Independent mental health service

Ivetsey Bank Hospital

Inadequate

Ivetsey Bank, Wheaton Aston, Stafford, Staffordshire, ST19 9QT (01785) 840000

Provided and run by:
Active Young People Limited

The provider of this service changed. See old profile

We issued two warning notices on Active Young People Limited on 24 April 2026 for failing to meet the regulations related to good governance and safe care and treatment at Ivetsey Bank Hospital.

All Inspections

Ivetsey Bank Hospital is a Child and Adolescent Mental Health (CAMHS) hospital for young people aged 12-17 with a diagnosed mental health condition.

Ivetsey Bank was registered with CQC on 5 March 2023 to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of Disease, Disorder or Injury (TDDI).

We carried out an on-site assessment at Ivetsey Bank Hospital on 10,11,12, 17 March and 15 April 2026. We asked for and reviewed data related to the assessment.

We visited the following wards as part of the assessment: Hartley: Psychiatric Intensive Care Unit (12 beds), Thorneycroft: General Adolescent Service (12 beds), Wedgwood: Eating Disorders Service (6 beds). At the time of our inspection, Glazewood, the new Admissions and Triage Unit (6 beds) was not currently open and we were not given a date as to when this was expected to reopen.

We carried out this inspection in response to a number of incidents in which young people had experienced harm following the ingestion of items and the use of restraint. In addition, we had planned to inspect the Admissions and Triage Unit, Glazewood, as this was a new ward that had not previously been inspected.

We had previously inspected this service in July 2025. This was a responsive assessment due to some concerns we identified in relation to a serious incident that occurred at the service. During the inspection, we found that the provider had taken appropriate actions to address and mitigate safety risks. We assessed a small number of quality statements from the safe and well-led key questions and found areas of good practice.

At this assessment we undertook a fully comprehensive assessment and assessed 1 assessment service group; Child and adolescent mental health wards. We identified areas of concern around young people’s safety, environment and governance processes. As a result, we took enforcement action and issued 2 warning notices.

At this assessment we identified breaches of Regulations: 9 Person Centered Care, 12 Safe Care and Treatment, 15 Premises and Equipment, 17 Good Governance and 18 Staffing.

We issued two warning notices on Active Young People Limited on 24 April 2026 for failing to meet the regulations related to good governance and safe care and treatment at Ivetsey Bank Hospital.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

Ivetsey Bank Hospital is a Child and Adolescent Mental Health (CAMHS) hospital for young people aged 12-17 with a diagnosed mental health condition.

Ivetsey Bank was registered with CQC on 5 March 2023 to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of Disease, Disorder or Injury (TDDI).

We carried out an on-site assessment at Ivetsey Bank Hospital on 10,11,12, 17 March and 15 April 2026. We asked for and reviewed data related to the assessment.

We visited the following wards as part of the assessment: Hartley: Psychiatric Intensive Care Unit (12 beds), Thorneycroft: General Adolescent Service (12 beds), Wedgwood: Eating Disorders Service (6 beds). At the time of our inspection, Glazewood, the new Admissions and Triage Unit (6 beds) was not currently open and we were not given a date as to when this was expected to reopen.

We carried out this inspection in response to a number of incidents in which young people had experienced harm following the ingestion of items and the use of restraint. In addition, we had planned to inspect the Admissions and Triage Unit, Glazewood, as this was a new ward that had not previously been inspected.

We had previously inspected this service in July 2025. This was a responsive assessment due to some concerns we identified in relation to a serious incident that occurred at the service. During the inspection, we found that the provider had taken appropriate actions to address and mitigate safety risks. We assessed a small number of quality statements from the safe and well-led key questions and found areas of good practice.

At this assessment we undertook a fully comprehensive assessment and assessed 1 assessment service group; Child and adolescent mental health wards. We identified areas of concern around young people’s safety, environment and governance processes. As a result, we took enforcement action and issued 2 warning notices.

At this assessment we identified breaches of Regulations: 9 Person Centered Care, 12 Safe Care and Treatment, 15 Premises and Equipment, 17 Good Governance and 18 Staffing.

We issued two warning notices on Active Young People Limited on 24 April 2026 for failing to meet the regulations related to good governance and safe care and treatment at Ivetsey Bank Hospital.

This service is being placed into special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

Date of assessment: 22 and 23 July 2025

Reason for assessment: This was a responsive assessment due to some concerns we identified in relation to a serious incident that occurred at the service. The serious incident related to patient tying a ligature while under close supervision.

During the inspection, we found that the provider had taken appropriate actions to address and mitigate patient safety risks. The provider had demonstrated an active learning culture and acted where necessary.

We assessed a small number of quality statements from the safe and well-led key questions and found areas of good practice.

Ivetsey Bank Hospital, formerly known as Huntercombe Hospital Stafford, is a child and adolescent mental health service for 37 children and young people aged 12 to 18 years. When we inspected this service in October 2022, we identified areas of concern and took enforcement action resulting in conditions on the location’s registration and the service was placed in special measures. We last inspected this service in June 2023. Improvements had been made however we identified other areas of concern and took further enforcement action. At this inspection we noted improvements across our previous areas of concern.

Our rating of this service stayed the same. We rated it as requires improvement because:

Staff were concerned about the risk of physical assault and injury from children and young people. Not all staff felt fully supported by managers when they needed time off work.

Not all staff were bare below the elbow, in line with infection prevention and control guidelines.

However:

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.

The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team.

Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

The service was well led and the governance processes ensured that ward procedures ran smoothly.

Ivetsey Bank Hospital, formerly known as Huntercombe Hospital Stafford, is a child and adolescent mental health service for 37 male and female children and young people aged 12 to 18 years. At an inspection in October 2021 this service was placed into special measures as we found the service to be inadequate overall. We inspected again in September 2022 and found some improvements. However, we again inspected in November 2022 based on concerns that were raised with the CQC. We issued a Warning Notice to ensure that our immediate concerns were addressed and the service remained in special measures.

At this inspection, we found the service had made improvements against the Warning Notice, however we did identify other areas of concerns and have taken further enforcement action. The service remains in special measures.

Our rating of this location improved. We rated it as requires improvement because:

Staff were not always following the Rapid Tranquilisation policy; physical healthcare observations were not always completed after rapid tranquilisation was used.

Staff were not always managing young people’s physical health needs. Paediatric early warning scores (PEWS) were not always completed correctly, and staff recorded repeated entries of ‘refused’ for weeks at a time without escalation to the multi-disciplinary team.

There were gaps in electronic records and it was difficult to access young people ’ s records.

Young people told us staff did not offer debriefs after incidents had occurred.

Young people did not receive weekly one to one sessions with their named nurse.

Young people did not receive 25 hours of therapeutic intervention each week in line with NHS England guidance

Staff did not always manage dynamics between young people within the wards; young people said this made them feel unsafe.

Families and young people raised concerns about the lack of experience of some staff working on Wedgewood specialist eating disorders unit.

Staff did not always respect a young person’s preferred name and pronoun on Wedgwood.

Staff did not regularly check emergency equipment was in working order.

Young people did not have regular access to outside space.

Young people and family did not always feel involved in their care.

However:

Staff now completed body maps after incidents where young people had sustained injuries after incidents of restraint. Staff now completed neurological observations after incidents of headbanging.

Staff now updated risk plans after incidents.

The provider ensured young people were given to opportunity to raise sexual safety concerns with the police and staff raised these with the local authority for external investigation.

The provider now ensured staff received training workshops on safeguarding and boundaries and used specifically developed crib sheets to identify potential safeguarding concerns.

Closed Circuit Television (CCTV) footage reviewed showed staff applied least restrictive principles when restraint was required to maintain safety.

Staff now completed personalised positive behavioural support plans for young people with a dual diagnosis of autism, which meet the guidance within the Mental Health Act 1983: Code of Practice. Closed Circuit Television reviewed showed staff followed positive behavioural support plans to de-escalate incidents when they occurred. The provider had recruited a full-time psychologist to work on site at the hospital. The provider ensured young people who had a preferred gender of staff delivering care were receiving this. Staff received a written handover for each shift and this information was included.

Ivetsey Bank hospital formerly known as Huntercombe Hospital Stafford is a child and adolescent mental health service for 37 male and female children and young people aged 12 to 18 years.

At an inspection in October 2021 this service was placed into special measures as we found the service to be inadequate overall. We inspected again in September 2022 and, we found improvements.

This was a focused inspection based on concerns that were raised with the CQC. We used the quality of life tool during this inspection. The quality of life tool was designed and is described on our website as being relevant for assessing the quality of a service for people with a learning disability and autistic people. This is now being trialled in settings where care is provided to a different population group.

The quality of life tool has not replaced our published methodology for assessing and evaluating the performance of registered providers, the Key Lines Of Enquiry remain in place under the 5 key questions as the focus of our inspections against the fundamental standards set out in the Health and Social Care Act 2008 regulations. The quality of life tool is being piloted for inspectors to assist them in emphasising good and poor care in line with our KLOES. We followed CQC guidance to make assessments and judgements on right support, right care, right culture’.

This inspection was a focussed inspection following patient safety concerns raised with us. The service will continue to remain in special measures.

Our rating of this location went down. We rated it as inadequate because:

Staff did not always develop holistic positive behavioural support plans for those with a dual diagnosis, consisting of the young person’s voice.
Young people did not always receive care in their preferred manner.
Staff did not always complete appropriate checks and records after young people had been injured after incidents.
Staff did not always assess and manage risk well after incidents.
Staff did not always label food safely and it was not always clear when food had been opened and when it should be consumed by.
The service did not ensure all incident forms were an accurate description of incidents to identify and safeguard young people from the use of disproportionate force during incidents involving restraint.
Not all areas of all ward were clean, and all furniture was not wipeable to meet infection control needs.
The service governance processes did not always ensure that ward procedures ran smoothly. The processes in place did not always identify gaps in recording, gaps in patient checks and whether risk management plans had been updated after incidents had occurred.
The service audit systems in place did not identify if all young people with a dual diagnosis had a positive behaviour support plan in place.

However:

Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
Staff actively involved patients in multidisciplinary meetings including ward rounds.
Staff worked as a team to de-escalate and support young people who were distressed using a range of methods including verbal de-escalation and distraction before using restraint.

Ivetsey Bank hospital formerly known as Huntercombe Hospital Stafford is a child and adolescent mental health service for 37 male and female children and young people aged 8 to 18 years.

At our last inspection this service was placed into special measures due to concerns identified. The overall rating is requires improvement and the hospital remains in special measures.

Our rating of this location improved. We rated it as requires improvement because:

The care notes system was not working and had not been for a number of weeks. This was beyond the provider’s control, and systems had been put in place to ensure staff could provide comprehensive and contemporaneous notes. However, some aspects of the provider’s IT system meant nursing staff could not always input onto the notes system in a timely manner. Some staff did not always know where some information was located.
We found some medicines and clinical tests were out of date, and opening dates were not completed on some sharp’s boxes and liquid medicines. Medicine audits had not been effective and had not identified these issues.
Only 37% of staff on Thorneycroft ward had received regular supervision and only 69% across the whole hospital which was not in line with the provider’s policy.

However:

The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They monitored the use of restrictive practices and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Apart from medicines, staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included a range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, and appraisal. Staff on Hartley ward and Wedgewood ward received regular supervision. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Staff planned and managed discharge well and liaised well with services that could provide aftercare. They provided facilities that promoted comfort and dignity and met their needs.
The service was well led, and the governance processes ensured that ward procedures ran smoothly. Improvements had been made across the whole service since our last inspection

Huntercombe Hospital Stafford is a child and adolescent mental health service for 37 male and female children and young people aged eight to 18 years. The hospital admits both informal and detained children and young people. Huntercombe Hospital Stafford is divided into three separate wards; Hartley, Thorneycroft and Wedgewood.

We most recently inspected the service in September 2018 and carried out a full comprehensive inspection. We rated the service as good overall, with key questions rated: safe, effective, responsive and well-led as good and caring as outstanding.

At this inspection, we undertook an unannounced inspection of all key questions:

Are services safe?

Are services effective?

Are services caring?

Are services responsive?

Are services well-led?

We visited the location on the 6 and 7 October 2021 during the day shift and due to concerns identified, we carried out a further visit on 12 October 2021 during the night shift. Following the onsite inspection visits, we carried out remote interviews with staff members and evidence gathering until 19 October 2021.

Our rating of this location went down. We rated it as inadequate because:

Not all staff were wearing personal protective equipment correctly or were bare below the elbow. Not all staff were observed to follow good hand hygiene practices and hand washing was inconsistent upon entry and exit to wards. There were no maximum capacity signs on doors and there was a lack of social distancing.

The service did not always have sufficient permanent staff to meet children and young people’s needs to keep them safe and relied on agency staff to fill vacancies.

Children and young people’s care and treatment was not always provided in a well-furnished, well-maintained or clean environment which did not always meet the needs of children and young people with Autism.
Children and young people’s records were not always personalised, goal-orientated, strengths based or demonstrated children and young people and family involvement.
Staff on Hartley ward did not always respect children and young people’s preferences with regard to the pronouns that they wished to be addressed by.
The hospital director within the service was not visible or approachable to staff or children and young people.
Some staff were sat with their eyes closed for prolonged periods of time whilst carrying out observations. There were not robust systems in place to ensure that staff working during the night shift were undertaking their roles appropriately.
Observations were not always recorded at the time they occurred and were completed retrospectively or not at all. There was a system in place to monitor the recording of observations, but this did not highlight any issues.
Audits that were in place were not robust to monitor and improve the quality of care and did not always demonstrate clear actions where appropriate.

However:

Psychology and occupational therapy care plans were well written and provided individual detail about children and young people’s care and treatment.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff planned and managed discharge well and liaised well with services that would provide aftercare.
Children and young people made choices and took part in activities which were part of their planned care and support.
Children and young people’s physical health was assessed on admission and reviewed on a daily basis throughout their stay.

As this service has been rated inadequate it will be placed into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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