Ivetsey Bank Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question as good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. Staff did not concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect. The service did not work well with people to understand and manage risks. Lessons were not learnt to continually identify and embed good practice. Medicines were not always managed in line with the providers own policies.

The service was in breach of Regulation 9: Person Centered Care, 12: Safe Care and Treatment and 15 Premises and Equipment.

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

We have not awarded this service a score for Safe.

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

We scored the service as 1. The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Incident records between January 2025 and January 2026 showed a total of 4 incidents resulting in major injury or major ill health to young people, a further 78 incidents involved moderate injury or young people requiring hospital treatment. There were 954 minor injuries requiring first aid. The service recorded 4,164 incidents where no harm or injury occurred and 58 near misses.

Staff knew how to report incidents and these were investigated by the service and outcomes shared with staff. There were systems and processes in place for the sharing of learning from incidents. Staff we spoke with were aware of some lessons learned from recent incidents and could provide details of learning.

However, due to repeated incident types, we were concerned that learning was not embedded. For example, although lessons learned were shared, we saw repeated incidents of self-harm where young people had ingested items and bruising following restraint. Two young people told us that they experienced bruising and pain following holds. One young person told us that their hair had been pulled during staff placing them in restrictive hold. We saw evidence in care notes and notifications received from the provided that these incidents had continued despite the service putting in additional measures to ensure the safe delivery of restrictive holds.

Staff and young people did not always have access to de-briefs following incidents. Two staff members told us that they did not have debriefs after an incident unless a complaint had been received from a young person. One staff member raised concerns that there was ongoing racial abuse from young people on Hartley and Thorneycroft and that a member of staff had been harmed by a young person. We saw that these concerns had been taken seriously by leaders and some steps taken to address concerns, but support staff raised that this behaviour continued.

Three young people told us that they did not have a debrief after every incident. We did not see evidence of debriefs taking place in young people’s care notes on Thorneycroft and Hartley wards.

We saw evidence that the service did not always take action when concerns were raised, to improve safety. Three young people told us that they did not feel listened to and that they continued to have access to risk items such as staples from furniture and screws despite previously having raised these concerns with staff.

We observed accessible risk items during our visits; such as peeling veneer on bathroom doors and broken furniture despite having fed back to the service about environmental risks on our previous visit.

Staff understood the duty of candour. They were open and transparent and gave young people and families a full explanation if and when things went wrong.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes did not always ensure that all essential information about young people was received to determine if the young people’s needs could safely be met. Staff told us about a recent admission of a young person who required specific physical healthcare support. Staff had raised concerns that they would need additional training prior to accepting the admission to enable them to meet the young person’s physical health needs safely. Specific training such as diabetes management was not recorded as a training programme that had been offered to staff since this young person was admitted. One staff member described attending an initial assessment and being surprised to find that secure transport had already been arranged to bring the young person to the hospital, despite these concerns still being outstanding. As a result of this admission, there were 2 reported incidents and a number of concerns related to the management of the young person’s physical health needs.

Staff did not fully involve all the necessary healthcare professionals to ensure young people had continuity of safe care. There was an incident reported to CQC in which a young person had been granted Section 17 leave on the basis that the local community team would provide ongoing support. However, this arrangement did not adequately mitigate the identified risks. On the morning leave was due to commence, the community consultant advised that they would be unable to provide the agreed support. This was despite prior involvement from the community case manager in pre-leave discussions. The support plan had not been fully confirmed or secured before the leave began. As a result of this the young person had to access a local emergency department due to a decline in their mental health and an increase in their risk whilst on leave.

The service did not always communicate all required information clearly to staff. One young person was able to self harm following missed observations as a result of inadequate communication to the staff group at the point of their admission.

However, the service did work closely with the local provider collaborative to discuss potential referrals. Partners praised them for being willing to take on some of the more complex cases which played a critical role in supporting the wider system by enabling the placement of young people closer to home, reducing the need for out‑of‑area placements. The service was also proactive in highlighting where young people were ready for discharge and were being delayed due to external resource issues ensuring that they were consistently advocating for the young peoples.

One young person we spoke to stated that they had been involved in their discharge planning. They felt that their care programme approach (CPA) and staff had prepared them well for discharge. Care plans outlined discharge planning for young people which had included the young person, family and external professionals.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Staff were trained in safeguarding and demonstrated a clear understanding of how to raise safeguarding alerts, doing so appropriately when required. Both the local authority and the provider collaborative confirmed that the provider appropriately shared safeguarding concerns with them and made referrals to the local authority when necessary.

Training records showed high completion rates for mandatory safeguarding training, with 91% of staff completing Safeguarding Adults (England) certification, 92% completing Safeguarding Children certification, and 100% completion for Safeguarding Level 4 training. Safeguarding Level 3 face to face (Adults & Child) Certification was 92% completion.

Although training compliance was good, this did not translate into good practice in keeping young people safe from harm. The restraint practices in place at the service were not always safe and young people had been placed at risk of harm. Staff had used a significant amount of restrictive practices.

During the period of December 2025 to February 2026 the provider had recorded 669 episodes of physical restraint across all wards. The service reported 13 incidents that involved a prone position during the use of restraint between November 2025 to March 2026. However, in all incidents young people had put themselves in the prone position and holds were released when this occurred.

The service had moved from using PRICE (Protecting Rights In a Caring Environment) holds to Maybo holds in early 2025. We saw that despite delivering Maybo training and implementing additional measures such as CCTV reviews of incidents, refresher training and shared learning, young people were still experiencing pain and bruising following the use of Maybo holds. This was evidenced in body maps completed following incidents held in care files and the feedback from 4 young people.

CCTV we reviewed did not show that staff had offered therapeutic interventions or attempted de-escalation before restraining young people. This meant that restraint was not always carried out in line with national guidance.

During our assessment, we reviewed 7 incidents across Thorneycroft and Hartley wards and 3 CCTV recordings. We identified concerns relating to staff responses and the use of physical interventions. These concerns included inappropriate holds and delays in staff response. A staff member reviewing these incidents alongside us acknowledged that further investigation was needed and immediate action was taken. The service had implemented enhanced audits and checks relating to incident reporting and CCTV, while ensuring that internal human resources (HR) processes were being followed in relation to the staff involved.

Between 2 February and 2 March 2026, CCTV coverage was unavailable across both wards. As a result, incidents occurring during this period could not be reviewed, limiting the ability for staff to identify poor practice or take away learning points. This risk was recognised and recorded on the risk register at the time.

We received speaking up concerns from staff both prior to and since our site visit who raised ongoing concerns around the use of Maybo holds. These included the risk of harm to young people and the risk to staff who had experienced assaults and injury whilst carrying out restraint. Concerns related to staff availability and response time. One incident on CCTV showed no staff responding despite alarms being activated putting young people and staff at risk of harm. This incident occurred after additional staffing measures had been implemented, following concerns raised by the provider over the Christmas period when the additional ward was open and staffing issues had been identified. At the time of the incident, it was recorded that there were sufficient staff present on the ward.

Between December 2025 and February 2026, there were 83 episodes of intramuscular (IM) medication administered across all 3 wards; 68 of which were rapid tranquilisation. We did not see evidence of consistent debriefs or physical health monitoring following these interventions. This placed young people at risk of harm. National institute for Health and Care Excellence guidance states that: “After rapid tranquillisation, monitor side effects and the service user's pulse, blood pressure, respiratory rate, temperature, level of hydration and level of consciousness at least every hour until there are no further concerns about their physical health status.”

Upon entering the wards, lists of blanket restrictions were observed, including items such as pens, plastic bags, and electrical equipment. Further restrictions were applied on an individual basis, with decisions considered and discussed within the multi-disciplinary team (MDT) for each young person.

Mental Capacity Act

Staff kept up to date with training in the Mental Capacity Act, which was mandatory for all care staff. At the time of our inspection, training compliance was at 90.7%

Nursing staff had a good understanding of the Mental Capacity Act and knew where to get advice including on deprivation of liberty safeguards. The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act.

Staff took steps to enable young people to make their own decisions taking into account Gillick competence (Gillick competence is a legal standard used to determine whether a child under 16 has the maturity and understanding to consent to their own medical treatment without parental permission). We saw that capacity assessments were completed in line with the Mental Capacity Act, which were time and decision specific however these were not consistently updated or recorded in all young people’s files.

Leaders recognised that there were additional training needs around the Mental Capacity Act and how and when to complete assessments. One staff member we spoke with wished to attend additional training so that they would be able to complete audits in this area but had at the time of the inspection not yet met with the new hospital director to discuss training opportunities.

No applications for Deprivation of Liberty Safeguards (DoLS) had been submitted within the previous 12 months. Such applications are required when a person lacks the mental capacity to make decisions about their care and may need legal safeguards to ensure their rights are protected. The provider had a policy on the Mental Capacity Act, including DoLS. Staff were familiar with this policy and knew how to access it.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 14 care records which showed that young people and their carers were not consistently involved in developing risk management plans or care plans, including in relation to the use of restraint. The plans had not been written collaboratively with young people, nor did they demonstrate consideration of the young person’s previous trauma.

Young people’s physical health needs were not always assessed or incorporated into planning around the use of restraint. We found direct evidence of an incident where restraint had impacted a young person’s physical health which resulted in them requiring treatment in hospital.

Staff enabled young people to give feedback on the service they received but this feedback did not always result in changes being made to the service. Young people had raised concerns around environmental issues such as peeling wood on bathroom doors, but changes had not been implemented.

Each ward held a weekly community meeting. We reviewed 5 sets of community meeting notes and 1 meeting record in relation to the refurbishments on Wedgwood ward. One meeting on Thorneycroft ward had no young people attend but all others saw at least 3 young people in attendance. In 1 community meeting young people were reminded that there was a poster near the nurse station door with a QR code to scan and complete a young people’s survey although we did not see the result of this survey. Young people were asked about safeguarding and Maybo holds and restrictions and complaints in community meetings. In 1 meeting we saw that a young person was recorded as saying that they had a safeguarding concern and that they felt it had been taken seriously.

Staff ensured that young people could access advocacy and young people were made aware of the availability of advocates in community meetings.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider was completing both weekly and quarterly environment walk arounds to identify areas of the wards which required repairing or improvement, however they did not lead to safety improvements and environmental changes. Hartley and Thorneycroft communal ward areas were not clean, well maintained, well-furnished or fit for their therapeutic purpose. Wallpaper had been removed from the communal areas walls on Hartley ward leaving bare plaster. Due to damage caused by young people on the ward there were a number of areas that had been boarded up including bathroom windows and various places on walls and skirting boards.

Young people had drawn on the walls on both Hartley and Thorneycroft ward in communal areas and bedrooms. One young person’s bedroom on Thorneycroft was filled with rubbish and they had chosen to sleep on the floor on a mattress.

A fire door at the end of a corridor on Hartley ward was boarded up and inaccessible. Illuminated fire exit signs had also been boarded over so fire exits were not clearly labelled.

We had significant concerns about fire safety at the service we took immediate action to share these risks with the fire service. Staff had reported the issues with the broken fire doors, however, were advised there was a lead time of 3-4 weeks for a replacement door to become available. It was also recorded on the fire door survey and noted that this was part of a larger action across estates.

Staff received Fire Evacuation and Safety Certification however there was a low compliance rate which was 60% at the time of the inspection.

We observed risk items within the ward environment which placed young people at risk of harm. We saw reported incidents where young people had accessed such items for self-harm. Young people on Thorneycroft were able to show us furniture where they had been able to access staples to self-harm.

We observed bathroom door veneers on Hartley and Thorneycroft wards were peeling and a young person on Thorneycroft was able to pull some of the wood off and stated that they could use this to self-harm. We also observed two broken plastic chairs with sharp edgings in the art room on Thorneycroft and screws throughout the wards which were accessible. The provider did assure us that screws used to fit the boards were tamper proof and suitable for purpose.

We saw food was left out of the fridge on Thorneycroft for young people to eat several hours after mealtimes. We saw a bowl with a layer of mould had been left in a plate warmer. Young people shared photographs with us of mouldy food they had been served and reported milk being ‘sour’ from the fridge not being at the correct temperature. We did not see evidence that the communal fridge temperatures were routinely checked.

We noted that on Thorneycroft ward they were not following guidance for mixed sex accommodation. One of the corridors on the ward had recently been used for long term segregation for a young person. This had resulted in both male and female young people being accommodated on one corridor. There was no clear evidence that that room placement had been planned to maintain appropriate separation.

Arrangements to protect young people’s privacy, dignity and safety were not robust or consistently understood. We were told that one bathroom on this corridor was out of use for some young people due to the viewing panel not working but when asked not all staff were clear on which young people this applied to.

The long-term segregation (LTS) room on Hartley Ward had been damaged, resulting in the CCTV in this area becoming non-functional. During our initial site visit, we observed that the LTS observation room was being used to store broken furniture and other items, rendering it inaccessible for its intended purpose. Additionally, the storeroom connected to the LTS, which was used to store young people’s belongings, was found to be cluttered and disorganised.

Both concerns were fed back to staff, and we noted improvements in these areas by the end of the inspection period. During this time, the extra care area (ECA), located off the ward, was also limited in how it could be used due to environmental damage, including broken doors. This created a risk by limiting staff access to the area in the event of an emergency. This risk had been identified and was recorded on the risk register at the time.

All clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Ward layouts allowed staff to observe all parts of the ward. Potential ligature anchor points were identified, and staff had mitigated the risks adequately.

Wedgwood had reopened in December 2025. During our visit, we found no concerns with the environment. The ward was clean, bright and appropriately maintained, and the layout met the needs of young people. There had been some initial issues with toilets not flushing in 2 bedrooms, but this had been rectified and we saw no ongoing concerns with this ward during the onsite assessment.

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Managers had calculated the number and grade of nurses and healthcare assistants required and shared with us their staffing requirements for the 3 wards which were open at the time of our inspection. The number of nurses and healthcare assistants did not always match this number on multiple shifts between 22 February and 22 March 2026.

At the time of the inspection, vacancy rates for qualified staff stood at 7%, while vacancy rates for unqualified staff were significantly higher at 25%. Staff sickness levels were recorded at 6%, and the service had an overall staff turnover rate of 9%.

The ward manager could adjust staffing levels daily to take account of young people’s needs and observation levels. When necessary, managers used agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, staff were able to complete a supernumerary shift prior to starting at the hospital.

Between 19 February and 19 March 2026, bank and agency staff covered a total of 608 shifts. During the same 4 week period, permanent staff covered 992 shifts. The service had committed to reducing the use of agency staff by transitioning to internal bank staff. This would support greater consistency, ensuring staff received organisational induction and were familiar with local policies and procedures.

One ward manager explained that due to the high levels of observations there hadn’t been a shift where agency staff had not been used. They stated that due to some staff being unable to engage in holds for medical reasons this could put pressure on other staff reducing the time they had for breaks from observations. One staff member told us that the service had to previously pay staff for working through their breaks, but things had started to improve.

At the time of our inspection the assessment and triage ward was not open so staff from this ward were available to support the other wards. Staff stated that they were not sure however, how staffing would be affected after this ward reopened. There had been reported issues with staffing in December when all 4 wards were open.

Although a qualified nurse was always present on all of the wards, a ward manager shared that there was not always 1 experienced permanent nurse on the ward. Although some agency nurses were experienced, they were not there regularly. Rotas showed that there was not always a permanent nurse on all shifts.

Despite sufficient staffing levels, there was a lack of consistent recording in care plans to demonstrate that young people were receiving regular one‑to‑one time with their named nurse on Hartley and Thorneycroft wards. On Hartley ward it had been recognised that this was an area for improvement. The ward manager stated this was due to one to one’s not being recorded properly and they had seen them taking place. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff were not always up to date with appropriate mandatory training. All e‑learning training courses had completion rates of 81% or above. However, some face‑to‑face training courses showed lower completion rates, including Positive Behaviour Support (PBS) for direct support staff at 57%, Epilepsy Theory at 53%, and Mental Health Act training at 75%.

Despite staff receiving training in Maybo holds to meet the complex needs of the young people, staff and young people reported concerns with the use of these holds. Maybo training feedback noted that 13 out of 28 staff who attended the training needed further refresher training for reasons including; the use of unsafe holds, using too much force and to build confidence. Staff continued to report they did not feel safe or confident to support young people by providing feedback after our inspection.

We scored the service as 1. The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service had an infection prevention and control lead who had undertaken audits across all wards. Hand hygiene and PPE inspection reports completed in December 2025, January 2026 and February 2026 noted that the hand wash basin on Hartley ward had shelves above which meant that staff had to bend to access the sink. This was an ongoing issue across the 3 months audited and had not been rectified. It was also noted that staff were not consistently bare beneath the elbows in the first 2 audits with improvements seen in February 2026. It was noted in the report and observed that there were missing soap dispensers in some young people’s bathrooms on Hartley due to young people removing them from the wall. Anti-ligature dispensers had been ordered but not installed at the time of our inspection.

Although the cleaning records were up to date, not all ward areas were cleaned effectively. Bathrooms on both Thorneycroft and Hartley had black mould and smelt of damp. Some corridors had spilled drinks down the walls and skirting boards on both wards. The dining room on Thorneycroft had dirt and grime around the food warmer and water dispenser.

The service completed and shared their monthly infection prevention and control inspection report. The report noted that the clinic rooms had items stored on the top of the cabinets which needed to be removed. There was poor storage in the Wedgwood clinic, and they were awaiting further storage to be built to accommodate medical equipment. It also recognised that there needed to be areas such as cleaning of the high touch surfaces that needed to be discussed with the new head of housekeeping.

We observed Wedgwood ward was clean with new furniture and fixtures. We saw evidence of cleaning staff on the ward. However, one family member did raise that their relatives’ socks/feet would be black from dirt if they did not have footwear on, but they felt that generally the cleanliness on the ward was good.

We scored the service as 1. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

We found limited monitoring and management of medicines, particularly around stock control and record keeping. Stock levels shown on the electronic medicines administration record (eMAR) system did not match the medicines held on the ward. When nurses recorded medicines as given, the system often showed minus stock levels, which meant that stock was not being checked or updated properly. There was no clear or up-to-date list showing what medicines were kept on the ward or what and how much stock was available. Staff were unable to show evidence of regular stock checks to support the safe ordering and monitoring of medicines. Sometimes medicine was not always available when needed during a medicines round. For example, iron medicine was out of stock and staff had to collect it from another ward on the day.

Diabetes was not always effectively managed and monitored. For example, blood sugar monitoring had been missed which resulted in medication given in the incorrect dosage. This exposed the young people to risk of serious harm.

The eMAR system also did not always allow medicines to be recorded accurately. For example, there was no option to record a particular dose of a medicine as the system did not allow the two tablet strengths to be entered separately. Staff told us they would select the closest dose on the eMAR system instead of the exact prescribed dose, even though the prescribed dose was administered. This meant there was a risk that records did not clearly show what young people had been given. We found that young people’s own medicines were stored together with ward stock. This was against their medicines management policy.

Some opened liquid medicines did not have an expiry date written on them, even though they could only be used for 2 months after opening. This issue had already been identified in an audit completed in February 2026 but was still found during this inspection.

Temperature checks for medicines fridges were not managed properly. Some fridge temperatures were recorded below the safe range, and no action had been taken. The missing expiry dates and temperature checks were picked up in previous audits; however, it was unclear what learning or system improvements had been implemented to ensure future temperature excursions would be promptly escalated and managed.

Records for physical health checks following rapid tranquillisation via intramuscular route were not always clear. Although it was recorded that a young person refused checks, it was documented the young person was alert and breathing but was not clear about what alternative actions were taken or whether concerns were escalated. This meant records did not always show that young people were monitored safely in line with policy.

Pharmacy staff visited the ward once a week and would order medicines as needed. However, staff were unclear about the process for identifying what stock was required or how this was monitored between visits.