Legal entitlement of Ivetsey Bank Hospital

Registration details

The location ID for Ivetsey Bank Hospital is 1-10206536582.

CQC register Ivetsey Bank Hospital to carry out these legally regulated activities. Contact us if you think Ivetsey Bank Hospital is operating services not listed here.

Type of service

Hospitals - Mental health/capacity

Service specialism

Caring for children (0 - 18yrs)
Caring for people whose rights are restricted under the Mental Health Act
Eating disorders
Mental health conditions

Local authority

Staffordshire

Monitored services

CQC register Ivetsey Bank Hospital to carry out the following legally regulated services here:

Treatment of disease, disorder or injury

Dr Amit Chatterjee is responsible for these services.

Condition of this registration relating to carrying out this regulated activity

The Registered Provider must not admit any new service users to Ivetsey Bank Hospital, Wheaton Aston, Stafford, Staffordshire, ST19 9QT, other than young people with a diagnosed eating disorder to Wedgewood ward, without the written agreement of the Care Quality Commission.

The Registered Provider must undertake a review of Positive Behaviour Support (PBS) plans and associated risk management arrangements for every young person currently receiving care on Hartley ward and Thorneycroft ward. The Registered Provider must ensure:
a. that each young person’s current risk assessment and PBS plan is communicated to, understood by and accessible to all permanent, bank and agency staff involved in that young person’s care.
b. a process is in place to ensure that PBS plans and associated risk management arrangements are reviewed following significant incidents, changes in presentation, changes in risk or where existing
strategies have not been effective.
By 4pm on 4 September 2026 the Registered Provider must provide CQC with evidence demonstrating completion of the review of all PBS plans and associated risk management arrangements, outlining any actions taken where gaps or deficiencies have been identified.

The Registered Provider must review and assure itself of the competence of all permanent, bank staff and agency staff working on Hartley and Thorneycroft who are involved in the management of escalating situations, including de-escalation, physical restraint, observations and seclusion. The Registered Provider must ensure that staff who have not demonstrated the required competence are not deployed to undertake duties for which they are not competent until this has been addressed.
The review must include consideration of whether staff:
a. can recognise and respond appropriately to early signs of distress and escalation and use effective de-escalation techniques to prevent situations escalating wherever possible.
b. have the knowledge and practical skills to safely and appropriately undertake physical restraint and seclusion, including understanding the associated risks and required safeguards
c. are competent to undertake and record observations at the required level and frequency and
recognise and respond to deterioration in a young person’s physical or mental health
d. can apply these skills effectively in practice, with any identified gaps in competence addressed through
appropriate training, supervision, competency assessment and reassessment.
By 4pm on 4 September 2026, the Registered Provider must provide CQC with evidence of the competence review undertaken, any gaps identified, actions taken to address these, and how it will
assure itself on an ongoing basis that staff remain competent in practice.

The Registered Provider must review the existing contingency arrangements for the decommissioned seclusion room serving Hartley ward to ensure that the arrangements are safe, effective and provide clear direction to staff about the actions to be taken when seclusion is required while the designated
seclusion room is decommissioned.
The review must include:
a. consideration of whether the arrangements are sufficiently detailed to ensure that young people can be safely supported, including appropriate levels of observation, effective observations staffing, environmental safety, escalation and access to appropriate clinical support.
b. action to ensure the contingency arrangements are communicated to, understood by and embedded in the practice of all permanent, bank staff and agency staff who may be required to implement them.
c. a regular test and review of the effectiveness of the contingency arrangements, which must make amendments where identified risks, incidents or changes in the environment indicate that this is
necessary.
By 4pm on 4 September 2026, the Registered Provider must provide CQC with a report of the review undertaken, including any identified gaps or risks, actions taken to address these, and evidence of how it will assure itself on an ongoing basis that staff understand and can implement the contingency
arrangements in practice.

The Registered Provider must ensure a system is in place to review all incidents on Hartley and Thorneycroft wards to:
a. ensure that they are reviewed within appropriate timescales, fully and accurately recorded, and that all relevant supporting information is available and appropriately linked to the incident.
b. ensure that learning and actions arising from incidents are clearly identified, implemented and
monitored to reduce the likelihood of similar incidents occurring.
By 4pm on 4 September 2026, the Registered Provider must provide CQC with evidence of the review undertaken, any gaps identified, actions taken and how it has assured itself that incident reviews will remain effective.

The Registered Provider must ensure that there is sufficient senior management oversight and leadership present at the hospital, during all operational hours, to ensure the safe and effective operation of the service.
This must include:
a. arrangements for a suitably senior and experienced member(s) of staff to be onsite and have clear oversight of the hospital, including staffing arrangements, service user safety, incidents, clinical risk, safeguarding concerns and any emerging issues requiring escalation or management intervention.
b. ensuring that all permanent, bank and agency staff are aware of who holds senior responsibility and how they can access support and decision making.
By 4pm on 1 September 2026, the Registered Provider must provide CQC with evidence of the deployment of suitably senior and experienced member(s) of staff.

Assessment or medical treatment for persons detained under the Mental Health Act 1983

Dr Amit Chatterjee is responsible for these services.

Condition of this registration relating to carrying out this regulated activity

The Registered Provider must undertake a review of Positive Behaviour Support (PBS) plans and associated risk management arrangements for every
young person currently receiving care on Hartley ward and Thorneycroft ward. The Registered Provider must ensure:
a. that each young person’s current risk assessment and PBS plan is communicated to, understood by and accessible to all permanent, bank
and agency staff involved in that young person’s care.
b. a process is in place to ensure that PBS plans and associated risk management arrangements are reviewed following significant incidents, changes in presentation, changes in risk or where existing strategies have not been effective.
By 4pm on 4 September 2026 the Registered Provider must provide CQC with evidence demonstrating completion of the review of all PBS plans and associated risk management arrangements, outlining any actions taken where gaps or deficiencies have been identified.

The Registered Provider must review and assure itself of the competence of all permanent, bank staff and agency staff working on Hartley and Thorneycroft who are involved in the management of escalating situations, including de-escalation, physical restraint, observations and seclusion. The Registered Provider must ensure that staff who have not demonstrated the required competence are not deployed to undertake duties for which they are not competent until this has been addressed.
The review must include consideration of whether staff:
a. can recognise and respond appropriately to early signs of distress and escalation and use effective de-escalation techniques to prevent situations escalating wherever possible.
b. have the knowledge and practical skills to safely and appropriately undertake physical restraint and seclusion, including understanding the associated risks and required safeguards
c. are competent to undertake and record observations at the required level and frequency and recognise and respond to deterioration in a young person’s physical or mental health
d. can apply these skills effectively in practice, with any identified gaps in competence addressed through appropriate training, supervision, competency assessment and reassessment.
By 4pm on 4 September 2026, the Registered Provider must provide CQC with evidence of the competence review undertaken, any gaps identified, actions taken to address these, and how it will assure itself on an ongoing basis that staff remain competent in practice.

The Registered Provider must review the existing contingency arrangements for the decommissioned seclusion room serving Hartley ward to ensure that the arrangements are safe, effective and provide clear direction to staff about the actions to be taken when seclusion is required while the designated
seclusion room is decommissioned.
The review must include:
a. consideration of whether the arrangements are sufficiently detailed to ensure that young people can be safely supported, including appropriate levels of observation, effective observations staffing, environmental safety, escalation and access to appropriate clinical support.
b. action to ensure the contingency arrangements are communicated to, understood by and embedded in the practice of all permanent, bank staff and agency staff who may be required to implement them.
c. a regular test and review of the effectiveness of the contingency arrangements, which must make amendments where identified risks, incidents or changes in the environment indicate that this is necessary.
By 4pm on 4 September 2026, the Registered Provider must provide CQC with a report of the review undertaken, including any identified gaps or risks, actions taken to address these, and evidence of how it will assure itself on an ongoing basis that staff understand and can implement the contingency arrangements in practice.

The Registered Provider must ensure a system is in place to review all incidents on Hartley and Thorneycroft wards to:
a. ensure that they are reviewed within appropriate timescales, fully and accurately recorded, and that all relevant supporting information is available and appropriately linked to the incident.
b. ensure that learning and actions arising from incidents are clearly identified, implemented and monitored to reduce the likelihood of similar incidents occurring.
By 4pm on 4 September 2026, the Registered Provider must provide CQC with evidence of the review undertaken, any gaps identified, actions taken and how it has assured itself that incident reviews will remain effective.

Diagnostic and screening procedures

Dr Amit Chatterjee is responsible for these services.

Condition of this registration relating to carrying out this regulated activity

The Registered Provider must undertake a review of Positive Behaviour Support (PBS) plans and associated risk management arrangements for every young person currently receiving care on Hartley ward and Thorneycroft ward.
The Registered Provider must ensure:
a. that each young person’s current risk assessment and PBS plan is communicated to, understood by and accessible to all permanent, bank and agency staff involved in that young person’s care.
b. a process is in place to ensure that PBS plans and associated risk management arrangements are reviewed following significant incidents, changes in presentation, changes in risk or where existing strategies have not been effective.
By 4pm on 4 September 2026 the Registered Provider must provide CQC with evidence demonstrating completion of the review of all PBS plans and associated risk management arrangements, outlining any actions taken where gaps or deficiencies have been identified.

The Registered Provider must review and assure itself of the competence of all permanent, bank staff and agency staff working on Hartley and Thorneycroft who are involved in the management of escalating situations, including de-escalation, physical restraint, observations and seclusion. The Registered Provider must ensure that staff who have not demonstrated the required competence are not deployed to undertake duties for which they are not competent until this has been addressed.
The review must include consideration of whether staff:
a. can recognise and respond appropriately to early signs of distress and escalation and use effective de
escalation techniques to prevent situations escalating wherever possible.
b. have the knowledge and practical skills to safely and appropriately undertake physical restraint and
seclusion, including understanding the associated risks and required safeguards
c. are competent to undertake and record observations at the required level and frequency and
recognise and respond to deterioration in a young person’s physical or mental health
d. can apply these skills effectively in practice, with any identified gaps in competence addressed through appropriate training, supervision, competency assessment and reassessment.
By 4pm on 4 September 2026, the Registered Provider must provide CQC with evidence of the competence review undertaken, any gaps identified, actions taken to address these, and how it will
assure itself on an ongoing basis that staff remain competent in practice.

The Registered Provider must review the existing contingency arrangements for the decommissioned seclusion room serving Hartley ward to ensure that the arrangements are safe, effective and provide clear direction to staff about the actions to be taken when seclusion is required while the designated
seclusion room is decommissioned.
The review must include:
a. consideration of whether the arrangements are sufficiently detailed to ensure that young people can be safely supported, including appropriate levels of observation, effective observations staffing, environmental safety, escalation and access to appropriate clinical support.
b. action to ensure the contingency arrangements are communicated to, understood by and embedded in the practice of all permanent, bank staff and agency staff who may be required to implement them.
c. a regular test and review of the effectiveness of the contingency arrangements, which must make
amendments where identified risks, incidents or changes in the environment indicate that this is
necessary.
By 4pm on 4 September 2026, the Registered Provider must provide CQC with a report of the review undertaken, including any identified gaps or risks, actions taken to address these, and evidence of how it
will assure itself on an ongoing basis that staff understand and can implement the contingency
arrangements in practice.

The Registered Provider must ensure a system is in place to review all incidents on Hartley and Thorneycroft wards to:
a. ensure that they are reviewed within appropriate timescales, fully and accurately recorded, and that all relevant supporting information is available and appropriately linked to the incident.
b. ensure that learning and actions arising from incidents are clearly identified, implemented and monitored to reduce the likelihood of similar incidents occurring.
By 4pm on 4 September 2026, the Registered Provider must provide CQC with evidence of the review undertaken, any gaps identified, actions taken and how it has assured itself that incident reviews will remain effective.