Ivetsey Bank Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

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

This meant people’s needs were not always met. The service did not always ensure young people were at the centre of their care and treatment choices or decisions, and did not agree, in partnership with them, how to respond to any relevant changes in their needs. The design, layout, and furnishings of the ward did not always support young people’s treatment, privacy and dignity.

The service was in breach of Regulation 9: Person Centered Care.

We have not awarded this service a score for Responsive.

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

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Staff did not always provide personalised or responsive support when young people were experiencing distress. Four young people told us that staff were not responsive and did not show sufficient care and empathy following incidents.

We reviewed 14 care plans during the inspection. These included young people’ risks and clinical needs, and all included crisis and safety planning. However, care plans were written by staff and showed limited evidence of involvement from young people or carers. They were predominantly clinically focused and did not consistently reflect young people’s views, preferences, or individual recovery goals.

Young people had opportunities to provide feedback through community meetings. We saw that young people on Wedgwood had been involved in discussions about improvements to the ward environment, including how they would like the ward to look. In addition, a young people’s council meeting had taken place in September 2025, during which young people made a number of suggestions regarding activities and service improvements. However, we did not see evidence that these suggestions had been implemented consistently across all wards or that there were plans for further young people’s council meetings.

The service was working towards integrating co‑production. Meetings were beginning to be held to promote young people’s involvement and ensure that young people’s voice was increasingly included across the service. However, this work was at an early stage and had not yet been embedded across all areas.

We scored the service as 2. The evidence showed some shortfalls. There were some shortfalls in how the service understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

Staff ensured that young people had access to education across all wards. Staff told us that uptake of education on Hartley and Thorneycroft was lower compared to Wedgwood, where young people were generally more willing to engage. Staff also reported that young people were sometimes removed from lessons to attend therapy sessions, which could disrupt learning and, at times, result in lessons being unable to continue if only 1 young person remained.

There was no dedicated education space on Wedgwood. Education was delivered within the ward lounge, which meant young people did not have access to a social space during periods when education was taking place. This also meant that opportunity for study in an educational environment was limited.

We saw that staff supported young people to maintain contact with their families and carers, and young people had access to their own mobile phones. Young people and family members spoke positively about the work of the family therapist and occupational therapists.

One young person had been supported to access their chosen place of worship within the community. Although this young person explained that a doctor had been disrespectful to their spiritual views by making light of their requests to attend different places of worship.

We scored the service as 1. The evidence showed significant shortfalls. The service did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service had not always made notifications to external bodies as needed. Internal audit data showed incidents were not consistently shared with partners. The service had not submitted notifications to the CQC in accordance with the requirements of their registration for all incidents. When we raised this with the provider it was rectified immediately with all relevant information being shared.

Young people could access information on treatment, local services, their rights and how to complain. Information was displayed on noticeboards throughout the wards however was not consistent and some needed to be updated.

MDTs were used to ensure that other professionals were updated on the young people’s progress, and we saw that multiple agencies attended meetings both in person and online. External partners such as commissioners were happy with the level of information sharing and noted that the service were open about incidents occurring on the wards.

We scored the service as 2. The evidence showed some shortfalls. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. However, they did not always involve people in decisions about their care or tell them what had changed as a result of them raising concerns.

The service had a complaints policy in place. The policy provided detailed information on how to report a complaint and what to expect during the complaints process.

The service had received a total of 12 formal complaints between 18 September 2025 to 18 March 2026, 1 of which was withdrawn with 58.3% being upheld. The most recorded category for complaints was attitude and behaviour of staff.

Some staff within the service promoted a culture in which people using the service felt empowered to give their views; however, this was not consistent across all wards. Young people and family members on Wedgwood Ward reported that they felt listened to and concerns acted upon. In contrast, 2 young people and one family member from Thorneycroft Ward did not feel empowered to raise concerns.

A family member told us that they had been reluctant to raise complaints with the hospital as they had found it more effective to try to work with them to address concerns. However, when they did raise concerns with the service, they did not get an adequate response. For example, they were told that they would hear back from leaders about concerns raised but despite assurances given they were never emailed as promised. Another family member stated that they had raised a complaint and felt that they had been listened to and the issue was resolved.

Young people told us that they knew how to complain, and we saw that where young people had complained about bruising during holds it had been recorded and upheld fully. However, this had not prevented repeated incidents of this nature.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

Staff told us that they could meet the needs of young people with mobility issues and this was not currently an issue on the wards. It had been noted that wheelchair access to Wedgwood was limited and mitigating actions had been taken to support with this.

There was adequate medical cover in place during both the day and night, and a doctor was able to attend the ward promptly in an emergency. However, we saw evidence of delays in 2 incidents where young people required transfer to an acute hospital following an incident. These delays were due to the time taken to arrange secure transport.

The service told us that there had been 14 delayed discharges from the wards in the last 6 months. These delays were attributed to external system pressures outside of the hospital’s control. The provider had raised these concerns with partner agencies to highlight the impact that delayed discharges were having on young people. Staff planned for young people’s discharge, including good liaison with external partners.

We scored the service as 2. The evidence showed some shortfalls. Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Staff were trained in equality and diversity with 96% having completed training.

Although the provider had undertaken equality impact assessments in relation to the use of long‑term segregation (LTS) and the reconfiguration of wards, with the aim of ensuring that vulnerable people and those with protected characteristics were not placed at a disadvantage. However, the assessment for LTS did not adequately consider the impact of converting a female-only corridor into LTS and the male corridor in to mixed-sex accommodation. This meant that the potential effect of this change on other young people on the ward, including the impact on young people with a history of trauma, access to gender‑specific bathroom facilities was not considered.

We did not see evidence that equality impact assessments had been completed for other policies and procedures currently in place, which limited assurance that equality considerations were consistently embedded across the service.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff ensured that all relevant healthcare professionals and appropriate external bodies were involved in planning young people’s care and treatment. A young person who was due for discharge told us they felt well prepared for what to expect following discharge and reported that they had been actively involved in planning their ongoing care.

Young people on Wedgwood similarly shared that they felt well prepared for discharge and that they had been involved in the planning process.

Young people’s records demonstrated that discharge planning was taking place and evidenced young people’s involvement in meetings with the wider multidisciplinary team (MDT). However, documentation did not consistently capture the young people’s voice in sufficient detail.

Staff supported young people to access post‑discharge care and worked collaboratively with partner services, including community mental health teams, to ensure young people’s needs were met and continuity of care was maintained when transitioning from hospital to community services or other in-patient facilities. Transition planning was done in a person-centred way and the hospital started planning in advance of a young person’s 18th birthday to ensure that they were fully involved in the transition.