Ivetsey Bank Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent. Staff developed individual care plans which were reviewed but were not consistently updated and lacked the young people’s voice. Staff provided a range of treatment and care for young people however this was not always delivered in line with national guidance and best practice. Staff did not receive regular supervision, which prevented them from being able to discuss areas for improvement.

The service was in breach of Regulation 12: Safe Care and Treatment and Regulation 18: Staffing.

We have not awarded this service a score for Effective.

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

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

We reviewed 14 young people’s care records which were stored electronically. Staff completed a mental health assessment of the young people on admission. Staff also assessed young people’s physical health needs and completed physical examinations on admission.

However, staff were not always updating young people’s care plans consistently across all wards. Staff did not record young people’s involvement in care plans, and it was unclear if care plans had been shared with young people on Thorneycroft and Hartley wards. When speaking with young people while 8 out of 11 asked had heard of care plans, only 1 young person said they had seen a care plan and only 3 young people had been consulted as part of their care planning.

Risk assessments and care plans around the use of restraint were not evident in all young people’s files. It was noted on site that physical health conditions had not been considered as part of safety plans and young people’s voices had not been included in how best to support them if they became dysregulated and needed to be placed in holds. This was raised with the provider who reviewed all care plans and was able to show that they had implemented a specific physical health care plan for 2 young people whose physical health could have been impacted by the use of holds.

Observations were not always clearly recorded in care records with dates and changes to levels being mixed, which meant that it was unclear what level the young people were on. This was fed back whilst on site in March 2026 and when we returned in April 2026, we noted an improvement in how they were being recorded. We did however note that in 1 care record, the risk assessment had been updated following an incident but despite a change in observation levels, in practice it remained at the previously prescribed level.

On Hartley and Thorneycroft ward we saw that staff discussed young people’s care and treatment regularly and updated care records following incidents and multidisciplinary reviews. However, incident updates only listed the date and incident record number and did not always reflected why risk had increased or potential future triggers.

On Wedgwood ward we saw that staff developed care plans that met young people’s needs which were comprehensive, person-centred and holistic. We saw that staff discussed young people’s care and treatment regularly and updated care records following incidents and multidisciplinary reviews.

We scored the service as 1. The evidence showed significant shortfalls. The service did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Managers took part in clinical audits, benchmarking and quality improvement initiatives. They held rapid reviews and shared lessons learnt to ensure that information was shared with staff. However, we saw a theme of repeated incidents of ingestions and concerns around the appropriate use of holds which suggested that improvements were not being made. Staff continued to report they did not feel safe or confident to support young people when using Maybo holds. Two staff members detailed how they were concerned about the harm that young people were coming to due to staff being unable to effectively implement appropriate holds.

The service had not ensured that staff received appropriate supervision and support. As of 16 March 2026, supervision figures for all staff including clinical and managerial was 55%.

We saw through observation and incidents that staff did not always have the right skills and knowledge to meet the needs of the patient group. Staff on one to one observations did not engage with young people and holds were implemented following a risk behaviour when steps had not been taken to prevent it from happening.

There was a regular handover meeting where staff were informed of any updates from the previous shift. However, on Hartley and Thorneycroft we did not see evidence that staff were invited to regular staff meetings in the previous 3 months. On Wedgwood there had been a qualified staff meeting held in February with plans to hold these quarterly. The previous staff meeting on Wedgwood had been held in September 2025.

Staff provided a range of care and treatment suitable for the young people in the service. The team included a full range of specialists required to meet the needs of young people. As well as doctors and nurses, there was a multi-disciplinary staff including teachers, occupational therapists, clinical psychologists, dietician and a family therapist.

Young people had access to physical healthcare, including access to specialists when needed. However, we saw that 1 young person had to buy their own medical equipment due to a shortage of supplies with the designated supplier and a lack of joined up working with other specialists external to the service.

There was an occupational therapy programme in place which offered a variety of recovery-based activities for young people. These included activities that focused on daily living skills, healthy lifestyles, and social skills. Young people on Wedgwood ward praised the input from the occupational therapist and enjoyed the activities they were involved with.

Mental Health Act

Staff had completed their mandatory Mental Health Act awareness training. As of 16 March 2026, the training for compliance was; Mental Health Act Awareness Certification 100%, Mental Health Act level 1 Certification 94%, Mental Health Act level 2 Certification 100% and ELFH Mental Health Support Worker Certificate (CAMHS In Patient) 99%.

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff were aware of their designated Mental Health Act administrator, and the necessary policies and procedures were in place.

Young people had access to independent mental health advocacy. Care plans recorded that young people had their rights under the Mental Health Act explained.

Staff requested an opinion from a second opinion appointed doctor when necessary.

Staff ensured that young people were able to take Section 17 leave (permission to leave the hospital) when it had been authorised. We saw that staff documented this authorisation clearly. However, we heard from 2 young people that leave was sometimes cancelled if there wasn’t a staff member who was able to drive.

Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits. However, copies of young people’s detention papers were not always stored appropriately, ensuring they were accessible to all staff who required them. In 1 care record we were unable to find the Approved Mental Health Professional (AMHP) report and in another 2 records it was not always easy to identify which section someone was on. This was fed back to the service explained that they would look into the issue but did find that not all paperwork was provided when young people were admitted.

The service did not display a notice to tell informal young people that they could leave the ward freely.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

Staff held regular multidisciplinary meetings where young people’s needs were discussed. Staff also shared information about young people at handover meetings at the end of every shift. However, the service noted that whilst handovers were effective, key information could sometimes be missed. For example, if staff had not been able to attend handovers and this increased the risk of observations being missed. The service were taking actions to mitigate this including having a 1-page profile on young people’s risks and care needs.

Electronic systems evidenced that risk information was not easily accessible and risk and observation levels were not always recorded in electronic care records. Two staff undertaking observations were not aware of the 1-page young person’s profile that outlined further information in relation to their needs and identified triggers and risk.

We saw that the observation levels for young people noted on the whiteboard in the Hartley ward nursing office were incorrect. One young person admitted the previous week did not have their information entered on the whiteboard. This meant that staff had limited insight into their observation levels to manage risks. We saw evidence that young people had come to harm during times when observations had been missed.

The teams had working relationships with external specialist services and General Practitioners (GPs), providing additional clinical support where required. Staff told us that there was a GP who visited every Wednesday.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported young people to live healthier lives by promoting a non‑smoking and non‑vaping site. The service actively supported smoking cessation by helping young people access appropriate aids, including inhalators, nicotine patches, and lozenges.

Staff supported young people to engage with physical activity and young people had access to a personal trainer who visited the service twice a week and tailored programmes to young people’s specific needs.

Young people could also use outside space during the day with the cutoff point being ten o’clock to promote sleep hygiene. Sleep hygiene was also promoted by young people being asked to hand in phones after 10 o’clock. However, we observed that on Hartley and Thorneycroft blinds had been removed from the windows due to safety concerns. One young person told us that they found it difficult to sleep as they needed it to be dark.

A healthy diet was provided across the wards and if any dietary needs were identified staff referred to the dietician who would then work with the young people. The dietician’s involvement was greater on Wedgwood, but we saw positive interactions across all wards.

Half the young people we spoke with stated that the food was good whilst others told us they did not think it was healthy. We observed that meals were tailored to meet young people’s choices.

We scored the service as 2. The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Staff used recognised rating scales to assess and record severity and outcomes, including the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) and the Children’s Global Assessment Scale (CGAS). We saw that outcome data was routinely discussed within clinical governance meetings. Minutes from the clinical governance meeting held on 31 January 2026 showed that a majority of young people on Hartley and Wedgwood wards had positive outcomes.

However, across all 3 wards there were several records where the most recent score had been missed. In addition, outcomes for Thorneycroft ward showed notable gaps, with over half of the scores either missed, missing both baseline and follow-up scores, or showing a decrease. This meant that the data was not accurate and the service could not be assured that outcomes for young people were positive and consistent.

An occupational therapist told us they used the Model of Human Occupation (MOHO) to assess young people’ needs. This included use of the Child Occupational Self‑Assessment (COSA) to explore areas such as leisure, self‑care, and productivity. Staff used this information, alongside functional skills assessments for example, cooking skills to inform and develop individualised care plans.

We scored the service as 2. The evidence showed some shortfalls. The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Staff took steps to enable young people to make their own decisions. For young people who might have impaired mental capacity, staff sometimes assessed capacity to consent, and this was done on a decision-specific basis regarding significant decisions. However, capacity assessments were not consistently completed and often held on the physical health electronic recording system and not the young person’s care file, so it was not easy to quickly access assessments by all staff.

It was noted on the provider’s own Mental Capacity Act/DoLS / Adults with Incapacity Inspection Report that the hospital scored a 79% for compliance with 3 repeat key findings. It was recorded that doctors had a good understanding of when capacity needed to be assessed but they would need to be reminded to ensure these were completed regularly.

Care records contained young people’s wishes around family contact and preferences in relation to the form in which medication was given.

When young people lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.