VOLUNTARY patients were detained against their will for days in a Hampshire mental health unit where staff are not properly trained to care for vulnerable people, inspectors found.

The care industry watchdog has given health bosses two weeks in which to address serious concerns found at Antelope House in Southampton, which replaced the Department of Psychiatry (DoP) at the Royal South Hants Hospital last year.

As well as fears over patients being “inappropriately” held on an open ward at the £25m unit, the Care Quality Commission (CQC) has expressed concerns some members of staff had been given no training on substance abuse, and others not receiving up-to-date advice.


• Records did not show patients consistently received safe care that met their needs.

• Staff didn’t always respond to patients’ needs or minimise risks to them in timely manner.

• Staff not fully aware of what to do in reporting concerns and “are detaining individuals inappropriately”.

• A lack of training put patients at risk of receiving care and support that is not up-to-date with latest guidance.

Read the full report below

It comes just months after an inquest jury ruled there had been serious failings in the care given to a DoP patient who died hours after being seen drinking neat vodka at the unit before being allowed to walk out of a secure exit.

Jurors said “insufficient steps” were taken to ensure Michelle Connor, 26, received time and attention by the allocated staff before she died from a combination of heroin and alcohol in May 2008, and raised concerns over inadequate risk assessments and communication.

Now, the CQC report raises major fears patients in the NHS-run successor unit at Brintons Terrace are being put at risk because records do not show they are receiving the care they need.

Worried inspectors found staff do not always respond to the needs of patients, or minimise potential dangers to their safety.

They concluded: “Despite the trust providing training for staff, there is concern that staff are not fully aware of the action they should take when reporting concerns and are detaining individuals inappropriately.”

During their inspection last month they found several areas of concern over care being given to patients, including:

• Doors to an open ward were locked because two voluntary patients were asking to leave. They had been asking to leave for several days.

• One of those patients, who had a borderline personality disorder, had threatened suicide. They managed to leave the ward but were persuaded to return, but there was no record of an assessment of whether the patient should be detained. Even after inspectors intervened, there was no action plan for staff on what to do if the patient tried to leave again.

• An action plan for a person at risk of self harm and not eating or drinking stated they should be “monitored”, but there were no records to show that was happening.

• Records for a patient supposed to be observed every 15 minutes had gaps of up to three hours.

• A patient’s risk assessment had not been updated for five months, despite daily notes revealing changes in behaviour.

• Staff were unclear about the decision making process leading to the door being locked for all patients on the ward.

• Workers unable to attend training sessions because of staffing problems.

The CQC has given health bosses 14 days to provide details of how it will make improvements, and then carry out further unannounced checks to ensure changes have been made.

Southern Health NHS Foundation Trust, which runs Antelope House, has admitted failings but said steps have already been taken to improve services.

If inspectors are not satisfied by the response, they have powers to step in to restrict practices, and could ultimately shut the unit down.


A LEADING mental health charity last night said it was “deeply concerned” the CQC found Antelope House was failing to provide safe and consistent care.

Marjorie Wallace, chief executive of SANE, said: “This is especially disturbing in view of the death of a patient at the unit that Antelope House replaced in 2008.

“Equally troubling are the reports of voluntary patients being detained inappropriately, poor record keeping, lack of staff training and the failure to assess and manage risk adequately.

“At times of crisis people need asylum, in the truest sense of the word.

“We can only hope that both patients and staff are given greater support in fostering those therapeutic relationships and activities that can best aid recovery.”

HEALTH TRUST RESPONSE: Our priority is to put things right as soon as possible

HEALTH bosses said they “fully accept” the CQC’s findings, and insist changes are already being made to address inspectors’ concerns.

Huw Stone, medical director for the Southern Health NHS Foundation Trust, which runs Antelope House, said the “inappropriate” detentions had happened because doors were locked pending formal assessment of the patients mentioned.

Risk He said staff feared the patients might be at risk to themselves if they were allowed to leave and they had a duty of care to them.

Mr Stone said the CQC found that a notice instructing voluntary patients who want to leave the ward to ask the duty nurse to unlock the doors was not properly displayed.

Although inspectors found no evidence of voluntary patients being systematically detained against their will, Mr Stone admitted formal assessment of whether they should be detained under the Mental Health Act should have been conducted sooner.

He said: “We are both disappointed and concerned our services fell short of our customary high standards and immediately began taking steps to rectify the issues raised in the CQC report.

“Although it is important to emphasise no service users suffered any harm there were clearly issues of risk and we have produced an action plan which we have shared with the CQC which addresses the concerns they raised.

“We are committed to providing the best care possible and we pride ourselves on being a learning organisation – and our priority is to put things right as quickly as possible.”

Mr Stone said changes put in place include reviewing all care plans and risk assessments, ensuring all self harm incidents are reported at shift changes, increasing the time spent by senior staff at the unit, and completing extra checks on standards of care.

He said: “Our priority has been to address the issues raised by the CQC and remove the risks they identified. We will be training and supporting our staff to address these issues but we will of course take any appropriate action against individuals if necessary.

Click below to read the full CQC report:
Click RW1_Southern_Health_NHS_Foundation_Trust_RW1GE_Antelope_House_RoC_201109.pdf