Huntercombe CAMHS units: A timeline of failings.
Please note, this page details events which include descriptions of abuse, including sexual abuse, neglect and institutional violence.
The following timeline summarises twelve years of systemic abuse endured by service users under the so-called-care of the Huntercombe Group, now Active Care Group. Unless otherwise stated, all lived-experience quotes are sourced from articles written by Sky News and the Independent.
Lived-experience voices found below have been included in this timeline because their words are in the public domain. However, the horrors faced at Huntercombe/ACG units are not limited to this timeline and these stories do not reflect the immense scale of the harm caused by Huntercombe.
February 2011 - September 2013
February 2011
Huntercombe Maidenhead, CQC inspection findings.
The Care Quality Commission undertakes its first recorded inspection of Huntercombe Maidenhead on its modern system of regulation. Maidenhead is rated as meeting the expected standards in all areas bar one.
Throughout 2012
Huntercombe Maidenhead, lived-experience of abusive treatment.
Natasha experiences cruelty and neglect at Maidenhead in 2012. She describes being "left unattended" on one-to-one supervision and being "subjected to very, very brutal restraints", where staff would "smack [her] head on the walls" and "drag [her] across floors".
February 2013
Huntercombe Stafford, focused CQC inspection findings.
The CQC carries out an unannounced inspection at Huntercombe Stafford, following concerns about "the care and welfare of people who were staying at Huntercombe Hospital-Stafford"
Throughout 2013
Huntercombe Maidenhead, lived-experience of abusive treatment.
Lyra experiences cruelty and neglect at Maidenhead in 2013 and for a number of following years. She explains that on "leaving their care I felt I was going to be a revolving door patient for life, deflated and more mentally ill and traumatised than when I initially was admitted."
October 2013 - October 2015
October 2013
Huntercombe Maidenhead, CQC inspection findings.
During a routine inspection of Huntercombe Maidenhead, the CQC finds that action needs to be taken in three of the five areas it inspects: 'consent to welfare and treatment'; 'assessing and monitoring the quality of service provision'; and 'records'.
Throughout 2014
Huntercombe Maidenhead, lived-experience of abusive treatment.
Danielle experiences cruelty and neglect at Maidenhead in 2014. She says "I break down crying because I remember those things that happened to me, and I might sound like I'm exaggerating, but it affects me every single day. I wake up some nights and I really struggle with it, I'd panic."
August 2014
The Huntercombe Group, general changes.
Valerie Michie becomes Chief Executive Officer of The Huntercombe Group. She remains in this position until 2020.
October 2015
Watcombe Hall, focused/first CQC inspection findings.
Recently re-opened as a Huntercombe CAMHS service, Watcombe Hall is inspected by CQC in response to "concerns raised around safety and effectiveness of the organisation". CQC identifies 8 actions Huntercombe should take to improve the service.
November 2015 - May 2016
Throughout 2016
Huntercombe Maidenhead, lived-experience of abusive treatment.
Rhianna is admitted to Maidenhead. She days “[p]eople do not understand what happens when you are inside.” Now, Rhianna is diagnosed with P-TSD and experiences flashbacks as a result of her time in Maidenhead.
February 2016
Watcombe Hall, CQC inspection findings.
A routine CQC inspection into care and treatment at Watcombe Hall identifies a number of issues, including gaps in staffing, use of restrictive practice and physical observations not being completed. Watcombe Hall is rated 'requires improvement'.
February 2016
Huntercombe Maidenhead, CQC inspection findings.
A routine CQC inspection into care and treatment at Huntercombe Maidenhead identifies the use of blanket restrictions. Also, "[a] decision had been made to allow staff to use a room for seclusion that did not comply with [Huntercombe's] own policy or the guidance in the Mental Health Act Code of Practice."​
May 2016
Huntercombe Stafford, responsive and routine CQC inspection findings.
A CQC inspection undertaken in response to concerns about patient safety at Stafford discovers that "hospital managers had failed to protect patients from the risk of abuse". CQC also carries out a routine inspection of Stafford at this time. Stafford is rated 'inadequate' and placed into special measures.
December 2016 - March 2017
December 2016
Huntercombe Edinburgh, MW commission for Scotland inspection findings.
An unannounced visit to Huntercombe Edinburgh finds high levels of nasogastric feeding being carried out by non-qualified carers. Huntercombe Hospital Edinburgh is asked by the MWCS to provide a policy for their use of restraints.
Throughout 2017
Huntercombe Stafford, lived-experience of abusive treatment.
Danae experiences cruelty and neglect as a patient at Stafford. She is restrained "pretty much [...] every day" and is frequently injured by staff during these incidents.
February 2017
Huntercombe Stafford, CQC inspection findings.
A routine CQC inspection into care at Stafford finds that unjustified blanket restrictions "[limit] the independence of the young people at the hospital". Huntercombe Stafford is rated as 'requires improvement'.
March 2017
Huntercombe Norwich, death of young person and CQC inspection findings.
Mia, aged 17, dies in her room at Huntercombe Norwich. Mia was "deemed a high risk patient" and was meant to be checked on by Huntercombe staff every 15 minutes. However, "[s]taff had not checked on her for 57 minutes before she was found". A routine CQC inspection into Huntercombe Norwich rates the hospital as 'requires improvement'.
April 2017 - July 2017
April 2017
Watcombe Hall, lived-experience of abusive treatment.
Nima is groomed and sexually abused by a senior member of staff at Watcombe Hall. The abuser is later sentenced to 11 years in prison for abusing 3 female children, all CAMHS patients at Watcombe Hall.
May 2017
Watcombe Hall, CQC inspection findings.
Watcombe Hall is placed into 'special measures' and rated as 'inadequate' by CQC after a routine inspection identifies a number of serious concerns.
June 2017
Meadow Lodge, service changes.
Huntercombe opens Meadow Lodge, a 10-bedded general adolescent unit with an attached high-dependency unit in Chudleigh. Meadow Lodge is registered with CQC.
July 2017
Huntercombe Maidenhead and Huntercombe Stafford, focused CQC inspection findings.
Maidenhead is inspected by CQC following concerns related to the 'well-led', 'safe', and 'effective' key questions. CQC identifies 17 areas for improvement. Stafford's 'Hartley Ward' is inspected for the first time since re-opening in April 2017 after being closed in May 2016. CQC identifies a number of failings, including 4 unmet legal requirements.
September 2017 - April 2018
September 2017
Watcombe Hall, service changes. Huntercombe 'well-led' focused CQC inspection findings.
Watcombe Hall is permanently closed. A focused CQC inspection into the key question of 'well-led' across England's current Huntercombe CAMHS units (Meadow Lodge, Costwold Spa, Stafford, Maidenhead and Norwich) identifies 11 areas for improvement.
November 2017
Huntercombe Norwich, focused CQC inspection findings and service changes.
CQC undertakes an urgent inspection into the safety of Huntercombe Norwich in response to serious concerns about immediate risks to young people. CQC takes steps to remove the 8 patients currently admitted to Norwich, after which Huntercombe Norwich is permanently closed down.
Throughout 2018
Huntercombe Stafford, lived-experience of abusive treatment.
Mae experiences cruelty and neglect whilst at Huntercombe Stafford. She is treated like an "animal"; "dragged around, locked out of my room, bruised, constantly shouted at and verbally abused". At Stafford, Mae is given"no autonomy or say in [her] own care or [her] own body."
February 2018
Huntercombe Edinburgh, service changes.
Huntercombe Hospital Edinburgh halves its beds despite an increasing need for specialist inpatient eating disorder care, following staffing shortages and concerns from Scotland's health inspectors that “[t]he culture within the hospital [has] resulted in a high level of self-harm and maladaptive behaviour”.
May 2018 - January 2019
Throughout 2018
Huntercombe Maidenhead, lived-experience of abusive treatment.
'Jane' (not her real name) experiences abusive treatment at Maidenhead. She says, "it was such a horrible place that people resorted to horrible things." Years later, Jane explains that her time at Huntercombe "[...] made things worse". She now experiences "flashbacks of everything that happened."
April 2018
Meadow Lodge, CQC inspection findings.
The first routine inspection into care at Meadow Lodge in Devon following its opening identifies a number of concerns. Meadow Lodge is given the CQC rating of 'requires improvement'.
November 2018
Meadow Lodge, focused CQC inspection findings.
Meadow Lodge is issued a warning notice by CQC (meaning it must take immediate action) after a focused inspection into patient safety finds that patients are not always receiving emergency treatment, and first-aid trained staff fail to provide first aid to patients who require it.
Throughout 2019
Huntercombe Maidenhead, lived-experience of abusive treatment.
Amber experiences abusive treatment at Maidenhead. She describes being restrained "for hours and hours" and says that "when the restraint got too much they'd come in, pull your trousers down and IM you." Amber explains that during restraints she would be "crying" and "screaming". "Sometimes it would be painful and they wouldn't listen."
February 2019 - May 2020
February 2019
Meadow Lodge, CQC inspection findings and Huntercombe Edinburgh, service changes.
Meadow Lodge is rated 'inadequate' by the CQC after a routine inspection identifies serious concerns, including a lack of "positive culture" and failure to raise appropriate safeguarding issues. Huntercombe Hospital Edinburgh is closed down after "a series of reports highlighted concerns about care".
April 2019
Meadow Lodge, service changes.
Meadow Lodge is closed down. Valerie Michie, CEO of Huntercombe during this time, claims that the service closed due to "[a lack of] sufficient demand to keep the service open".
November 2019
Huntercombe Stafford, innapropriate discharge leading to death of young person.
Mia, aged 18, dies in Hartland Hospital after being pressured to move to an adult inpatient unit from Stafford following her 18th birthday. Mia's community care coordinator (Tanya), claims Huntercombe "had also been keen for the move" to happen.
Throughout 2020
Huntercombe Maidenhead, lived-experience of abusive treatment.
Ami is admitted to Huntercombe Maidenhead and is left feeling "embarrassed" and "assaulted" by her admission. Ami is confined to her room for a six-week period, following an incident of self-harm.
June 2020 - December 2020
June 2020
The Huntercombe Group, general changes.
Sylvia Tang takes over from Valerie Michie as Chief Executive Officer of The Huntercombe Group. Tang previously worked as CEO at Priory Healthcare.
Throughout 2020
Huntercombe Maidenhead, lived-experience of abusive treatment.
Alice experiences harm and neglect as a patient at Maidenhead. Reflecting on her time at Huntercombe, Alice asks, "[h]ow can anyone get better if that's the way the hospital treats people?". She says "I think it's awful. It shouldn't be open."
September 2020
Cotswold Spa, service changes.
The Huntercombe Group sell their CAMHS eating disorder specialist service 'Cotswold Spa' to Elysium Healthcare. Out of the 6 CAMHS hospitals opened and managed by Huntercombe since 2016, only 2 remain open and/or in the management of the Huntercombe Group.
December 2020
Huntercombe Maidenhead, focused CQC inspection findings.
A focused CQC inspection into safety and the quality of the service at Huntercombe Maidenhead identifies 4 actions which the provider must take in order to ensure their service complies with legal obligations. Huntercombe Maidenhead is rated as 'inadequate' and served a "letter of intent", indicating the severity of CQC's concerns.
January 2021 - January 2022
Throughout 2021
Huntercombe Maidenhead, lived-experience of abusive treatment.
A young person who wishes to remain anonymous describes being "restrained up to 10 times a day, sometimes for hours at a time, by four or five people" during their time at Maidenhead. They "came in with a little bit of trauma and came out with a lot more".
March 2021
Huntercombe Stafford and Huntercombe Maidenhead, service changes.
Huntercombe Hospital Maidenhead is renamed 'Taplow Manor'. Likewise, Huntercombe Hospital Stafford is renamed 'Ivetsey Bank Hospital'.
October 2021
Huntercombe Stafford/Ivetsey Bank Hospital, CQC inspection findings.
During a routine inspection of Ivetsey Bank, formerly Huntercombe Stafford, CQC identifies a number of serious concerns. Ivetsey Bank Hospital is rated as 'inadequate' and is placed into special measures.
January 2022
The Huntercombe Group, general changes.
Four Seasons Health Care, previous owners of The Huntercombe Group, sell Huntercombe to Montreux Capital Management who merge Huntercombe with their 'operating asset', Active care Group.
February 2022 - June 2022
Throughout 2022
Huntercombe Stafford/Ivetsy Bank Hospital, lived-experience of abusive treatment.
A young person who wishes to remain anonymous describes their experiences at Huntercombe Stafford, explaining that they "[were] once left with a ligature for over 30 minutes, despite being on 15-minute checks." This ex-service user was also able to "self-harm without staff noticing".
February 2022
Huntercombe Maidenhead/Taplow Manor, death of young person.
Ruth, a 14 year-old patient at Huntercombe Maidenhead dies following an incident at the hospital. A police investigation is opened. Ellie, a service user at Huntercombe Maidenhead, starts a petition to close Huntercombe Maidenhead which is signed by over 2000 people. The petition is closed down.
June 2022
Huntercombe Maidenhead/Taplow Manor, focused CQC inspection findings.
Taplow Manor, formerly Huntercombe Maidenhead, receives the CQC rating of 'requires improvement' after a focused inspection finds that Taplow "failed the meet the conditions of a warning notice that had been issued at the previous inspection". CQC are currently carrying out a review of quality at Taplow Manor.
Throughout 2022
Huntercombe Maidenhead/Taplow Manor, lived-experience of abusive treatment.
Tyson experiences harm and neglect whilst he is a patient at Taplow Manor. A member of staff at Taplow Manor told Tyson he "would never get out, that [he] was just going to be stuck there forever and [he] couldn't get help." Now, Tyson suffers flashbacks as a result of his time as a Huntercombe patient.
September 2022 - March 2023
September 2022
Huntercombe Stafford/Ivetsey Bank Hospital, focused CQC inspection findings and proposed planning application.
Following Ivetsey Bank Hospital being placed into special measures in October 2021, a focused CQC inspection takes place to check on the hospital's progress. During this inspection, Ivetsey Bank is rated 'requires improvement'. Ivetsey Bank Hospital remains in special measures. In the same month, Active Care Group applies to South Staffordshire Council for planning permission to expand Ivetsey Bank to include a new 12-bedded CAMHS unit and an onsite SEND school.
October 2022
Active Care Group/The Huntercombe Group, media exposés.
Working in collaboration to gather evidence, Sky News and The Independent release the first of a series of reports into Huntercombe's failings. Sylvia Tang, CEO of Active Care Group, claims that ACG are "unable to comment on the services provided prior to this date", because "most" incidents took place before ACG took over.
December 2022
Active Care Group/The Huntercombe Group, media exposés.
A further 30 patients speak with Sky News and The Independent, bringing the total number of children who experienced harm and abuse whilst under the care of Huntercombe/ACG to more than 50. Many of these ex-patients and their families describe their concerns and complaints being consistently ignored by Huntercombe/ACG.
Between September 2022 and February 2023
Huntercombe Stafford/Ivetsey Bank Hospital, service changes.
Despite being currently placed in 'special measures' and rated as 'requires improvement' by CQC, Active Care Group are given the green light to open Ivetsey House, a CAMHS 'step-down' sister service to Ivetsey Bank Hospital. Ivetsey House has not yet been rated by the CQC.
March 2023 - Present
March 2023
Huntercombe Stafford/Ivetsey Bank Hospital and Huntercombe Maidenhead/Taplow Manor, CQC inspection findings. Taplow Manor, service changes.
A routine CQC inspection into care and treatment at Ivetsey Bank Hospital, formerly Huntercombe Stafford, finds that Ivetsey Bank is 'inadequate'. Ivetsey Bank Hospital remains in special measures. A First Do No Harm member starts a petition to shut Ivetsey Bank down.
A routine CQC inspection into care and treatment at Taplow Manor, formerly Huntercombe Maidenhead, finds that Taplow Manor is 'inadequate'. Following this report, Active Care Group announces that Taplow Manor is to close at the end of May 2023.
April 2023
Taplow Manor/Huntercombe Maidenhead and Ivetsey Bank/Huntercobme Stafford, Independent
investigation findings and Independent interview with Chris Dzikiti.
Rebecca Thomas, Health Correspondent for the Independent identifies that over half of 'sexual safety incidents' across all CAMHs inpatient units since 2019 originated from Taplow Manor, formerly Huntercombe Maidenhead.* Another article by the same author confirms that police are investigating a new case of the sexual assault of a child patient at the hands of an Ivetsey Bank staff member. In an interview with Chris Dzikiti, Director of Mental Health for the Care Quality Commission, Mr Dzikiti acknowledges 'systemic' difficulties in mental healthcare provision. He states, 'We [the CQC] have to be brave. We have to challenge each other. We have to hold organisations to account when there is poor practice.'
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*Please note: the content of this article is currently under investigation, owing to a complaint that has been raised by Active Care Group.
May 2023
The Independent reports details of inquest hearing and information supplied by the GMB union on treatment of international care workers.
Rebecca Thomas at the Independent reports on the pre-inquest hearing into Ruth's death in February 2022, detailing that Ruth was left unattended by a care worker, who was supposed to be on her one-to-one supervision. The CQC also announce they have launched a criminal investigation into 'whether the provider had “brought about avoidable harm or exposure to risk” in relation to [Ruth's death]'.
In a separate article, Rebecca Thomas also reports concerns over the treatment of migrant workers in ACG facilities, following the closure of Taplow Manor. The GMB union highlight the 'callous treatment' of overseas support workers; the report details groups of staff being transferred to Ivetsey Bank in Stafford, staying in unsuitable accommodation whilst other support workers face losing their right to work in the UK if they do not accept relocation.
August 2023
First Do No Harm members gather for a vigil at Taplow Manor in Maidenhead.
Dozens of First Do No Harm members gather at the gates of Taplow Manor in Maidenhead to mark the closure of Taplow Manor. You can find out more about the event on our blog, here.
October 2023
CQC inspection report is published for Ivetsey Bank hospital. First Do No Harm protest the expansion of Ivetsey Bank. Planning permission is approved, subject to conditions.
On the 6th October 2023, the results for a CQC inspection into Ivetsey Bank in June of the same year are published. CQC rates Ivetsey Bank hospital as 'Requires Improvement'. The hospital remains in special measures. Ivetsey Bank has been in special measures for over two years.
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First Do No Harm organises a protest outside South Staffordshire Council on the 17th October 2023, the evening of the planning committee meeting which discussed Ivetsey's plans, in objection to the expansion of Ivetsey Bank Hospital. At this meeting, Ivetsey Bank's application is approved subject to certain conditions. Find out more about the history and expansion of Ivetsey Bank here.
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