Cheadle Royal Hospital

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• 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 inspection we rated this key question requires improvement. At this inspection the rating has remained 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. The information on young people’s records about the risks relating to their care was not always updated in a timely manner following incidents. We identified some maintenance and infection prevention and control issues in the care environment. Young people and staff were not consistently supported with debriefs following incidents on the ward, information about lessons learned from incidents was not shared with all staff and medicines were not always stored safely. When considered together these issues were sufficient to evidence a breach of Regulation 12: Safe care and treatment. However, incidents were responded to and reported effectively and young people were kept safe from abuse and neglect. The ward was usually adequately staffed and staff worked well together both within the hospital and with external stakeholders to share information in order to keep young people safe.

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.

We scored the service as 2. The evidence showed some shortfalls. Staff and young people did not consistently receive debriefs following incidents and information about lessons learned from incidents was not always widely shared to continually identify and embed good practice. However, the service overall 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.

There were 132 serious incidents on the ward in the 12 months preceding our inspection (May 2025 to April 2026). Most of the incidents were self-harming behaviours by the young people and the reports of these showed that staff acted quickly and appropriately to mitigate any immediate risks and support the young person involved. However, some staff and young people told us that they did not consistently have a debrief following incidents. Family carers told us that they were not always informed in a timely manner when incidents did occur. Stakeholders such as commissioners of the young people’s care told us that there had been some communication difficulties relating to incidents, but these had recently improved.

Feedback from staff was variable about whether information was shared about lessons learned from incidents, with some staff saying they received this at team meetings and some staff saying they did not get any information about this. The ward governance meeting minutes showed that some information about lessons learned from incidents had been shared with the staff present at these meetings. However, these meetings had been temporarily replaced by safety huddle meetings since January 2026 and the records of these meetings did not show that lessons learned from incidents had been discussed.

The records showed that rates of incident reporting were high, with a range of incidents ranging from minor to severe documented on the young people’s care records. The incident reporting process was clear and accessible to staff in the provider’s incident management, reporting and investigation policy. The staff we spoke with were aware of what incidents to report and how to report them. We saw examples of improvements which had been made on the ward as a result of lessons learned from incidents, including enhanced restraint training for staff and improved measures to enhance the privacy and dignity of young people receiving nasogastric feeds.

We saw that the provider had recently implemented a new system of incident management on the ward due to the high level of incidents which occurred. Each shift had a member of staff allocated to the role of incident manager at all times and they were responsible for supporting with and documenting incidents, as well as taking the lead on the post incident debriefs. The ward manager told us how this system was starting to improve the governance around incidents and ensure that young people and staff felt better supported during and after they occurred. Stakeholders told us that historically there had been some issues with the management of incidents on the ward but that improvements had been made in response to these concerns.

Staff understood the duty of candour. They were open and transparent and gave young people and families a full explanation if and when things went wrong. There were 7 incidents on Woodlands ward requiring a duty of candour response in the 12 months preceding our assessment. The provider’s records showed that lessons learned from these incidents were identified and an explanation and apology was offered to the young person, and their carers where this was appropriate.

We scored the service as 3. The evidence showed a good standard. 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’s referral and admission processes ensured that all essential information about each young person was received to determine if their needs could safely be met. The ward manager told us, and records confirmed, that the ward were able to decline to admit young people where they were not able to safely meet their needs. All the care records we reviewed included information about the young person’s history, which was documented at the point of their admission and kept under regular review. This included detailed information about the risks relating to their care, which were assessed on admission and used to inform detailed risk management plans.

Information about risk was shared appropriately between staff teams. We observed a handover meeting and each young person’s risks and needs were discussed in detail with the incoming staff team. This included a summary of their presentation and activities on the preceding shift and any particular needs for the upcoming shift were highlighted. The records showed that handover meetings took place at each change of shift and always included detailed risk information about each young person, as well as other risk management information such as a reminder of the environmental risks on the ward.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. We also observed a ward round which included collaborative partnership working with the patient’s community team to facilitate their discharge to a suitable community placement. The young person’s community care coordinator and commissioning case manager were present at the meeting through video link and the ward’s multidisciplinary team included a social worker who was involved in their discharge planning.

We scored the service as 3. The evidence showed a good standard. 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 were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. Staff told us that they were up to date with their mandatory training, which included safeguarding children and vulnerable adults and management of violence and aggression (including verbal de-escalation of incidents). The training records showed that 96% of staff were up to date with this training at the time we inspected. Staff protected patients from harassment and discrimination, including those with protected characteristics under the Equality Act. None of the young people or carers we spoke with raised concerns of this nature. Records showed that young people’s protected characteristics were taken into account in their care, for example young people had their dietary and spiritual cultural needs considered.

Staff knew how to identify young people at risk of, or suffering, significant harm. This included working in partnership with other agencies. All the staff we spoke with were aware of the procedure for reporting safeguarding concerns. The ward manager said they were well supported by the hospital’s safeguarding lead and had a good working relationship with the local authority’s safeguarding children team. The records of safeguarding referrals showed a range of concerns being reported including disclosures made by young people about historical abuse and allegations relating to staff conduct. Staff followed safe procedures for children visiting the service. There was a family room available off the main ward where family visits with younger siblings could take place and the carers we spoke with told us that this was fit for purpose.

The provider’s records showed that 1271 incidents occurred on the ward in the 6 months preceding our inspection (October 2025 to March 2026) of which 860 involved some form of restrictive practice such as physical restraint (68%). This very high level of incidents and restraints was due to the complex needs of young people receiving care on this ward. Young people who had experienced restrictive interventions, such as physical restraint or rapid tranquillisation, told us that this was usually only used as a last resort, however they felt staff had been quicker to use restraint following a period where there had been a lot of incidents on the ward.

Staff also told us that restrictive interventions were only used on the ward as a last resort and said that restraint was generally used to facilitate nasogastric feeding of young people with an eating disorder who were refusing food and needed to be fed to prevent malnutrition and physical health issues. Restraint was also used to prevent incidents of severe self-harm. Young people’s care records showed that restrictive interventions were used proportionately to manage risk and were regularly reviewed to ensure the least restrictive approach possible was being taken to keep young people safe. Managers carried out regular CCTV spot checks and took action in relation to any concerns identified from this, for example non-approved restraint holds being observed on the footage. Young people had access to written information about restrictive interventions used on the ward, as required by the Mental Health Units (Use of Force) Act 2018.

A register was kept of all restrictions which were applied as a blanket policy across the ward, for example the occupational therapy kitchen was kept locked when not in use and the young people did not have free access to outside space due to this being down a flight of stairs. The restrictions listed on the register matched those we observed on the ward. They were proportionate to the risks presented to the young people by the restricted areas or items and the register was regularly reviewed to ensure the least restrictive approach needed to maintain safety was being taken.

Mental Capacity Act

Staff told us they received training on the Mental Capacity Act and records showed that 91% of staff were up to date with this mandatory training module. The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it and had access to Mental Health Act administrators who could also give advice and support in relation to the Mental Capacity Act.

There were no deprivation of liberty safeguards applications made in the 12 months prior to inspection, as all the young people admitted to the service who had lacked decision making capacity were detained on the ward under the Mental Health Act.

Staff took all practical steps to enable patients to make their own decisions. During our observations of care we observed staff asking young people for consent where appropriate. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately, in line with the requirements of the Mental Capacity Act. They did this on a decision-specific basis with regard to significant decisions. We saw examples of capacity assessments and best interests decision making on young people’s records and Mental Health Act documentation relating to each young person’s capacity to consent to their medical treatment was stored with their prescription charts.

The capacity assessment records showed evidence of attempts to support the young person to retain and understand the information in order to make the decision themselves, for example the use of easy read information and social stories for a young person with a diagnosis of autism. However, there was no specific documentation of the assessment of Gillick competence (a test in medical law to decide whether a child under the age of 16 is competent to consent to medical examination or treatment) on the capacity assessments for young people aged under 16 years which would have been good practice.

The service did not have specific arrangements to monitor adherence to the Mental Capacity Act. However, we were told that a check that capacity assessments had been completed where required was included in the records quality audits. These took place regularly on the ward, most recently on 8 April 2026 which confirmed 91% compliance with the provider’s record keeping standards.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed the care records for all 7 young people who were admitted to the ward at the time we inspected. All the records included a detailed risk assessment and formulation and a care plan setting out the measures in place to mitigate the identified risk, for example enhanced levels of therapeutic observations, psychological therapy to enhance coping skills and restricted access to high risk items or environments. All the records showed that the risk assessments were completed on or shortly after the young person was admitted and were reviewed regularly. However, we saw that the risk assessment had not been reviewed and updated since the most recent incident involving the young person on 5 of the 7 records. Following the inspection, the provider told us that 4 out of 5 of these risk assessments were completed within 24 hours of the incident in question in line with the provider’s policy. Also, the risk assessment for 1 young person said they were receiving a higher level of observations (12 in 60 minutes) than their care plan (1 in 60 minutes). They were in practice receiving the higher level of observations so there was no impact on the young person from this, but the conflicting information did pose a risk of the young person receiving insufficient staff supervision to adequately mitigate their self-harm risks.

The young people’s care records all included a summary section on the main dashboard which listed the key risks relating to the individual’s care, for example specific self-harm risks. However, it was not always clear in the individual’s detailed risk assessments and care records what the specific risks were or what the plan was to mitigate these risks. For example, a young person had attempted to self-harm by ingesting paper, requiring staff to administer first aid to prevent choking. Their risk assessment had not been updated since the incident and did not clearly refer to choking on paper as an identified risk for them, although this was referenced elsewhere in the care documents, including on the list of risks on the main dashboard. Prior to the inspection, in December 2025, we received a notification of an incident in which another young person had accessed tissue paper which was an identified as a risk on their care plan, which resulted in them attempting to ingest this which also led to first aid intervention being required to prevent choking. We also heard from family carers that security procedures did not always ensure that items which could be used to self-harm were removed from young people when this was warranted.

We observed a ward round and a handover meeting and at both meetings the recent incidents the patient had been involved with and their current level of therapeutic observations were highlighted and discussed. The handover meeting also included reminders for staff about general risks on the ward, for example relating to the care environment.

Young people told us that they felt safe on the ward and said that staff helped them to manage their individual risks. Young people had varying degrees of staff supervision ranging from long term segregation with their own staff team to hourly checks depending on their individual needs and risks. The records showed that staff involved young people in the risk assessment process and offered them copies of their care plans unless this was not appropriate on the basis of risk. Staff used communication aids to enhance the involvement of young people in their care as appropriate, for example pictorial information and social stories to support an autistic young person to be move involved in their care.

The young people were able to give feedback on the running of the ward and give suggestions for changes they would like to see at weekly community meetings. The records of these showed that they took place regularly and were well attended, with the young people engaging with the discussions and giving a lot of varied feedback about their experience and preferences. The minutes of the meetings included a ‘you said, we did’ section which documented changes which had been made as a result of previous feedback received from young people. This was also displayed in poster form on the ward.

Staff ensured that young people could access independent advocacy. An independent mental health advocate attended the ward weekly, and the young people told us that they felt well supported by the advocate. We received feedback from the advocate who felt their role was supported by the ward manager and staff. The advocate reported a historical concern about not being informed of young people’s review tribunals and managers’ hearings but said this was resolved when concerns were raised.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The ward environment was safe and well maintained overall, however we identified a number of environmental issues which were likely to negatively impact on the young people admitted to the ward. The clinic room was secure and well maintained, although the work surfaces were chipped and in need of repair. In the seclusion room there were cracks on the bathroom floor which had also been present when we last inspected. These had been temporarily repaired with resin to reduce the infection prevention and control risk, but they still made the environment less pleasant for young people who needed to be nursed in seclusion. The registered manager said that a request for capital investment to refurbish the whole seclusion suite had been submitted to the provider. We also observed a taped notice on the seclusion room bathroom door window which partially obscured the view of observing staff, which could present a safety risk if young people at risk of self-harm were using the room. The mattress in the seclusion room had a cracked cover which presented an infection control risk. The registered manager told us this had been replaced before the end of the inspection. We found significant mould in the space between the external and internal windows in the ward kitchen and debris including a dead spider in the seclusion room window cavity.

Equipment was present to meet the needs of the young people and was usually in a good state of repair, this included emergency equipment which was regularly checked. We saw records which confirmed that equipment needing servicing and calibration had this done regularly and portable appliance testing was carried out to ensure the safety of electrical equipment. There was a system in place for staff to report maintenance issues with the environment and equipment. One young person told us that the maintenance staff could be slow to repair things when they were reported, for example their bedroom door kept slamming and they had been waiting some time for this to be resolved. However, the maintenance log for the ward showed that maintenance issues were usually resolved promptly. Young people had their own rooms with en suite toilet and shower rooms and all rooms had a nurse call point, these were also present in communal areas. The ward complied with guidance on eliminating mixed-sex accommodation, the ward was for females only. The seclusion room allowed two-way communication and had a clock that young people could see.

There were systems in place to monitor and manage environmental risks on the ward such as ligature risks, including mirrors and CCTV to monitor blind spots on the ward and information displayed to remind staff about the areas of ligature risk on the ward. Staff all completed ligature risk management competency assessment as part of their induction. Young people did not have unsupervised access to high risk areas, for example the ward kitchen or the stairs leading down to the secure garden. However, a member of staff we spoke with told us that less experienced colleagues did not always comply with the security procedures for the ward kitchen, which required staff to lock the door whenever they entered or left the room. We also observed staff not locking the door when they entered the room on more than one occasion while we were on the ward. A poster was put up to remind staff to do this while we were still on site. The entire hospital last had an independent fire risk assessment in March 2025 but a local assessment of fire risks on Woodlands ward had also been carried out more recently. Records showed that fire safety checks were taking place as required, for example fire alarm tests and tests of the emergency lighting and fire evacuation instructions were displayed. The nurse in charge of each shift completed and documented environmental safety checks 3 times per shift.

We scored the service as 3. The evidence showed a good standard. The service 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.

At the time we inspected the ward was staffed over their establishment levels for nurses and healthcare support workers and had a fully staffed multidisciplinary team. The registered manager told us that 2 of the MDT members would be leaving imminently, but there were plans in place for recruitment to these roles. The provider’s safer staffing data for the 6 months preceding our inspection (October 2025 to March 2026) showed that the ward was staffed at or over their baseline safer staffing levels for healthcare support workers at all times. For registered nurses there were 24 days in this 6 month period (19%) where the ward was staffed below establishment, but this was compensated for in terms of total staffing numbers by overstaffing of support workers. Following the inspection, the provider confirmed that their e-rosters stated that on 20 of these 24 days the ward did not have the required number of 2 registered nurses. However, they stated that further investigations had identified inaccuracies within the data due to information being inputted on incorrect days or the e-roster not being updated to include deployment of agency nurses. Following this review, they confirmed that the ward was staffed with 1 registered nurse on only 3 occasions during this period, and on these occasions the ward manager or another senior nurse provided cover. All the support staff we spoke with said that a registered nurse was always present and accessible on the ward. The ward was fully staffed for nurses and support workers on the day we visited.

The ward manager could adjust staffing levels daily to take account of case mix. Staffing was reviewed daily at the ward’s morning meeting and there was an out of hours escalation process for staff to request additional support when required. Sickness absence rates were low at 5% on average in the 12 months preceding our inspection. The average turnover rate for all staff was higher, at 21% in the 12 months preceding our inspection (April 2025 to March 2026). The ward manager said this was due to the challenging nature of the ward and we saw evidence of ongoing work to support staff wellbeing and so reduce the rate of staff turnover.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Bank and agency use on the ward were low (5% agency and 1% bank hours worked on the ward in the 6 months preceding our inspection). The staff and young people told us that when agency or bank staff worked on the ward, they were usually people they were familiar with. However, young people and carers did raise concerns about agency staff being more likely to make mistakes, for example medicines errors. The provider told us that, in the 12 months prior to the inspection, there were 27 medication errors on Woodlands ward and of these 2 (7%) were made by agency nurses. There was a system in place to ensure that agency and bank staff completed an induction and observations competency assessment before commencing work on the ward. Staff said that agency and bank use had decreased in recent months and was now usually just on night shifts or to cover enhanced observations.

The young people we spoke with told us that staff were visible on the ward at all times. Some young people told us that sometimes their leave was cancelled due to insufficient staff being available to facilitate this, however the provider stated that this had not happened in the 12 months preceding our inspection and we saw no evidence of this happening on the records we reviewed. The advocate told us that there had been a recent issue where the policy on taxi use to facilitate leave had been changed by the provider which had led to some leave being cancelled due to the late notice of these changes. The provider told us that this had not been a change of policy but rather a reinstatement of reasonable boundaries in line with promoting independence and recovery due to use of taxis for section 17 leave having increased over time. The provider stated this had not led to any instances of cancelled leave that they were aware of. Young people told us that it was difficult to access fresh air and outside space as the garden was off the ward down a flight of steps. Staff were not always available to support them to access the garden and our observations confirmed that this was a challenge on the ward due to the risks relating to people’s care. Young people also said that it could be hard to get the attention of a staff member during lengthy incidents involving multiple members of staff, such as nasogastric feeds involving physical restraint.

Staff told us that the ward was usually adequately staffed to ensure young people’s needs were met and they were kept safe. They said if they were short staffed this was usually due to a young person’s presentation changing and additional staff could be sourced reasonably quickly, for example support from other wards within the hospital. Staff also told us they felt the staffing levels were sufficient to maintain the safety of the young people and said they felt safe at work themselves. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. Staff told us that they were usually able to take their breaks.

The staff we spoke with told us that they were up to date with their mandatory training and said they had time to complete this in working hours. Staff also told us that they had regular supervision meetings and performance reviews and that they were up to date with these. Staff described having a comprehensive induction when they started working on the ward. The provider’s training data showed that over 85% of staff were up to date with all mandatory training modules except for crisis management (83%) and Oliver McGowan Tier 2 autism and learning disability training (23% as this was in the process of being rolled out at the time of our inspection). Staff were 100% compliant with Tier 1 of the Oliver McGowan training at the time of our inspection.

We scored the service as 2. The evidence showed some shortfalls as we identified some infection prevention and control risks during our time on the ward. However, the service had systems to assess and manage the risk of infection and usually took action control the risk of it spreading and share concerns with appropriate agencies promptly.

During our inspection of the clinic room, we observed a weighing chair which needed to be cleaned. This was due to staff preparing nasogastric feeds for young people who needed this due to severe food restriction on the treatment couch which resulted in liquid nutritional supplements being splashed on the chair. We also observed a pile of used linen on the clinic room floor. The mattress in the seclusion room had a cracked cover which presented an infection control risk. The registered manager told us this was replaced before the end of the inspection. The provider’s dress code policy required staff to be bare below the elbows (BBE) in clinical areas as infection prevention and control best practice, however not all staff working on the ward on the day we visited were compliant with this. We also saw that this was identified during spot checks of the CCTV footage across the hospital on multiple occasions, including on Woodlands ward. Following the inspection, the provider told us that, during ward level audits in March and April 2026 the compliance of staff with the BBE guidance was checked on 29 occasions and on 4 occasions staff were found to not be compliant with the guidance, which resulted in corrective action.

However, all communal areas of the ward were clean and we observed cleaning taking place during our visit. There were sufficient handwashing facilities in the clinic room and bathrooms. Clinical waste, including sharps, was safely stored and regularly collected, although the sharps bin was not dated to document the date of opening which is best practice. The young people we spoke with told us that the ward was kept clean and that cleaning took place every day and we saw cleaning records which confirmed this. The family carers who gave us feedback said the visiting facilities were always clean.

Staff received infection prevention and control training as part of their mandatory training modules and training data showed that 88% of staff were up to date with this at the time of our inspection. An infection prevention and control audit was carried out in April 2026 on the ward which showed 99% compliance with the provider’s standards of cleanliness and infection prevention and control practice. There had been no outbreaks of infectious disease on Woodlands ward in the 12 months preceding our assessment. We saw evidence in the care records that barrier nursing was carried out where necessary to prevent the transmission of infection on the ward. The kitchen providing food to the ward received regular environmental health assessments by the Food Standards Agency, most recently in March 2026, when it received a 5 star rating.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe. However, medicines met people’s needs, capacities and preferences and staff involved people in planning.

Medicines were not always stored safely. We found 1 open bottle of liquid medicine which was out of date and another medicine which was not being used in date order (the opened box was due to expire later than an unopened box). The medicines audits for the 3 months preceding our inspection also showed issues relating to medicines storage (opening/expiry dates not documented on a topical medicine and medicines not always being stored at the correct temperatures). Following the inspection, the provider told us that the April 2026 pharmacy audit report, which was not available at the time of the inspection, showed 99% compliance with their medicines management standards on Woodlands ward. The young people we spoke with told us that there had been a number of medication errors recently due to an agency nurse giving incorrect medicines or doses to multiple patients. The provider was in the process of investigating these concerns.

Controlled drugs were stored appropriately and the record keeping requirements in relation to these medicines were being met. There were arrangements in place for controlled drugs to be disposed of safely to reduce the risk of diversion. Records of temperature checks of the medicines fridge and clinic room showed that medicines were being stored at the recommended temperatures at the time we inspected.

Young people’s medication records were accurate and up to date, any allergies were clearly recorded on their records and documentation confirming the legal basis for prescription of medicines was present and correct for all patients.

Staff reviewed the effects of medication on young people’s physical health regularly and in line with National Institute for Health and Clinical Excellence (NICE) guidance, especially when the young person was prescribed specific antipsychotic medicines requiring additional health checks. Where young people had received rapid tranquillisation in response to disturbed behaviour the records showed that they received physical health checks following this as recommended by national guidance and the Mental Health Act Code of Practice.

There were effective arrangements in place to monitor the management of medicines on the ward, including stock checks by ward staff and monthly audits carried out by the pharmacy which supplied medicines to the ward. A pharmacist was available to provide advice to staff about medicines when required. A stock of emergency medicines was kept in the clinic room, and these were regularly checked and replenished as needed. The ward complied with guidance on stopping the overmedication of young people with a learning disability and/or autism including regular review of young people’s regular and ‘as required’ medicines at their ward rounds.