Riverdale Grange Clinic

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 previous inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant people were safe and protected from avoidable harm.

All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. Improvements had been made since the previous inspection in completing patient medication records. The service managed patient safety incidents well. However, mandatory fire training compliance rates were low. In addition, patients and staff told us that the routine use of video consultations with doctors could be difficult.

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.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

In the 12 months prior to our inspection, the adult ward recorded 14 serious incidents. Over the same period, the young people’s ward recorded 17 serious incidents.

The majority of serious incidents recorded related to patient self-harm incidents. A smaller number of serious incidents included attempts to abscond, and admission to general hospital due to deterioration of physical health. There was 1 reported serious incident of abusiveness towards staff in the 12 months prior to inspection. This incident was followed up in line with hospital policy and did not require further actions to be taken.

Staff reported all incidents they should report, and staff told us they felt supported to use the hospital’s reporting systems. We observed a patient safety/handover meeting during which a serious incident was reported, discussed, and allocated to a senior member of staff for follow up.

Staff received feedback from investigation of incidents, both internal and external to the service and lessons learned were shared with external organisations and stakeholders.

Staff told us they shared and discussed learning from serious incidents and described a no‑blame culture within the team. They said managers held debrief meetings after each incident and provided feedback from incident investigations during staff meetings. Staff told us improvements were made from lessons learned during investigations.

Staff described the processes they followed after incidents had occurred. They explained that SWARM meetings took place after serious incidents. SWARM meetings are held as soon as possible after an incident to review what happened, why it happened, and what action was needed to reduce risk. This approach helped staff share insights and reflections promptly, which supported timely learning.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider moved to the Patient Safety Incident Response Framework (PSIRF) in May 2025. PSIRF is the national approach to developing effective systems for responding to patient safety incidents to support learning and improvement. The provider worked with other independent hospitals and local NHS services to strengthen its’ incident response systems and processes.

The service’s referral and admission processes ensured staff received the essential information needed to decide whether they could safely meet a person’s needs. We observed a multi‑disciplinary bed management meeting where staff reviewed referrals, identified priority needs, and arranged pre‑admission assessments. Referrals for new admissions were reviewed in line with prioritisation and the current waiting list, and staff also considered discharge plans when planning admission flow, and to support safe and well‑coordinated transitions.

Staff worked effectively together and with other health and social care professionals to support safe pathways and smooth transitions for people using the service. Staff told us they had positive working relationships with local hospitals. For example, when patients required transfer for physical health or emergency treatment needs. When patients needed to transfer to a general hospital for physical health care, the service provided staff for enhanced observations and to support them. Staff escorted the patient during the transfer and continued to offer support in the general hospital setting.

The provider used an electronic system to store all care records, plans, notes, risk assessments and formulations. At the time of the inspection the service was conducting a quality improvement project looking to individualise care planning, and to ensure personal behaviour plans were integrated throughout to ensure consistency of care.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff had received mandatory training in adult and child safeguarding. Training compliance rates were 92% for adult safeguarding, and 85% for child safeguarding.

The provider had an up-to-date safeguarding adult’s policy and procedure, and an up-to-date safeguarding children and child protection policy and procedure. Staff we spoke with understood safeguarding concerns, they knew how to identify adults or young people at risk, and who to report concerns to in the staff team.

Staff had good knowledge of safeguarding procedures, and they made safeguarding referrals when appropriate to do so. Safeguarding referrals and actions were discussed at the weekly patient safety oversight panel and patient safety oversight committee meeting.

Staff told us they had good working relationships with the local authority and social care organisations. Stakeholders told us they worked effectively when there were circumstances of complicated care proceedings.

Patients told us they felt safe and supported, and there were no reports of harassment or bullying. They told us that staff intervened in any minor conflict between patients, and staff described de-escalation techniques they were trained in.

The provider had a blanket restrictions policy and monitored restrictive practice and blanket restrictions. They had a blanket restriction register for each ward, and restrictive practice was a standing item on the ward meeting agenda. We saw evidence of oversight of the use of restraints in detailed notes recorded in the patient safety oversight committee minutes and clinical governance meetings.

Mental Capacity Act

Staff we spoke with had a good understanding and knowledge of the Mental Capacity Act. The provider reported that compliance for staff training in the Mental Capacity Act was 78%.

The provider had an up-to-date Mental Capacity Act policy. It included explanations and procedures on best interests and deprivation of liberty safeguards. The policy also referenced Gillick competence assessment for children under the age of 16 years (a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment).

We found that staff, including qualified nurses, support workers, and other members of the multi‑disciplinary team, were aware of the Mental Capacity Act policy and had access to it. Staff told us they knew where to seek advice within the provider, and that they were able to approach colleagues with relevant knowledge and experience who could offer guidance, clarification, and support if capacity issues arose.

In the 12 months prior to the inspection there had been no patients assessed as lacking capacity. There were no applications for deprivation of liberty safeguards submitted in the same period to protect people who were unable to make decisions about their own care.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 5 electronic care records, which included risk assessments and risk management plans. We saw evidence that risk assessments were completed on admission, reviewed at the required intervals, and updated to reflect changes in assessed risk. One young person’s care record contained a risk assessment that had not been updated since admission The provider addressed this immediately following feedback from the inspection team.

We observed 2 daily incident safety huddles during which staff discussed patient risk and risk management. The provider held several meetings where patient risk and management were addressed, including daily handovers, safety huddles, and ward round meetings. Weekly patient safety oversight panel meetings reviewed incidents and agreed responses and actions. These meetings allowed staff to identify and respond to current risks and review management and mitigation plans.

We reviewed data provided by the hospital on the use of restraint between June 2025 and November 2025. There were 605 recorded restraints on the adult ward and 719 on the young people’s ward. On the adult ward, most restraints related to incidents of self‑harm, while on the young people’s ward the highest number of restraints were associated with nasogastric feeds and self-harm. The provider had developed a decision-making tool to review risk and decision-making before starting nasogastric feeds that might involve physical restraint. Managers and staff told us that the number of restraints in the service could fluctuate, for example the adult ward had gone through a period of high use of restraint in the preceding months but at the time of the inspection there was no use of restraint for current patients.

Staff received mandatory restraint and de-escalation training. Compliance rates were 84% for this training. Staff told us they used de‑escalation techniques routinely and that restraint was only used as a last resort or as part of a planned intervention within a person’s care plan, for example during nasogastric feeds.

We reviewed care plans, care records and observed ward round meetings, which showed patients were involved in decisions about their care and treatment. We spoke with patients who understood the use of restraint as part of their care plans in relation to nasogastric feeding. Patient choice was supported in relation to the location of nasogastric feeding. For example, on the young people’s ward, the provider had identified a room that could be used in line with patient preference. This room contained equipment designed for safe nasogastric feeding in restraint.

The provider reviewed all use of restraint at weekly and monthly patient safety oversight and reducing restrictive practice meetings. This included review of the reasons for use and duration of restrictions. The provider’s audit of positive behaviour support plans showed all plans for patients requiring restraint included patient wishes while being held in restraint. Where best interests’ decisions were made for nasogastric feeding, the provider followed a process that included reviewing the use of restraint and associated physical and psychological risks.

Stakeholders told us the service worked in a least restrictive way while balancing risk and used restrictions only when necessary for the safety of people using the service. They said any restrictions implemented were supported by clear evidence and that restrictions were removed as soon as it was safe to do so.

We found that staff involved people in care planning and risk assessment. We observed ward reviews, reviewed care records, and spoke with patients and family members, which confirmed their involvement in these processes. Of the 8 adults and young people we spoke with, all reported that they felt involved in their care and treatment plans and had been provided with copies of their care plans.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider maintained an organisational risk register that used clear colour‑coding to support risk identification, planning, and analysis. Risk‑related actions demonstrated that the provider balanced risk management with maintaining a homely environment. We saw evidence that risks on the register had been updated. For example, following completion of the wards’ ligature risk assessments, the provider undertook a full review of the relevant policy and procedure, which led to several improvements to reduce the risk of suicide.

We found that ligature risks were managed and mitigated through the provider’s risk register and an up-to-date ligature anchor point and blind spot risk assessment, recording document, and associated action plan. Risk areas were clearly colour‑coded in the plan, and each included identified clinical and environmental mitigating actions, with blind spot actions where relevant. We observed that all patient‑accessible and communal areas had convex mirrors in place to mitigate blind spots.

We assessed the clinic room on each ward and found that they were fully equipped. Emergency resuscitation equipment and drugs were checked regularly.

We found that the provider complied with guidance on mixed‑sex accommodation. The approach provided safe practice and ensured that the hospital met required standards. The provider admitted both male and female patients, and privacy was maintained through a ward layout that prevented male patients from passing female bedrooms to access their designated bedrooms and bathroom. Detailed arrangements for bedroom and bathroom allocation for use by male, trans-men, trans-female and non-binary patients were set out in the provider’s transition (admission, discharge, and transfer) policy.

Staff had easy access to alarms and patients had easy access to nurse call systems in bedrooms, and communal areas.

The provider used electronic sign‑in technology for visitors at the entrances to both wards, which included capturing photographic identification of those signing in.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe and effective care that met people’s individual needs. The service made sure staff received effective support, supervision and development.

Managers had calculated the number and grade of nurses and support workers required. Patients told us there were enough staff available on each shift.

Patients told us, and managers confirmed, there had been incidents of agency night staff using personal mobile phones and occasions where staff slept during night shifts. The provider took action to address this, including safeguarding referrals, adding individual staff to a prohibited staff list, and spot-checks by manager. We saw evidence that all staff had been reminded of expected standards. The provider had introduced a policy requiring personal mobile phones to be stored in lockers and used only during break times. The provider also met with agency companies to reinforce expectations with their staff. The agency staff induction checklist included a clear statement outlining the requirements for personal mobile phone use.

When agency and bank nursing staff were used, they had received an induction and were familiar with the ward. This included the provision of a ‘meal support booklet’ and training to enable staff to support patients effectively. However, we found an induction record that was not fully completed for one member of agency staff at the time of inspection. The provider repeated the induction on the day to address this.

Medical cover was adequate and was provided by a team of 3 consultants. The adult ward consultant used remote access to attend ward round meetings and appointments on Tuesdays and Wednesdays and attended the ward in person for admissions. The young people’s ward consultant psychiatrist, who was based on site, provided medical cover and support to the adult ward when required. The third consultant provided cover on Fridays and during periods of leave. A new consultant was due to take over this role at the time of the inspection. An on‑call rota was in place to provide out‑of‑hours cover. However, 2 patients told us that video calls could make communication difficult and that this approach was not always helpful. Staff also told us that the absence of an onsite consultant could present challenges, although they confirmed the consultant responded to emails and attended staff meetings when available.

Although the adult ward had adequate clinical cover and patient's physical health care needs were robustly checked on a regular basis, the responsible clinician for the adult ward worked remotely and only attended the ward occasionally when new patients were admitted. This meant there were very limited opportunities for the psychiatrist to engage with patients and their carers / families, and key workers on a face-to-face basis. This might impact on patient choice and the nature and quality of person-centred care provided. The adult ward handbooks did not make these remote working arrangements clear for patients and carers.

At the time of inspection, the service reported a 0.5 whole time equivalent staff vacancy.

Staff turnover rates for the hospital on the adult and young people’s ward were 4% and 1% respectively. Therapy staff and non-clinical staff both had turnover rates of 1%. All but 1 member of staff had left their positions for career progression, to study, move from bank to permanent staff, or retirement. Sickness absence for clinical staff for the 12 months prior to the inspection was 3.2%.

For the previous 12-month period, the staff supervision compliance rate for both ward and therapy staff was 85.3%, which was within the provider’s key performance target.

The service deployed agency and bank staff to maintain safe staffing levels. For the previous 6 months, agency staff average usage on the young people’s ward was 19.5% of staffing, and bank staff average usage was 13.7%. For the same period on the adult ward, agency staff average usage was 11%, and bank staff average usage was 12.2%.

Senior leaders had put in place service specific checks in addition to agency provided checks to ensure agency staff were appropriately vetted prior to working at the hospital. The provider requested regular agency staff where possible.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff received mandatory infection prevention and control, hand hygiene, and food hygiene training as part of their induction programme. Compliance rates for these were 87%, 87%, and 91% respectively.

All ward areas were clean, had good furnishings and were well-maintained. Patients and carers provided feedback that bedrooms and other ward areas were clean and tidy. One patient commented that a change to laminate flooring from carpet had been helpful for cleanliness and 1 carer commented that a bedroom carpet needed changing.

We found that staff ensured the premises were clean. We observed housekeeping staff cleaning ward areas during the inspection, and people told us that daily checks of their bedrooms took place and that cleaning was carried out when needed.

We observed staff using appropriate food hygiene procedures in the kitchen and adhering to the use of colour-coded equipment.

We found clinic rooms were clean and tidy and that regular cleaning audits were completed.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

We observed multi‑disciplinary ward round meetings where staff reviewed patient’s medicines, and patients were involved in these discussions. All the patients we spoke with told us that their medication was discussed weekly in ward round meetings, and 3 reported that doctors had supported reductions or changes to their medicines that they wished to make.

Staff followed good practice in medicines management, and we saw evidence of robust procedures and completed checks. All clinic rooms were clean, and staff had access to all appropriate equipment.

We saw evidence that clinic room and fridge temperature checks had been completed and recorded for the previous 3 months. There were no gaps in the records, and all temperatures were within the safe and recommended range.

We reviewed evidence of medicines governance recorded within the clinical governance action logs. Medication management and clinic room compliance audits were documented, along with the most frequent errors identified. We saw that medicines incidents and errors were reviewed in the lessons‑learnt and escalation section of the clinical governance log. For example, one medicines incident was described in detail, with actions taken, the correct procedures followed, increased patient care provided, no resulting harm, and escalation through reporting to the hospital board.