to live in.
HMPPS
In Progress
London short term holding facilities (STHF) (2025)
The mattresses in the holding rooms are very thin. We would like Mitie Care & Custody to continue their search for thicker mattresses.
Other
Drake Hall (2021)
The number of mental healthcare staff has increased. With the potential to increase the range of therapeutic interventions available. However, there is a lack of private and confidential interview space available to allow the team to work effectively and for women to engage in therapeutic work (see section 6.3).
HMPPS
In Progress
Liverpool (2023)
The Board has raised repeated concerns over the lack of access to activities for prisoners in the CSU for mental health or self-isolation reasons to promote positive health. What action will be taken to ensure that such segregated prisoners have appropriate access to activities?
Governor / Director
Health investigations(15)
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 2
The Trust should remove the old nursing station and provide a seating area for patients and staff.
north_west
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 3
The panel recommends that the Trust reviews within three months the activities provided for inpatients to ensure that adequate and meaningful activities are available in order to manage the issues of boredom and thus reduce the risk of absconding, violence and aggression. (Paragraph 5.1)
east_of_england
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 7
The range of therapeutic activities available for younger adults in the wards should be broadened by the involvement of a planned programme of weekly activities, coordinated by occupational therapists & psychologists
north_west
Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000) — Rec 28
In accordance with such assessment, appropriate activities should be made available on and off the ward, and priority should be given and resources applied to providing sufficient activities to meet demands
london
Independent investigation: Eshun Marnade Chattun, Springfield hospital Tooting (2003) — Rec 13
The John Meyer Ward team should continue efforts to improve services in light of the patient experience survey findings. Particular emphasis is needed to find ways of improving the range of activities for patients, particularly at evenings and weekends.
london
Independent investigation: Eshun Marnade Chattun, Springfield hospital Tooting (2003) — Rec 7
Pending the completion of the new purpose-built PICU consideration should be given the need for short-term improvements to the present ward environment, for example through the use of colours in the décor and of light and space. (The King’s Fund "Enhancing the Healing Environment" programme and the NHS Estates "Art …
london
An independent investigation into the care and treatment of Colin … — Rec 8
The acute hospital environment did not support improvements in Colin’s mental health and wellbeing. The Trust should expedite the refurbishment of designated cubicles which can appropriately accommodate patients who have behavioural and psychological symptoms.
east_of_england
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 47
Firm efforts should be made to devise and supervise an inpatient programme to occupy and assist in the rehabilitation of a patient.
midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 6
The care plan should specify a programme of activities within the Ward Programme relevant to the patient's care and to assist rehabilitation.
midlands
Independent investigation: Catherine Ogram, Aldershot (2002) — Rec 5.96
Notwithstanding the Trust reconfiguration the new Surrey and Borders Partnership NHS Trust should continue to regard the replacement of Acorn accommodation at Frith Cottage as a very high priority.
south_east
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 13
The Trust should consider rolling out the Productive Ward and STAR Wards initiative to all other inpatient units within the Trust.
north_west
Independent investigation: Jenny Morrison (s/w), Balham,S London (1998) — Rec 4
The London Borough of Wandsworth urgently review the staffing levels, safety provisions, procedures for supervising medication, and day activity programmes in the residential mental health care homes within the Borough.
london
Independent investigation: Tina Stevenson&2 babies, Hull (2005) — Rec 19.8
There should be a review of the staffing levels available at the unit visited by the Team which now manages without the support of the CMHT staff once located within the building. The MH Trust Board should assure itself that this facility is a safe environment for both patients and …
north_east_yorkshire
An independent investigation into the care and treatment of service … — Rec 4
We recommend that commissioners of the NHS mental health service give urgent and positive consideration to the improvement of inpatient facilities on the ward where X was a patient; this would ideally include number and location of beds; services for people with Personality Disorder, as well as the appointment of …
midlands
An Assurance Review of the Independent Review into the care … — Rec 5
The Trust needs to have a better understanding of the quality of its estate and the impact of this on the delivery of high-quality care, including providing a safe environment. It must ensure that essential maintenance is identified and carried out in a timely manner and that the cleanliness of …
Greater Manchester Mental Health NHS Foundation Trust
north_west
Detention investigations(4)
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R22
Serco should review the activities, education and training programmes available to residents to ensure they allow them adequately to occupy their time and provide meaningful activity, education and training, even for the most able residents.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R16
Managers should continue to look for opportunities to improve the physical environment at Yarl’s Wood and make it less prison-like. In particular they should discuss with the Home office whether they can give residents access to more open space and whether they can increase natural light in the corridors and …
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R17
Serco should routinely redecorate parts of the centre showing wear and tear.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 36
I recommend that the Immigration Service considers introducing music or radio into vans and that detainees be offered something to read or do during the wait.
Immigration Detention
Independent reviews(12)
Shaw Detention Review — Rec 38
Recommendation 38: The Home Office should review all the rule 40 and rule 42 accommodation to ensure that it is fit for purpose. All contractors should be asked for improvement plans to ensure that the name Care and Separation Unit is something more than a euphemism.
Immigration
Wessely Review — Rec 87
A review should be undertaken of the physical requirements for ward design for mental health units (e.g. the building notes, regulatory standards).
Health & Social Care
Accepted
Wessely Review — Rec 84
The physical environment of wards needs to be improved, through co-design and co-production with people of relevant lived experience, to maximise homeliness and therapeutic benefit and minimise institutionalisation.
Health & Social Care
Accepted
Shaw Detention Review — Rec 56
Recommendation 56: I recommend that the creation of care suites across the IRC estate should be taken forward as a priority.
Immigration
Shaw Detention Review — Rec 33
Recommendation 33: I recommend that the Home Office review detainees' access to natural light and to the open air, and invite contractors to bring forward proposals to increase the time that detainees can spend outside.
Immigration
Shaw Detention Review — Rec 32
Recommendation 32: I recommend that all IRCs should review the range of activities offered to detainees; in particular, those that could provide skills to detainees that would be useful on their return to their home country.
Immigration
Wessely Review — Rec 90
All existing dormitory accommodation should be updated without delay to allow patients the privacy of their own room.
Health & Social Care
Accepted
Wessely Review — Rec 82
The CQC should develop new criteria for monitoring the social environments of wards. These criteria should be the yardstick against which wards are registered and inspected and this should be reflected in ratings and enforcement decisions.
Health & Social Care
Accepted
Wessely Review — Rec 70
Providers should take urgent action to end unjustified use of 'blanket' restrictions applied to all patients.
Health & Social Care
Accepted
Wessely Review — Rec 69
Wards should not use coercive behavioural systems and restrictions to achieve behavioural compliance from patients, but should develop, implement and monitor alternatives.
Health & Social Care
Accepted
Shaw Detention Review — Rec 5
Recommendation 5: I recommend that the Home Office draw up plans either to close Cedars or to change its use as a matter of urgency.
Immigration
Wessely Review — Rec 83
Patients should have a daily one-to-one session with permanent staff in line with NICE guidelines.
Health & Social Care
Accepted
PHSO casework decisions(1)
LGO / SPSO decisions(2)
201202797 — The State Hospital Board for Scotland
In September 2011, the hospital introduced a new clinical model, which set up new hub and cluster units (a central point and areas for activities). Each of the four hubs supports a cluster of three 12-bedded wards, with various therapeutic, physical, creative and social activities taking place in the hub. …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2013
201301762 — Scottish Prison Service
Mr C complained that the television set in his prison cell had not been working properly for several months, despite the fact that he had to pay a fee each week for its use. We established that the Scottish Prison Service had taken reasonable action in respect of this and …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Oct 2013
Domestic Homicide Reviews(1)
CJINI inspection reports(4)
A Review into the operation of Care and Supervision Units in the Northern Ireland Prison Service
Prisons, Prisoner Safety
Feb 2022
An announced inspection of Woodlands Juvenile Justice Centre
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
May 2015
Report on an unannounced inspection of Ash House Women’s Prison (9-19 May 2016)
Hydebank Wood Women’s Prison, Prisons
Oct 2016
Report on an unannounced inspection of Hydebank Wood Secure College (9-19 May 2016)
Prisons, Hydebank Wood Secure College
Oct 2016
CQC enforcement actions(6)
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) told Greater Manchester Mental Health NHS Foundation Trust that it must improve the quality of care provided to patients in its acute ward for adults of working age and psychiatric intensive care unit (PICU) at …
Park House, North Manchester General Hospital
Feb 2021
Warning Notice: West London Mental Health NHS Trust
The Care Quality Commission issued a Warning Notice to West London Mental Health NHS Trust, requiring significant improvements in the care of patients at Broadmoor Hospital. Inspectors found the trust did not have enough suitably qualified staff to meet patient …
Broadmoor Hospital in Berkshire
Dec 2016
Warning Notice: Cambridgeshire and Peterborough NHS Foundation Trust
The CQC inspected an acute ward for adults of working age and psychiatric intensive care unit at Fulbourn Hospital in May. Inspectors found that staff could not observe patients in all parts of the ward, recording of patient observations were …
Fulbourn Hospital, Cambridge
Jul 2022
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
CQC issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an unannounced focused inspection in November at Woodlands Hospital. Inspectors found staff had not completed mandatory training, risk assessments and care plans were not appropriately completed, …
Woodlands Hospital
Feb 2023
Conditions Imposed: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission imposed conditions on Greater Manchester Mental Health NHS Foundation Trust following an unannounced inspection in March 2024. The conditions require the trust to make improvements in specific areas, including effective service management, ensuring a clean, smoke-free …
Acute wards for adults of working age and psychia…
Dec 2024
Conditions Imposed: Isle of Wight NHS Trust
Immediately after an inspection, CQC placed conditions on the registration of the trust to minimise the risk of patients being exposed to harm. The trust was required to operate an effective system to prioritise patients needing access to community mental …
Apr 2017