Ivetsey Bank Hospital

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• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

This means we looked for evidence that the service involved people and treated them with compassion, kindness, dignity and respect.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not treated with compassion and dignity; staff caring attitudes had significant shortfalls. Staff did not always understand the individual needs of young people or support young people to understand and manage their care, treatment or condition. Young people were not consistently involved in care planning and risk assessment. Staff did not inform and involve families and carers appropriately. Staff wellbeing had not been sufficiently prioritised, as there was a lack of accessible toilet facilities and adequate rest areas.

We have not awarded this service a score for Caring.

Find out about when we will not publish a key question score and what we look at when we assess Caring.

We scored the service as 1. The evidence showed significant shortfalls. The service did not treat people with kindness, empathy and compassion, or respect their privacy and dignity. Staff did not treat colleagues from other organisations with kindness and respect.

Staff attitudes and behaviours when interacting with young people did not always show that they were discreet, respectful and responsive, providing young people with help, emotional support and advice at the time they needed it. We saw one young person on observations was not given the privacy they required in line with their care plan. The staff member had sat with the door open despite the young person being prescribed 15 minutes of bathroom privacy at times they required it.

Three young people across Hartley and Thorneycroft said staff did not treat them well or behave appropriately towards them. Staff and 2 young people told us of an incident where a staff member had to be physically removed from a young person following an altercation. Young people told us that this incident was not the first time that staff had acted inappropriately and needed other staff to intervene. The service were following their internal HR processes and had shared information of the incident with relevant external partner such as the local authority.

A young person told us that staff did not maintain their confidentiality by discussing their care openly in the communal area. They also shared that that staff would make it clear that they did not want to be on their observations. This was shared with staff on the ward who were not aware of these incidents but recognised some staff may have preferences to which young people they worked with.

However, all young people on Wedgwood told us that they felt safe. Two young people on the other wards stated that they thought that staff were caring, and they did not see a difference between day and night staff.

Carer feedback was mixed. Some said they did not like how staff spoke or treated young people and some staff were part of an escalation in their behaviour. However, others said staff were amazing and did support their relative for example, by doing their hair or supporting them with showering.

Staff told us that they could raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards young people without fear of the consequences. We did not see any records where staff had raised concerns about staff conduct internally. However, we did receive a number of speaking up concerns where staff raised concerns directly with CQC about other staff members conduct towards young people. Two staff members we spoke with explained that previous management had not always responded when people spoke up and therefore, they believed that some staff did not always feel that their concerns would be responded too.

We scored the service as 2. The evidence showed some shortfalls. The service did not always treat people as individuals or make sure people’s care, support and treatment met people’s needs and preferences. They did not always take account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.

The service made adjustments for disabled young people and met young people’s specific communication needs. There was lift to access to Thorneycroft ward, for those with mobility issues. There was a stair lift provided for Wedgwood young people alongside a lift that went from Glazewood up to Wedgwood. The service had looked at ways to risk assess and mitigate on a person-by-person basis.

Young people could obtain information on treatments, local services, their rights and how to complain. Information was displayed on the walls of the wards, such as general advocacy details and safeguarding. However, this information was not always up to date. We saw that a staffing chart on Thorneycroft ward was out of date with staff that had left the service remaining on the chart and new staff missing.

One young person told us that they did not feel that all staff understood how to act around or speak with transgender people. We also saw that a young person’s pronouns were inconsistent in all care plans. However, we did see that steps were taken to remind all staff of young people’s pronouns and information on preferred pronouns was shared with the inspection team.

One young person told us that a doctor had disrespected them by making light of their request to attend places of worship. However, they were pleased as other staff members had responded to their request and they had been supported to visit a church.

Young people had a choice of food to meet the dietary requirements of religious and ethnic groups and to account for allergies and intolerances.

There was a small multi faith room available off the ward although we were told that at the time of inspection young people did not currently choose to use this.

Leaders were aware of how to access interpreters and/or signers.

We scored the service as 2. The evidence showed some shortfalls. The service did not always promote people’s independence, so people did not always know their rights and have choice and control over their own care, treatment and wellbeing.

Documentation relating to staff reading young people their rights was inconsistent and it was noted in the provider’s audits that Section 132 rights were not recorded as having been read consistently between December 2025 to February 2026.

Care plans did not consistently reflect the young people’s choice and preference around how their care should be delivered. Care plans were not written in accessible wording and lacked young people’s voice.

Young people told us they had access to independent advocates where needed and that they knew how to complain and give feedback if they wished.

The service did not always fully communicate changes in a young people’s detentions effectively. One family member told us that they had not been informed when their relative had been moved to being held informally and was therefore free to leave. They explained that there had been conflicting information given to themselves, the nearest relative and the young person which had caused some distress and resulted in them having to be detained again.

One family member stated that it was sometimes very difficult to get through to the ward and wondered if this may be due to them having a lack of staff. However, they also stated that if they could not attend the MDT meetings, they would be sent the notes, and the young person’s plan would. Young people were also invited to MDTs.

We scored the service as 1. The evidence showed significant shortfalls. The service did not listen to or understand people’s needs, views and wishes. Staff did not respond to people’s needs in the moment or act to minimise any discomfort, concern or distress.

Staff did not ensure that there was adequate management of risk items within the ward environment. The service did not do all that was reasonably practicable to mitigate any such risks. This placed young people at risk of harm and we were aware of incidents where young people had access to risk items.

Three young people told us that staff on observations did not intervene when young people required additional support. We saw this reflected in the number of incidents of self-harm on the ward following young people damaging property and being able to ingest screws and other items despite being on observations.

Staff on young people’s observations did not always identify and responded to changing risks to, or posed by, young people. In debriefs and lessons learned we reviewed we saw that staff did not always respond in a timely manner despite changes in a young person’s presentation which pre-empted a risk behaviour towards themselves or others. We did not see effective systems in place to ensure that restrictive interventions, such as physical restraint were used appropriately and safely to protect young people from harm. The Mental Health Act Code of Practice states that restraint must be used only as a last resort and must be necessary, proportionate and used in the least restrictive way for the shortest time possible. It must never be used as punishment, coercion or to cause pain. Three young people told us that they felt unsafe on the ward due to the use of restraint. Young people showed us bruising on their arms and legs which they said were caused during holds.

One young person told us that they had suffered hair pulling during an incident of restraint and another told us that their body had been exposed during an episode of restraint.

We received speaking up concerns from staff who have raised ongoing concerns around the use of Maybo holds. Their concern included the risk of harm to the young people and the risk to staff who had experienced assaults and injury whilst carrying out restraint. Staff also raised concerns that there were not always enough staff available to carry out restraint safely and in line with training.

A young person told us that that that they did not feel that staff were trained to support them to manage their care and treatment in relation to 2 health conditions. Staff had failed to identify that they required their inhaler whilst in a hold which had resulted in a hospital admission.

We scored the service as 1. The evidence showed significant shortfalls. The service did not care about or promote the wellbeing of their staff. They did not support or enable staff to deliver person-centred care.

Leaders recognised that there was additional work to be completed to ensure that all staff felt respected, supported and valued. Due to recent changes in leadership, there had been a period of instability for staff.

The service’s staff sickness and absence were similar to the average for the provider at 6%. However, when we spoke with 2 staff members, they told us how they had felt unsupported after being injured at work. One staff member who sustained an injury in an incident felt unable to leave to seek medical treatment due to staffing requirements on the ward. Another staff member told us how a colleague was not called by leaders to see how they felt after receiving hospital treatment only to enquire when they would be returning to work.

Staff told us they were experiencing racial abuse from some young people. Learning from incidents had been shared in relation to the this and staff were supported to inform the police. However, staff told us that this did not solve the issue as it was not trauma informed for either the young people or staff member. We saw continued incidents of ongoing racial abuse to staff from young people.

Staff appraisals were currently at 43% and staff told us that due to a change in leadership discussions around progression were now starting again with leaders.

Staff told us that whilst at work there were limited rest facilities which meant they sat in their cars during break times. Toilet facilities for staff were limited and there were queues for the toilet with 1 staff member having to return to their observations before using facilities. The service was looking at ways in which to enhance the rest areas for staff but this had not been fully considered when making changes to the existing buildings.

Staff had access to support for their own physical and emotional health needs through an occupational health service.

Staff achievements were recognised and there was an individual star award and team of the month which was run across the site.

The service had introduced additional well-being offers such as the ‘positive-tea’ which was a monthly drop-in session with psychology provided to staff. Although the service had reintroduced reflective practice not all staff were able to consistently attend due to being on clinical duties' or similar.

Leaders told us that the service had implemented wellbeing boxes on all wards offering self-care, treats and relaxation items following feedback from reflective practice and we were told that these would be regularly replenished. All of the measures had been recently implemented and so it was not clear as to how they would be embedded and the ongoing benefits to staff welfare.