Cheadle Royal 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 Requires Improvement. The service was in breach of legal regulation in relation to Regulation 17 Good Governance. At this assessment the rating has remained Requires Improvement. 

Requires improvement: This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. 

At this assessment, the service was in breach of legal regulation in relation to Regulation 17 Good Governance.

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 provider has a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

• Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff we spoke to were keen to describe a positive, supportive, and safe service that prioritised the needs of young people, in line with the provider’s vision, “Making a real and lasting difference for everyone we support.”
• The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. Staff described significant changes in senior leadership and governance that have resulted in increased responsiveness and staff feeling more empowered.
• Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff told us the provider embraced change, and they were able to describe upcoming changes aimed at improving collaboration in care and effective working practices.

The provider has inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

• Stakeholders and staff described the Woodlands ward manager as friendly, supportive, responsive, present on the ward, and often available for the young people to speak to directly. Staff stated there had been a more recent positive focus on building and supporting the team.
• Leaders had the skills, knowledge and experience to perform their roles.
• Leaders had a good understanding of the services they managed. They could explain clearly how the staff team worked to provide high quality care. They were open about changes they would like to see in the service they provided.
• Staff told us that senior leaders were visible in the service and approachable for staff. We were told that the senior leadership team were available and supportive, stepping up during periods of high demand.
• Staff stated they felt able to take concerns to their line/ward manager or to the hospital director.
• Leadership development opportunities were available, including opportunities for staff to progress through professional training.
• Priory Group Cascade newsletters welcomed new staff members by name.
• There was intermittent use of ‘employee of the month’ celebrations on Woodland ward.
• There were no staff grievances over the previous 12 months.
• There were 2 staff disciplinary actions taken in the previous 12 months.

People did not always feel they could speak up and that their voice would be heard. 

• Parents gave mixed responses about providing feedback on the service. Staff were able to provide evidence of parent feedback, however this was ad hoc and there was not a consistent approach to gaining feedback from parents.
• Involvement of carers or parents in service or ward level shaping change was not evident although the provider shared Priory Group initiatives and hospital initiatives in this area. In 2024 Priory Group at national level launched the Carers Engagement and Participation strategy and the Lived Experience Partnership project. This had prompted plans in 2025 for a new relative support group, although this was not planned to be inclusive of the child and adolescent services, which aimed to launch a Parents and Carers Group.
• Responses to the latest staff survey had increased but was lower than the provider aimed for. Themes drawn from the survey flagged areas for the provider to work on hospital-wide including job satisfaction, communication across the provider site, valuing equality, diversity, and inclusion, and perceptions of leadership. Hospital-wide survey results limited their use by ward managers to apply the findings and make changes in their areas.
• Young people were invited to participate in appropriate areas of ward governance meetings. However, it was not clear how this was appropriately facilitated to support young peoples’ involvement and staff told us there was little uptake of the offer for this opportunity.
• The provider had a Freedom To Speak Up (FTSU) scheme and the champion role is fulfilled by a member of the senior leadership. Priory Group cascaded newsletters providing the name of the national FTSU Guardian. We reviewed freedom to speak up hospital-wide data and noted complaints in July – Sept 2024 concerned with colleague and leadership/management culture and behaviour.
• Young people were able to give feedback via the ward community meetings or in key worker sessions.

The provider values diversity in our workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for us.

• Equality, diversity and inclusion initiatives and updates were provided via the Priory Group Cascade publication that was distributed weekly. There were several in the 2024 publications including, the introduction of Unconscious Bias and Belonging and Inclusivity training courses to raise increase awareness and understanding about decision making and interactions within teams, celebrating LGBTQ+ History Month, Menopause in the workplace, Nelson Mandela Day and Black Leaders Awareness Day.
• Managers were up to date and aware of staff sickness and health issues within the staff team. They showed understanding for staff experiencing health difficulties and put reasonable adjustments in place for staff members to help them carry out their role.
• The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. An anonymous survey had been introduced for staff during their induction to gather monitoring data and their feedback.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

• There was not a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, were shared and discussed. We reviewed team meeting minutes for Woodlands, and these did not have standard format agenda and did not note actions completed. This meant that consistent updates and learning, and audit of actions did not take place.
• Leaders did not ensure that staff followed provider policies for dress code on the wards. Staff on Woodlands ward were not bare below the elbow, with most staff wearing fleece jackets 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. Management of risk, issues and performance took place via a monthly governance meeting. These were attended by the multidisciplinary team and included lessons learnt from incidents, although this was not a standard agenda item. Senior management meetings took place monthly, minutes showed they discussed progress from service improvement meetings at ward level, review of risk register, human resources and finance updates. 
• Staff did not always have access to the equipment and information technology needed to do their work. Staff told us that a lack of computers and laptops made it difficult for them to fulfil their role efficiently. Young people told us Wi-Fi was often poor and we saw this issue noted in ward community minutes.
• Staff concerns matched those on the risk register. Cleanliness that was identified during the assessment and by staff in Woodlands ward meetings was on the risk register and had updated actions against it. 
• Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. This included the implementation of keeping safe care plans which we saw in care records.  
• The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. Monthly submissions were collated by ward managers. Staff spoke positively of the improvements to oversight and support within the governance of the service.
• Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. The findings of these audits were reported in the monthly ward dashboard, and these were reviewed as part of the monthly clinical governance meetings. The Woodlands Ward manager and senior managers reviewed these to monitor progress and areas for improvement.
• Staff understood the arrangements for working with other teams, both within the provider and externally, to meet the needs of the patients.  
• Information governance systems included confidentiality of patient records.
• The ward manager had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. The recent introduction of monthly dashboards provided an accessible format of summary information of ward data and performance.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. 

Consider:

• Stakeholders told us that they did not always receive timely responses and had to repeat request information from Woodlands ward on occasions. It had also been necessary for stakeholders to escalate requests for representation of external professionals at meetings. This meant stakeholders were not always fully informed or involved in planning for the patients that they placed at the service. 
• There were no formal processes for patients, carers and staff to meet with members of the provider’s senior leadership team. There were plans to set up a carer support meeting in 2025. This was not inclusive of the child and adolescent ward, which had plans for separate parent and carer support. The main feedback from staff was via the freedom to speak up route. This meant there was limited partnership working in place. 
• Directorate leaders engaged with external stakeholders – such as commissioners, Integrated Care Boards, and advocacy services.

The provider 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.

• Innovations were taking place in the service. Members of Woodlands staff had conducted research to develop The Safe Intervention of Ligature Assessment Scoring (SILAS) approach. This intervention was implemented on the ward to support ligature management.
• Within the governance meeting, quality objectives were discussed. Minutes showed that there was a task and finish group in relation to the model of care.
• The provider delivered an in-house 12-week multi-disciplinary leadership programme that had received excellent evaluation feedback for participants. Staff were given time and support to attend this, and staff told us that the programme had helped them with leading their team.
• Staff were not given the time and support to consider opportunities for improvements and innovation. The provider had a quality improvement commitment to support people to be involved in quality improvement projects, however the clinical governance meetings for the last 6 months did not record any quality improvement projects that staff were involved in and there was an agenda item for this.  
• Staff did not participate in national audits relevant to the service. Minutes reviewed did not show involvement in any national audits.