Cheadle Royal 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 Inadequate. The service was in breach of legal regulation in relation to Regulation 12 Safe Care and Treatment and Regulation 18 Staffing. At this assessment the rating has changed to Requires Improvement. 

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. 

 At this assessment, the service was in breach of legal regulation in relation to Regulation 12 Safe Care and Treatment, Regulation 15 Premises and Equipment, and Regulation 18 Staffing.   

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 provider did not always have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices. 

• Lessons were learnt from incidents that occurred on Woodlands ward. Learning was shared with staff, and they could explain changes in practice. We saw incident review reports that recorded actions taken to inform all staff of relevant policies and procedures relating to an incident, and additional training for relevant staff. Examples of changes in practice included the removal of plastic cutlery from the ward following incidents of ingestion requiring admission to the emergency department for treatment. Bathroom doors were replaced for a design without magnets, which removed a further ingestion risk.
• Staff did not receive consistent feedback from hospital-wide investigation of incidents. We reviewed team governance minutes and night manager monthly supervision reports, and lessons learned was not a standard agenda item.
• The Priory Group publication Cascade, was shared with staff to explain actions taken following incidents and lessons learnt. Monthly patient safety meetings took place with senior managers and ward managers, the cascades were shared in that meeting too.
• Daily de-briefs took place at the end of shifts on Woodland ward to discuss what could be done differently.
• There were 39 serious incidents reported for Woodlands ward in the 12 months from January to December 2024. These included incidents of ingestion of objects, attendance at the Emergency Department for physical health needs and following incidents of self-harm, and following the use of restraints, seclusion, or self-harm.
• Stakeholders told us that they were informed about incidents and received timely updates.
• All staff knew what incidents to report and how to report them.
• Staff understood the duty of candour. There were no duty of candour reports for Woodlands ward in the previous 6 months. Staff were open and transparent and gave young people and parents a full explanation if and when things went wrong.
• Staff were debriefed and received support after a serious incident

The provider works with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

• The provider had changed their risk assessment approach that was in place at the time of the last CQC inspection. The previously used Strategic Tool for Assessing Risks (STAR) system had been replaced by a new Priory Risk Assessment. Staff told us this was a more thorough approach, which now included a narrative for each risk. The approach is based on a risk formulation, which importantly accounts for protective factors. Young peoples’ risk assessments were updated fortnightly in ward rounds, or as required following incidents.
• The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met.
• There was mixed feedback from stakeholders about communication with the provider. There were reports of good communication with external professionals, but also from stakeholders who had to ask several times for information about a young person’s care and treatment plans.
• We were given mixed feedback from parents and stakeholders about information sharing. Some parents told us that they were kept informed, while others felt information shared was limited. Stakeholders reported lack of information sometimes affected robust discharge planning.
• Stakeholders reported that there could be a lack of social care services representation at meetings to ensure patients had continuity of safe care in relation to section 117 aftercare.

The provider works with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

• Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate.
• There were 3 different safeguarding training courses that staff completed; Safeguarding Adults levels 1 and 2, Safeguarding Children levels 1 and 2 and Safeguarding Combined: Adults and Children Young People - level 3. All of these mandatory training courses had 100% compliance. 
• Safeguarding was a standard reminder at each ward community meeting and the name of the provider safeguarding lead and named staff with level 4 safeguarding training were noted in the meeting minutes. Young people were reminded and invited to contact the safeguarding team to discuss any issues.
• Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.
• Staff knew how to identify children at risk of, or suffering, significant harm. This included working in partnership with other agencies.
• Staff were aware of the potential harm of social media for young people.
• Staff undertook accredited reducing restrictive intervention breakaway training. Woodlands had 95.5% compliance for this mandatory training. Staff could describe following reducing restrictive practice techniques and we saw evidence in care plans of de-escalation approaches and when restrictions were applied.
• Parents and stakeholders described staff use of de-escalation techniques with distressed young people.
• We reviewed blanket restriction records, and these were discussed at ward and clinical governance meetings.

The provider works with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

• Young people received consistent support from staff to manage risks associated with their health and wellbeing. Policies and procedures were in place for staff including a physical intervention policy and an incident reporting and management policy. Staff were knowledgeable about risks. 
• We reviewed 4 care records including risk assessments / risk management plans during the assessment.  All risk assessments were in place and created to a good standard. We saw evidence that risk assessments were reviewed after incidents.
• Over a period of 3 months from September to November 2024, there were 141 uses of rapid tranquilisation. We saw evidence of completion of physical observations following rapid tranquilisation in line with the provider rapid tranquilisation policy.
• In the 6 months from June to December 2024, there had been 524 restraints on Woodlands ward. The total number included restraints for a small number of young people with complex care needs and treatment plans at the time.
• In the last 3 months from September to November 2024, there had been 3 uses of seclusion and no use of long-term segregation. 
• Staff involved patients in care planning and risk assessment, except where the young person’s presentation prevented this, and we saw this noted in care records.
• Stakeholders and parents told us that staff managed risk well and took approaches that were least restrictive. The Safe Intervention of Ligature Assessment Scoring (SILAS) approach was used on Woodlands ward. This scoring tool and intervention approach was developed by members of the provider’s clinical team. It enables qualified and unqualified nursing staff to assess three areas of importance when managing ligature behaviours and provides a procedure for intervention where young people are assessed to have capacity.
• Stakeholders reported that staff effectively communicated with young people so that they understood their care and treatment. Carers reported that staff were observant of non-verbal forms of communication.
• We saw evidence of individualised approaches to support communication with young people with communication difficulties. Individualised communication plans were in use and staff drew on different tools and devices to encourage and aid communication, e.g. social stories, communication cards. However, there was evidence of delays in acquiring communication aids where there were specific communication needs.
• Staff enabled patients to give feedback on the service they received, including at weekly ward community meetings. Notices were clearly displayed at the ward entrance about contact details for family ambassadors and information about the provider complaints procedure.
• Staff ensured that patients could access advocacy, and young people told us they had spoken with an advocate. Advocacy services reported that they were received well on the ward and were given appropriate and comprehensive information about young people who needed support from them.

The provider did not always detect and control potential risks in the care environment. They did not always make sure that the equipment, facilities and technology support the delivery of safe care.

• Staff carried out regular risk assessments of the care environment. Woodlands ward had an ligature risk assessment in place. However, the risk assessment was not completed in full. The ligature risk assessment did not have the ‘specific identified risks and controls to minimise harm’ section completed. There were potential ligature anchor points including doors, hinges, garden furniture and fixtures, fences, radiator covers however these were not recorded on the ligature risk assessments. This meant staff would not know what the risks were that they were supposed to be mitigating.  
• Ward layouts did not allow staff to observe all parts of the ward. Woodland ward had a blind spot audit completed but all 61 identified blind spots had the standard response comment: “Manage identified blind spot through local procedure”. There was “No action required” for any of the blind spots in the audit, e.g. to install mirrors or remove/move furniture. The provider took action at the time of the assessment to install mirrors in a blind spot in the stairwell to the garden.
• There was no system to accurately and consistently share with new or agency staff on Woodlands ward what the ligature risks and blind spots were, or if new risks or blind spots were identified. This meant staff were not consistently mitigating risks and blind spots and sharing information was down to the staff member facilitating the induction. This meant there would be variations, and staff would not be given consistent information.
• Safety checklists of occupational therapy kitchen equipment showed gaps in recording. Initials and signatures of the member of staff making the checks were not included as instructed.
• The ward complied with guidance on eliminating mixed-sex accommodation.
• Staff had easy access to alarms and patients had easy access to nurse call systems (in wards where this was necessary). We were told that parents were provided with alarms for visits to young people that took place in the ward visiting room.
• At the time of our assessment, Woodlands ward seclusion room allowed clear observation and two-way communication and had toilet facilities and a clock. Staff thought the seclusion room was out of use due to heating and the water supply for toilet facilities not working. However following the assessment, the provider told us that heating and water had been isolated as the seclusion room was not in use.
• The ward clinic room was fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. On the day of assessment some blood collection bottles were found to have gone beyond their expiry date.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

• The service had good establishment figures with 71% for registered nurses and 67% for health care assistants. There were no registered nurse vacancies and 5 (WTE) health care assistant vacancies. Several posts had been recruited to and the applicants were working through pre-employment checks.  Three preceptorship nurses were due to join the team. There were 123 leavers over the whole site in the last 12 months. Average sickness was 3.8% within the last 12 months.  
• Managers had calculated the number and grade of nurses and healthcare assistants required. There was an establishment dashboard in use.  
• The ward manager could adjust staffing levels daily to take account of case mix.
• When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. No bank registered nursing staff were used over the last 6 months and 12.9% bank health care assistants were used. Average agency staff usage over the last 6 months was 15.3% for agency registered nurses and 9.2% for agency health care assistants.
• We reviewed staff rotas and agency induction checklists and found that 2 of 8 records reviewed, showed agency staff did not have full induction records.
• Woodlands staff had received and were up to date with appropriate mandatory training with an overall compliance of 97%, and for all medicines related training there was 100% compliance.
• Staffing levels allowed patients to have regular one-to-one time with their named nurse.
• Four of the five young people we spoke to told us that lack of staff availability could result in delays in escorted leave being taken or had an impact on ward activities. This was during times of high acuity on the ward.
• There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely (and staff had been trained to do so). We observed additional staff from other areas attending when called via the ward alarm system.
• There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

The provider 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.

• There were unclean and poorly maintained areas in Woodlands ward, which young people, parents, and staff all commented on. For example, stains on the mattress and ceiling, and cracked flooring in the seclusion room, peeling paint, mould and drains smelling in shower rooms and bedrooms, old poster stickers on walls, windows and pictures, and dirt and debris in between Perspex covers and windows. Bedroom windows were fixed and could not be opened to let in fresh air. The Occupational Therapy room attended by young people off the main ward, was poorly maintained and decorated, with mould, damp and debris in several areas. Repairs were not completed in a timely manner, for example graffiti on pictures and smelling drains in bedroom had been long-standing issues. Smelling drains had been reported in senior manager meetings in July 2024. This meant patients were in an environment that was not supportive of their recovery. 
• Staff did not adhere to infection control principles or hospital policies. Staff on Woodlands ward were not bare below the elbow, with most staff wearing fleeces or long sleeved tops under short sleeved hospital tunics. Several staff had long nails, wore nail varnish, or had false nails, and some had false eye lashes. Staff had watches and jewellery on. Staff were not following the Standards of Dress, Uniform and Personal Appearance policy dated 03/08/2023 which states “ 6.2  Appearance - With regard to personal appearance the following applies: Fingernails must be kept short at all times to protect from any scratching and any infection.  Nail varnish is not permitted for any colleagues who have direct contact with service users. 6.3 Clothing - Arms must be bare below the elbow to allow appropriate hand hygiene.  This is defined in the Department of Health’s “Bare Below the Elbows” guidance and IPC03 Hand Hygiene. 6.5 Finger rings - One plain metal band may be worn. No rings with stones are to be worn when dealing directly with service users’ care as scratches and abrasions to the skin could occur.” 
• Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.
• Cleaning was sourced via an external provider on a daily basis. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. However, reports from young people, parents and staff were that cleaning was not always effective.

The provider makes sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

• The clinic room was well managed and there was a good audit of emergency bags and medicines.
• We reviewed 5 young people’s prescription records. These were all accurately completed. Patients’ allergies were recorded and there was evidence of medication reviews.
• Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication), and did it in line with national guidance.
• Rapid tranquilisation records and observations were fully completed and staff demonstrated knowledge of the procedure.
• For medicines related training there was 100% compliance.
• Medicines, including stock, controlled and emergency medicines, were stored securely and at correct temperatures. Staff knew how to reset temperatures if required. However, during site inspection we found some expired blood bottles.
• Staff reported stock issues with the supplier pharmacy for some medicines. We were told by staff that this could result in medications being borrowed by other hospital wards from the Woodlands stock.