Cheadle Royal Hospital

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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 requires improvement. At this inspection the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff usually felt respected, supported and valued. Governance processes usually operated effectively, although we did identify some shortfalls which had not been picked up by the provider’s quality monitoring processes. 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 and 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.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider had 7 strategic goals set out in their 2023-2025 strategy and a clear vision to become the leading European provider of high quality mental health and rehabilitation services. The organisational values were striving for excellence, being positive, putting people first, acting with integrity and being supportive. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The staff we spoke with said they were aware of the vision and values through team meetings and their supervision and performance review meetings.

Staff and young people spoke positively about the culture on the ward. Young people said staff treated them kindly and respectfully and staff told us that they had not witnessed any conduct from colleagues which caused them concern and said they would feel safe to challenge this if they did. We saw examples of how the ward culture was inclusive and person-centred, for example in the positive and affirming way neurodivergent young people were being supported. We heard anecdotally that some Black staff had raised concerns about not being treated equally to White colleagues, however none of the staff from ethnic minorities or global majorities we spoke with during our inspection had personally experienced any racial discrimination or inequality. The managers we raised this with confirmed action would be taken to investigate the issue further with the staff team to ensure everyone felt well supported.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels 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.

Leaders had the skills, knowledge and experience to perform their roles. The previous ward manager had left since our last inspection and there was an interim ward manager in post, pending recruitment to the substantive position. The staff we spoke with gave positive feedback about the interim ward manager and said that the hospital’s senior leaders, including the hospital director, were visible on the ward and approachable for staff and young people. Leaders had a good understanding of the services they managed. The interim ward manager had a good understanding of the governance of the ward and could explain clearly how the teams were working to provide high quality care. The safety and quality of care on the ward was reviewed by the hospital director and other senior leaders at quarterly senior management meetings for the whole hospital. Leadership development opportunities were available, including opportunities for staff. All the staff we asked about career development said they felt well supported in this respect and senior staff said they had received learning and development in relation to leadership and management. We saw examples of the leadership training that staff received.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Young people and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Weekly community meetings took place for young people to share their views and the minutes of these showed that the meetings were well attended and that young people felt able to raise concerns and make suggestions at these meetings. This included involvement in decision making about changes to the service – the meetings included standard agenda items relating to the care environment, therapy and activities and ideas and suggestions. Information was displayed on the ward and fed back at subsequent meetings to inform young people about the action taken in response to their feedback.

Staff had access to a freedom to speak up process to raise concerns confidentially. The staff we spoke with all told us that they were aware of how to use this process and said they would feel safe to raise concerns if they needed to. Freedom to speak up data was collated in quarterly reports for the whole provider which monitored rates of concerns raised and any trends or themes of concern from the subject matter. In the quarter immediately preceding our inspection (January to March 2026), 15 concerns were raised through the freedom to speak up process across all the provider’s services, of which 13 were reported openly, suggesting that staff did feel safe to voice concerns (although it was not possible to establish from the report whether any of this data related to Woodlands ward).

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

The provider organisation had identified embedding a culture of inclusion, openness and trust as one of the 7 core priorities in its 2023-2025 strategic plan. Staff had access to a wide range of equality networks including Black and Minority Ethnic (BME), LGBTQ+, disability, menopause, men’s, women’s, parents’ and neurodiversity networks. In the most recent staff survey for the whole hospital (April 2025), 76% of staff stated that they were satisfied with Priory’s efforts to improve equality, diversity and inclusion, 78% of staff said they felt they fitted in and could be their whole self at work and 71% of staff said they believed effective action would be taken in relation to concerns about harassment, bullying or discrimination.

We heard anecdotal evidence from staff that Black colleagues had raised concerns with them about not being treated equitably compared with White staff. However, none of the staff from ethnic minorities or global majorities we spoke with raised any concerns about racial discrimination from colleagues or any general wellbeing concerns. We fed this back to the ward manager and hospital director and were assured that action would be taken to investigate this further. Some staff reported having experienced racial abuse from young people using the service but said they had felt well supported by the provider organisation in relation to this. Staff had access to wellbeing support including reflective practice sessions on the ward and access to a counselling service as part of their employee benefits.

We scored the service as 2. The evidence showed some shortfalls. We identified some issues in relation to risk management, infection prevention and control, the care environment, medicines optimisation and record keeping which had not been identified and addressed through the provider’s quality monitoring processes. However, the service had clear responsibilities, roles, systems of accountability and good governance overall.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information was shared and discussed. However, some staff told us that they did not always get information about lessons learned from incidents. At the time of our inspection the ward had an enhanced level of support from the hospital’s governance team due to concerns which had previously been raised by commissioners of the young people’s care. This included safety huddle meetings and minutes of these meetings showed that a range of governance issues were being regularly reviewed and discussed, including management of incidents, measures to reduce restrictive practices and quality monitoring data. The regular ward governance meetings had been superseded by these meetings temporarily, but staff and managers told us that these meetings had previously taken place and would be reinstated when the safety huddle requirement was lifted.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. Examples of changes made as a result of incidents, complaints or feedback included improvements in incident management and measures on the ward to reduce restrictive practice. They had also made improvements to the arrangements for supporting young people with an eating disorder with nasogastric feeds to meet their nutritional needs.

Staff undertook or participated in local clinical audits. The audit calendar for the ward included a range of audits of care records, the environment, compliance with infection prevention and control guidance and Mental Health Act compliance. The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. A dashboard was maintained in relation to audit findings, incidents, staffing status and other key performance indicators for the ward, which enabled the ward manager to monitor the safety and quality of care on an ongoing basis. However, we found some issues in a number of areas where the provider’s quality monitoring systems had not identified the concerns. These areas included clinical and environmental risk management, medicines management and clinical record keeping.

There was a risk register for the whole hospital which enabled the senior leadership team to monitor organisational risks and ensure action was progressing to mitigate these risks as far as possible. The information on the risk register at the time of our inspection matched the issues managers and staff on Woodlands ward were aware of. These included challenges with community placements leading to delayed discharges, maintenance of the environment due to the age of the building and challenges with the IT infrastructure leading to WiFi issues on the ward at times. The ward manager told us there was a process for concerns at ward level to be escalated for consideration of whether they needed to be included on the hospital’s risk register. The service had plans for emergencies – for example, adverse weather, infectious disease outbreak and loss of essential utilities. These were contained in the hospital’s major incident contingency plan which was available to staff via the intranet.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, usually worked well and helped to improve the quality of care. However, some staff told us that WiFi access on the ward could be a problem and challenges with the IT infrastructure across the whole hospital were identified as an organisational risk on the hospital’s risk register. Information governance systems included confidentiality of patient records. Electronic records were stored on a password protected system and paper records were stored securely in the ward office.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care in the form of a daily dashboard which included key performance indicators relating to staffing numbers, care records, incidents and complaints and the findings of audits and environmental checks. A morning meeting took place each day during the working week at which this information was reviewed to ensure action was taken promptly in response to any issues, for example anticipated staffing shortfalls or patient safety concerns. The governance data was escalated to the hospital’s senior management team in monthly governance returns to enable high level oversight of any significant pressures or trends of concern on the ward.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and managers engaged with external stakeholders, such as commissioners and care coordinators. Records showed that commissioning case managers, community care coordinators and social workers were able to attend ward rounds and Care Programme Approach reviews for young people and had their views taken into account. External stakeholders were present at the ward round we observed and contributed meaningfully to the discussions. Stakeholders told us that the ward worked collaboratively with them and said that MDT meetings were well structured and accessible.

Young people and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. Commissioners confirmed that they were able to visit the ward and spend time with staff and young people, and said they found managers and staff to be supportive and approachable during these visits.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Innovations and improvements were taking place in the service. At the time of our inspection the provider had responded to concerns raised about unapproved restraint holds being used with a significant piece of work to improve the staff training and governance in relation to physical interventions and reducing restrictive practices. This included the introduction of the role of incident manager to the hourly allocations for each shift. This meant that one member of staff at all times on each shift was able to focus on documenting incidents, supporting colleagues with debrief and ensuring there was effective oversight of any restrictive practices used.

Staff used quality improvement methods and knew how to apply them. The provider had a system for staff to submit suggestions for QI projects. One example was a piece of work, led by the hospital’s director of clinical services, looking at making improvements to the ward round process on all the wards. Improvements were also being led by the ward team to the engagement of young people and their families and the systems in place to support staff wellbeing. These projects were supported by action plans with clear timescales for implementation of the work and indicators for successful completion of the projects.

Staff participated in national audits relevant to the service and learned from them. One of the doctors we spoke with said they had recently contributed to the national audit of the use of psychotropic medication in inpatient child and adolescent mental health services.

Wards participated in accreditation schemes relevant to the service and learned from them. The ward received regular peer reviews from the Royal College of Psychiatrists’ Quality Network for Inpatient Child and Adolescent Mental Health Services (QNIC). The most recent review prior to our assessment took place in December 2025. The ward was found to be between 74% and 100% compliant with the QNIC standards at this review across their 4 assessment domains, with only 2 standards being found fully not met. There was an action plan in place showing the proposals to address the issues leading to the standards which were not met where possible.