Riverdale Grange Clinic

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• 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 inspection we rated this key question Good. At this inspection the rating has remained Good.

Leaders had the skills, knowledge, and experience to perform their roles. Leaders and the service culture they created drove and improved high-quality, person-centred care. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. All staff felt respected, supported and valued. Governance processes were robust and operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They consistently used this to identify improvements.

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.

The service had a clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and a good understanding of the challenges and the needs of people and their communities.

The provider had a clear vision, set of values and a mission statement. The provider's vision was to provide a caring, supportive and inclusive environment where excellence is expected and delivered and their values were Kindness, Integrity, Nurturing, Dedicated (KIND). The provider's mission was ‘To always look forward and use our expertise and skills to equip our patients to achieve their best outcomes’.

Senior leaders and managers spoke passionately and with enthusiasm about the service provided, demonstrated professional behaviours, and set clear and high expectations for professional conduct and expertise within staff teams.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff were introduced to the vision, values and mission on joining the service through the provider’s induction handbook. These were also included within the opening sections of staff appraisal documentation. Staff we spoke with were able to identify where posters setting out the hospital vision and values were displayed and described key documents where information could be accessed.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff told us there was a staff survey. The provider used the Culture of Care Barometer (CCB) survey tool to gain staff views annually. The CCB is a self-diagnostic tool developed for health organisations to implement to generate reflections on the working environment and culture of care within their team. The 2025 annual survey showed that a majority of staff completing the survey either agreed or strongly agreed that the organisation listens to staff views, staff were able to influence the way things are done, and they were kept well informed about what was going on in their team.

Staff spoke with pride about the service they provided. The CCB staff survey results also showed that staff completing the survey felt respected by their co-workers, and that their line manager treated them with respect. The majority of staff also felt the organisation had a positive culture and that the organisation valued the service it provided.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff gave positive feedback about the service’s leadership. The annual staff survey results showed that over 80% of staff responses agreed that there was strong leadership at the highest levels in the organisation. They described the adult ward manager as “amazing” and the registered manager as “brilliant” and “inspirational”. Staff consistently reported that they felt respected and valued. They said they felt included and described opportunities to ask questions, for example at Board to Ward meetings, and to contribute to policy development. Staff told us they felt their voice was heard and described leaders as very open to hearing from staff. Overall, they described excellent team working.

Leaders had the skills, knowledge and experience to perform their roles. Leaders demonstrated an understanding of the key challenges, priorities and risks and were open in sharing these. Managers told us they were able to access appropriate support and development in their roles.

Leaders were described as very visible in the service and approachable for patients and staff. Staff described the registered manager as accessible and visible around the hospital.

Senior leaders responded appropriately to staff concerns when these were raised. They told us how they had addressed incidents of inappropriate and discriminatory behaviour directed towards staff by patients. For example, they had involved staff in an approach to dealing with an incident and its resolution. With appropriate support, staff had attended a meeting facilitated by managers to share the impact of behaviours and the distress caused by these.

Leaders demonstrated a good understanding of the services they managed and clearly explained how teams were working to provide high-quality care. For example, the provider had identified that the young people's ward required stronger leadership to strengthen the management of the ward. A new ward manager had been appointed, and interim ward manager arrangements were in place prior to them taking up post in January 2026.

Stakeholder feedback highlighted that senior medical staff on the young people’s ward built positive and effective working relationships with young people and demonstrated a “firm but fair” approach. This included involving young people in discussions and providing clear, compassionate explanations when difficult decisions were made.

Managers demonstrated understanding of individual staff workplace needs. Staff gave examples of support provided to return to work after a period of ill-health and sick leave, time off to attend health appointments, transitions in working full time from part time or in changing roles, and flexibility in shift patterns where family needs were complex. Staff told us they were given information about LGBT+, advocates, and flexible work arrangements for staff on night shifts were put in place during Ramadan.

Leadership development opportunities were available, including opportunities for staff. Managers told us they had undertaken leadership and management courses.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

All staff we spoke with told us they felt able to raise concerns without fear of victimisation. Staff described a no blame culture with results from the annual staff survey showing that over 80% of staff believed their concerns were taken seriously by their line manager. None of the staff we spoke with had experienced or witnessed bullying or harassment in the workplace.

The service told us they had 3 staff designated as freedom to speak up guardians. Staff told us they knew about the provider’s whistle-blowing process and could identify the freedom to speak up guardians. One member of staff was not aware of the hospital freedom to speak up process. The service had reviewed its freedom to speak up system and was planning changes. They had identified a senior clinician who would receive formal training and ‘buddying’ through the National Guardians Office.

The provider reported that there had been 4 duty of candour incidents recorded in the 6 months prior to the inspection; 2 on each ward. In all incidences verbal and letters of apology were given to the patients.

Senior leaders and managers spoke with openness and transparency. They demonstrated this through providing timely and detailed explanations in response to areas raised with them during the inspection. They were forthcoming about challenges the service had been presented with and how they had managed and overcome these. We saw evidence that managers had reported incidents with staff to outside regulatory organisations.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. They could do this through different ways, for example, anonymous feedback via suggestion boxes, at organised meetings such as connection evenings, festive events, and information events, through admission and care planning meeting feedback forms, and through the carer's forum.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Leaders valued cultural diversity across the workforce and demonstrated an understanding of people’s different backgrounds. Open communication with staff and patients took account of protected characteristics. Leaders provided examples of how discriminatory behaviours had been addressed, including involving the affected individual in an inclusive way.

Managers had made reasonable adjustments to support staff to carry out their roles. This included offering flexibility by adjusting working hours or ways of working to accommodate personal circumstances, such as caring responsibilities and health needs.

The provider undertook a range of equality, diversity and inclusion activities within the organisation. This included completing equality impact assessments for hospital policies, monitoring the ethnicity of patients where restraint had been used, and carrying out equality monitoring of the workforce.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. However, we found areas of low training compliance.

Mandatory training compliance was generally adequate, although compliance was low Mental Health Act training. This meant that systems for oversight and governance of training compliance were not sufficiently effective.

The provider had an effective governance structure that included a range of senior management team meetings.

The hospital’s risk register identified, monitored and red-amber-green rated clinical, financial, security, governance, organisational, and legal risks, and this included emergency situations. Action plans were also developed for the adolescent care plan audit, staff survey, and clinical governance.

The provider undertook an annual quality review. This involved members of the provider collaborative, representatives from the multidisciplinary team, and included feedback from patients. The review identified both achievements and areas for improvement within the service, as well as clear recommendations in the areas of patient experience, patient safety, clinical effectiveness, and the hospital environment. It was noted in the 2025 quality review report that the provider had a clear structure for risk reporting, management, escalation and sharing. We saw evidence that actions had been taken in response to issues identified through the quality review. For example, the review had highlighted errors related to prescription charts and medicines stock. Actions included additional reviews and checks, and measures to ensure staff training compliance and competency. At the time of the inspection, we found no prescription chart or medicines storage errors, and no concerns within the clinic.

The provider had changed its approach to monitoring risk and safeguarding through the implementation of the Patient Safety Incident Response Framework (PSIRF). Monitoring arrangements included the use of an incident tracker to support oversight and identify learning. The provider had also implemented Serious Worry And Risk Meetings ‘SWARM’ meetings, which took place within 48 hours of an incident. These meetings involved staff gathering promptly following an incident to review what had happened, how it had happened, and to agree actions to reduce future risk. The SWARM process supported the timely collection of insights and reflections and enabled learning to be identified and shared quickly.

A structured programme of meetings had been implemented to ensure effective incident oversight, monitoring and identification of learning and trends. This included weekly Patient Safety Oversight Panel meetings, monthly Patient Safety Oversight Committee meetings, and quarterly Patient Safety Oversight Group meetings.

Staff undertook and participated in a range of local clinical audits. These included audits relating to governance, infection prevention and control, medicines and pharmacy, use of patient outcome measures, care plans and records, therapy pathways, the Mental Health Act, and estates and the environment. Audit processes were used to provide assurance, and staff acted on findings where action was required. The provider gave examples of actions taken following audit – installing restricted fob access to garden meeting rooms to mitigate ligature risks, and the provider installed vision panels in 2 adult ward rooms. These panels were small windows in the doors that enabled staff to safely observe patients and check the rooms without the need to enter the room or disturb patients unnecessarily. Audits were mostly effective. We found an example of one young person’s care record that contained a risk assessment that had not been updated since admission over 5 weeks earlier when the provider’s audit schedule was 4 weekly audits.

Staff had implemented recommendations arising from reviews of incidents at service level. For example, following an incident where a patient absconded via the hospital gardens, a lessons learned review and associated action plan had been completed. Actions were ongoing and included consultation with local residents, neighbouring properties and the local authority to address securing the perimeter of the hospital gardens.

At the time of the inspection, leaders and the hospital board were aware of the impact of long-term sickness absence on the senior leadership team, which had created additional pressures within the team. Leaders told us the hospital board was responsive to requests for additional resources during this period.

Staff had access to the equipment and information technology needed to do their work. A change had been implemented whereby a hot desk area had been designated for private study by staff or patients. Staff told us they could access this area to complete online training.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

The provider recognised the importance of developing effective working relationships with other organisations and eating disorder services within the region. For example, the provider had worked collaboratively with another NHS provider during the implementation of a new incident reporting system, the Patient Safety Incident Review Framework (PSIRF).

The provider had worked collaboratively with a local third sector eating disorder organisation and had created training opportunities for this organisation. Staff from the organisation were invited to join physical health and PSIRF training sessions facilitated by the service.

The provider was working collaboratively with another organisation on future service developments. Senior leaders described this work as supporting the development of home‑based care models aimed at admission avoidance and reducing relapse across the service pathway.

The provider had previously worked in collaboration with other services to host a peer recovery worker funded by the NHS. The peer recovery worker supported patients while they were awaiting admission, during inpatient admission, and through transition when stepping down from inpatient treatment. The peer worker was also involved in the carer’s forum. This role drew on lived experience of recovery from an eating disorder and supported engagement with patients. The provider had co‑presented a paper about this role at the annual conference of the British Psychological Association in November 2024.

The provider had academic and training collaborations with organisations within the region to support professional development and training opportunities. The service had previously supported student nurse and occupational therapy student placements from local universities. At the time of the inspection, the provider was supporting 2 trainee psychologists from a local university.

The provider was due to host Autism Diagnostic Observation Schedule-2 training that the service’s clinical psychologist was delivering in January 2026.

Hospital leaders engaged with external stakeholders, including commissioners. Stakeholders told us the provider was responsive and demonstrated proactive, collaborative working. Leaders worked effectively with other local eating disorder providers and supported transitions between services. The hospital manager was described as key in supporting collaborative working across treatment pathways for adults and young people and was proactive in contacting partner organisations to address issues related to pathway management.

Representatives from the service attended a local provider collaborative clinical governance meeting for both Child and Adolescent Mental Health Services and adult services. The service also participated in quarterly innovation meetings facilitated by the provider collaborative.

Patients and staff had opportunities to meet with members of the provider’s senior leadership team and commissioners to provide feedback. This took place through the annual quality review process, community meetings, and other engagement forums.

Stakeholders described both adult and young people’s services as responsive and collaborative. They told us the service was welcoming, and that staff were sincere and compassionate. Communication was prompt, care was focused on patients’ needs, and a learning culture was evident.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Wards participated in accreditation schemes relevant to the service and learned from them. At the time of the inspection, the service was an accredited member of the Royal College of Psychiatrists Quality Network for Eating Disorders (QED). Members of QED have undergone a comprehensive process of review that identifies high quality standards of patient care and service organisation. The service was previously an accredited member of the Quality Network for Inpatient CAMHS (Child and Adolescent Mental Health Services) (QNIC) and was undergoing reaccreditation at the time of inspection.

The provider supported staff across the multidisciplinary team and at different grades, to complete Quality Network for Inpatient CAMHS (QNIC) and Quality Network for Eating Disorders (QED) accreditation training. This enabled staff to participate in peer review visits to other providers delivering similar services and supported their professional development and understanding of quality assurance processes.

Stakeholders told us that management demonstrated openness, reflective leadership, and a commitment to continuous improvement. This was also recognised and noted in the provider 2025 annual quality review.

Staff used quality improvement methods and knew how to apply them. For example, the provider was undertaking a quality improvement project to review care plans. Staff told us the current care plan template and format did not adequately support the recording of patient and carer involvement or ensure their views were visible and consistently captured. Staff held meetings with patients to gain their input to the development of the new care plan template. The next phase of the quality improvement project was digital transformation.

Staff were given the time and support to use opportunities for improvements and innovation and this led to changes. For example, senior leaders were not satisfied with the existing annual ligature audit, as it was considered overly complex. Through collaborative working with another independent mental health provider, the service implemented a revised system. This new approach used a concise and clearer Red, Amber, Green (RAG) rating framework to support more effective identification and monitoring of ligature risks. Following the new audit approach areas identified for improvement included fob access for garden rooms to mitigate ligature risks, and a plan for the installation of privacy vision panels for bedroom doors on the young people’s ward.

All support worker roles had been uplifted from band 2 to band 3, 2 years prior to the inspection. Support workers were supported to undertake further training and development for example, band 3 support workers had completed training in phlebotomy and nasogastric feeding to support patients’ clinical care.

The provider organised staff away days. The focus of the 2025 events was the launch of the service’s Positive Behaviour Support (PBS) strategy. As part of this work, the provider had completed an audit of positive behaviour support plans and identified 2 PBS champions to drive implementation and good practice. The service’s clinical psychologist planned to introduce a pre‑ and post‑training outcome measure to assess the impact of PBS training and monitor how effectively it supported staff practice.

The provider supported staff development and progression within the workforce and recognised the benefits to the hospital of retaining experienced and skilled staff. For example, support worker had been supported to complete nursing associate training, and another support worker had completed top‑up training to enable them to obtain their Nursing and Midwifery Council professional registration.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. For example, patients and carers were involved in decision-making about changes to the service through inclusion in the care plan quality improvement project.

Managers established training hubs at planned intervals to provide staff with dedicated time to complete mandatory training and maintain compliance. A hot‑desk area had been created to support this activity and enable staff to access training resources with minimal interruption.