Ivetsey Bank Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate.

This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

Staff did not consistently feel respected, supported, or valued. Governance processes were ineffective, and performance and risk were not well managed.

Additionally, staff did not reliably collect or use data to monitor outcomes and performance. Although some audits had been undertaken, they did not consistently demonstrate improvements. Ongoing risks remained, with recurring issues identified, particularly in relation to the recording and management of information.

The service was in breach of regulation for 17 Good Governance.

We issued a warning notice on Active Young People Limited on 24 April 2026 for failing to meet the regulation related to good governance at Ivetsey Bank Hospital.

We have not awarded this service a score for Well-led.

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

We scored the service as 1. The evidence showed significant shortfalls. The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The service had group behaviours in place, which were; ‘we will be kind and honest, we will listen learn and act and we will be fair and inclusive’ but not all staff were able to tell us about these.

Leaders did not evidence that they fully understood the challenges and the needs of staff and young people due to being a new senior leadership team.

Some staff told us that organisational leaders had been playing a significant role in the management of the hospital and had overridden clinical and hospital management decisions which they had not agreed with. They did not see a clear shared vision, strategy and culture which was based on transparency and engagement. Most staff we spoke with had not met or had limited communication with the new hospital director who had been in role for 3 weeks at the time of our inspection.

Staff did not have the opportunity to contribute to discussions about the strategy for their service, nor had they been involved in the strategy around changes to the service.

Staff said that current office space and lack of facilities had an impact on morale. Despite money being spent on developing the new wards, therapeutic areas for young people were lacking and staff had limited access to rest areas and toilets. Staff felt that their contributions to developments had not been considered. We saw that the current offices for therapy staff were of poor quality and were told that they became hot in the summer and so cold in the winter that staff were told to work from home. This indicated that the working environment did not consistently support staff wellbeing or enable them to carry out their roles effectively.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leaders did not demonstrate a strong understanding of the services they were responsible for, largely due to their limited time in post. While leaders from the wider organisation were providing interim support to the service, staff reported inconsistency in leadership approaches. This lack of consistency was seen as a barrier to delivering high-quality care, particularly regarding decisions about which members of the clinical team were involved in discussions on service development and risk management.

Staff raised concerns about a lack of continuity in leadership, reporting significant senior leadership changes over the past two years. One staff member described a historical culture of fear based on previous management approaches.

Staff told us that leaders were not always visible within the service and were not consistently approachable for either staff or young people.

Leadership development opportunities were available, and some staff were stepping up into interim leadership roles. However, staff reported that discussions about training and development opportunities were often disrupted due to leadership changes, resulting in conversations needing to be restarted and a lack of follow‑through.

There had been no staff survey completed recently which limited leaders’ ability to effectively understand staff experience, morale, and concerns or to demonstrate how staff feedback was used to drive improvement.

We scored the service as 1. The evidence showed significant shortfalls. People did not feel they could speak up and that their voice would be heard.

Family members and carers had recently been given opportunities to provide feedback on the service. Between 3 March 2026 and 18 March 2026, five surveys were completed. Overall, responses were predominantly negative, with 60% of respondents stating that they would not recommend the service.

When asked about satisfaction with communication, 80% of respondents reported that they were not satisfied. In addition, 60% felt that staff did not listen carefully to what they had to say. However, 80% of respondents reported that staff were welcoming and friendly.

The service had planned to discuss these survey results at the next clinical governance meeting. Young people’s and family feedback were set agenda items in clinical governance meetings. However, feedback from young people and carers had not been fully documented or considered in the previous 3 clinical governance meetings minutes. In the most recent meeting held in February 2025 future actions had been considered around how to include young people and carers and to provide support and gain feedback.

The organisation had freedom to speak up guardians whose details were displayed on TV screens which were in the communal areas of both buildings. The service had received 2 speaking up concerns between January and March 2026. A staff member told us that staff were reluctant to formally raise concerns due to fear of repercussions, which indicated a lack of psychological safety and confidence in internal reporting processes. CQC had received 7 concerns about the service between January and March 2026 which indicated that people did not feel able to use internal processes to report concerns.

We scored the service as 1. The evidence showed significant shortfalls. The service did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who work for them.

At the time of the inspection, there were no equality and diversity champions in place within the service. The service did not routinely undertake equality monitoring of its workforce to assess whether it was diverse in its composition or representative of the population it served. We observed that the staff group did not appear to reflect the demographic make‑up of the current group of young people.

Staff told us that incidents of racism from young people had occurred recently. Leaders had issued emails to staff stating that such behaviour was taken seriously and advising that the police should be involved where appropriate. However, staff told us that they did not feel all underlying factors contributing to the racist behaviour had been fully explored, nor that sufficient support or education had been put in place to help address and challenge young people’s behaviour in a therapeutic way.

Staff told us they were able to apply for flexible working arrangements to accommodate personal circumstances such as caring responsibilities or health needs. Managers made reasonable adjustments to support staff to carry out their roles, for example by implementing adjustments for staff who were pregnant.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders were unable to demonstrate that effective governance, assurance, and auditing systems and processes were in place. The service had not consistently assessed, monitored, or driven improvements in the quality and safety of care, including young people’s experiences. Existing systems had not been effective in identifying or mitigating risks to the health, safety, and welfare of both staff and young people.

Persistent issues within the service included a lack of specialised training for staff, ineffective staffing arrangements, limited learning from incidents, and concerns about staff culture. Although improvement work had commenced at the time of the inspection, we did not see evidence of measurable or sustained outcomes.

Staff undertook local clinical audits, where actions were identified, and staff took steps to respond. However, we saw repeated incidents relating to poor documentation and recording errors, despite these issues having been previously highlighted through audits, indicating that learning was not effectively embedded into practice.

Leaders failed to ensure that staff providing care and treatment had the appropriate qualifications, competence, skills, and experience to do so safely. This placed young people at risk of harm. We were aware of an incident in which an unqualified agency staff member worked in a nurse role despite not holding the required qualifications. The provider had taken immediate action in response to this incident, including reviewing their use of agency staff and implementing additional internal due diligence processes to ensure the competencies and qualifications of external staff working on the ward were appropriate.

Systems and processes were not effective in assessing and communicating young people’s risk. Information relating to enhanced observations was not consistently or clearly shared. This lack of effective risk communication placed young people at increased risk of harm.

There was a clear framework outlining what should be discussed during handovers, including the sharing of essential information such as learning from incidents and complaints. However, gaps in communication remained. This was evidenced through incidents such as medication errors and missed observations recorded across the wards, indicating that key information was not always effectively shared or acted upon.

Staff and clinical governance meetings were not held at a consistent or clearly defined frequency. Staff meetings across all wards had not taken place regularly, which limited opportunities for staff to raise concerns, discuss wider ward issues, or access support and guidance.

Records showed that clinical governance meetings had taken place infrequently, with meetings held in May 2025, November 2025, and February 2026. The lack of regular governance meetings limited leaders’ oversight of quality, safety, and risk, and reduced opportunities to monitor performance, share learning, and drive improvement.

Leaders within the organisation had begun to address ongoing concerns through the implementation of action plans and regular engagement with commissioners and partner organisations. However, these were recent developments within the governance structure, and the impact of the agreed actions had not been embedded.

We scored the service as 2. The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Leaders engaged effectively with external stakeholders, including commissioners, community health services, and the provider collaborative. Stakeholders confirmed that they were invited to visit the service and that the service was open in providing regular updates.

MDT meetings included external partners such as community mental health teams and commissioners. For young people placed out of area, there was consistent oversight, with regular monitoring by commissioners from their local areas.

However, there was no evidence that young people and staff had opportunities to meet with members of the provider’s senior leadership team to provide feedback. At the time of the inspection, the leadership team was exploring ways to improve communication between the service and families.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

At the time of the inspection, there were no active innovation projects underway within the service.

The service had clear strategic aims to improve crisis pathways and had invested in renovating the hospital to create an assessment and triage unit. This demonstrated a commitment to developing the service and responding to identified gaps in provision.

The unit had opened but was subsequently closed due to environmental and operational challenges, and therefore the intended improvements had not yet been realised. Staff told us that lessons had been learned from the initial opening, and leaders were continuing to review the model to ensure it could operate safely and effectively before reopening

The service was completing internal audits and had a quality improvement project plan in place, focused on improving supportive observations and staff management of risk during enhanced observations. However, this work was at an early stage and had not yet resulted in demonstrable outcomes.

None of the wards were participating in accreditation schemes relevant to the service at the time of inspection. Leaders told us that they intended to apply for the Quality Network for In Patient Child and Adolescent Mental Health Services. (QNIC) later in the year, but this had not yet been progressed.