Orri Wimpole Street

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 was the first inspection of the registered Wimpole Street location following the relocation of the service from its previous premises in Hallam Street.This key question has been rated Good. This meant people were safe and protected from avoidable harm.

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 3. The evidence showed good standard. The service had a strong, proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Staff fostered a proactive and transparent approach to safety. They raised concerns and reported incidents, which managers investigated thoroughly. This meant that opportunities to learn were shared so that improvements to safety could be made.

The service had one serious incident in the last 12 months. This had been investigated and an action plan developed to address the shortfalls identified.

All staff knew what incidents to report and how to report them through the service electronic reporting system. All staff were open and transparent and fully committed to reporting incidents and near misses. Leaders embedded, maintained, and sought to create a culture of openness and collaboration. The service followed the Patient Safety Incident Response Framework (PSIRF) for reviewing serious incidents.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. For example, where changes to individual appointments were necessary, staff apologised when communication about those changes had not been as clear as intended.

The service consistently identified lessons learnt and embedded good practice across teams. Managers and leaders routinely discussed incidents during team meetings, daily flash meetings, clinical governance meetings, weekly in-house training sessions, and at the Learning and Outcomes Group. This group reviewed incidents, complaints, and concerns to identify themes, extract learning, and highlight opportunities for continuous service improvement.

Staff reported that they consistently received debriefs and managerial support following serious incidents. They described the service as having a positive, inclusive learning culture. Teams were given structured opportunities such as team meetings to contribute suggestions in response to emerging themes, and they were supported to embed agreed actions into their everyday practice. All staff reported that the culture was one of openness and reflection so that improvements could be made from any mistakes.

The service used every opportunity to learn from internal and external incidents, to support improvement and safety. Staff were consistently encouraged to raise safety concerns and share ideas for improvement. Leaders continually reinforced the value of learning through their actions and communication. For example, following an incident the service had developed a care protocol for managing insulin use in clients with eating disorders and further training diabetes management training.

Managers completed a monthly audit of incidents, complaints and compliance with the duty of candour. The service used an electronic system to track all incidents, ensuring that actions were completed within agreed timescales to reduce the likelihood of similar events occurring again. Lessons learned were shared through the system, which also recorded when staff had read and acknowledged the information. This provided clear oversight of learning, accountability and staff engagement with safety processes.

We scored the service as 3. The evidence showed a good standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service had a robust referral and admission process to ensure all necessary information was gathered to ensure patient safety. All referrals to the service whether online or face to face were received through Orri’s intake and assessment processes to determine whether the service was appropriate to meet the needs of the individual. The service did not accept patients who were medically unstable or experiencing acute psychiatric illness requiring a different level of care. Once accepted, thorough assessments were carried out to determine if the service could meet the needs of the patients safely, this included clinical suitability, risk and the patients’ ability to engage in treatment. Staff utilised clinical meetings and detailed handovers to communicate any identified risks and ensure a safe transition into the service.

We received feedback from commissioners who were very positive about how well the service worked with patients, their families, and system partners to ensure effective admission to the service.

The service provided comprehensive information for patients and their families as appropriate. For children and young people, the service involved parents/carers in the assessment process.

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. Staff worked collaboratively with GPs, inpatient and community mental health services to ensure continuity of care. For example, patients who were pregnant or had diabetes received tailored treatment and care plans to support their needs. Orri worked collaboratively with the patient’s obstetrics or specialist diabetes team to ensure informed, coordinated and multi‑agency care.

The service demonstrated a well‑coordinated and proactive approach to maintaining patient safety, particularly for individuals presenting with severe physiological instability. The service had implemented a clearly defined escalation pathway with the local Accident and Emergency department, ensuring staff understood when urgent medical intervention was required. A structured handover process was in place, enabling the timely and comprehensive transfer of clinical information to the acute hospital team and supporting safe continuity of care.

Commissioners told us the service was very responsive and effective in managing physical health risks, such as weight loss and abnormal blood results and stabilising the individual.

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.

Patients using the service told us they felt safe and knew how to raise concerns when they did not feel safe.

The service had clearly defined and embedded systems, processes and policies to keep people safe and safeguarded from abuse.

Safeguarding was embedded within everyday practice across the service. All clinical and non-clinical staff completed mandatory safeguarding training for adults and children. Clinical leads and team leaders completed level 3 safeguarding training. The provider reported that all staff would be trained to level 3 and those that were outstanding of that training would be receiving it in the current quarter. Staff we spoke with demonstrated a proactive, confident and consistent understanding of how to recognise and raise safeguarding concerns. Staff provided clear and relevant examples of how they protected patients from abuse, harassment and discrimination, including those with protected characteristics under the Equality Act. The service had a Head of Diversity, Equity and Inclusion (DEI) lead, supported by a multidisciplinary DEI Committee with representatives from across the organisation and all departments. This promoted an open culture that supported staff to recognise and respond to any unintended or covert discrimination within the service.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Each team had a designated safeguarding lead and an overall safeguarding team that had oversight of safeguarding across all three service lines. The overall service safeguarding lead was due to undertake their level 4 safeguarding training.

The service went beyond mandatory training requirements to strengthen safeguarding practice. The service produced a quarterly safeguarding bulletin which detailed any themes and trends identified from safeguarding incidents, training requirements and details of the service safeguarding flow chart. This ensured that beyond the mandatory training staff were always thinking about safeguarding. The service ran safeguarding awareness campaigns such as ‘Remember, Remember Safeguarding November’.

Staff told us that safeguarding concerns were routinely discussed during morning flash meetings, multi‑disciplinary meetings and handovers, and that safeguarding referrals were reviewed through clinical governance processes. Staff were confident in how to raise a safeguarding referral and understood who to escalate immediate concerns to. They had access to safeguarding leads for advice and support whenever needed.

The service worked in collaboration with an external organisation to provide independent case review, oversight of training, and scrutiny of the service’s culture, knowledge and skills. This partnership offered an additional layer of external assurance and helped ensure the service operated in line with national guidance for children, young people and adults. The external organisation provided objective challenge and supported the service to maintain safe, evidence‑based practice.

Commissioners fed back that the service was highly responsive in addressing any safeguarding concerns.

Mental Capacity Act

Staff demonstrated an excellent understanding of the Mental Capacity Act particular the five statutory principles and how they applied the core principles throughout their daily practice. Staff consistently presumed capacity and took practical steps to support patients to make their own decisions. When staff assessed patients as not having capacity, they made decisions in the best interest of patients and considered the patient’s wishes, feelings, culture and history. Staff kept records of capacity assessments and best interest decisions.

Mental Capacity Act training was mandatory and compliance was at 100%. Managers had created a Mental Capacity Act song for staff to remember the five principles. They also held regular social learning sessions called ‘Cake and Capacity’.

The service monitored how well it followed the Mental Capacity Act and made changes to practice when necessary. Staff assessed and recorded capacity to consent clearly each time a patient needed to make an important decision.

Staff were clear about recording consent for care and treatment, and each patient was expected to complete a consent form upon admission to the service. This included information about whether the patient consented to their information being shared with their family or carers and external services. Managers completed a quarterly audit to evaluate how well staff applied the Mental Capacity Act.

Staff we spoke with had a good understanding of consent including the Mental Capacity Act. Patients were supported to communicate and make decisions to enable the service to deliver person-centred care and treatment in line with people's best interests. Multi-disciplinary team discussions involved the patient and patient's family as appropriate in decision making and planning care and treatment.

We scored the service as 4. The evidence showed an exceptional standard. The service always worked well with people to fully understand and manage risks by thinking holistically. They provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them. Staff assessed and managed risks to patients and themselves well.

Patients told us they were involved in managing their individual risk and contributed to their risk management plans. Patients were provided with information on who to contact in a crisis and out-of-hours arrangements for support or if their condition worsened. This information was provided through emails, the patient handbook and information on the service website.

Staff were very proactive in assessing, managing and anticipating risks to patients and themselves. Staff had open conversations with patients concerning their risks and produced a safety plan in collaboration with them. This was updated if there was a change in current risks. All patients we spoke with said they felt safe whilst using the service.

We looked at 9 risk assessments and risk management plans. The service had a robust approach to clinical risk management. Staff completed a full medical screening and risk assessment before admission to ensure that the patient’s level of risk was suitable for this service. For patients undertaking online treatment the service had protocols for coordinating physical health care and monitoring with the patient’s named GP.

All patients with either acute or chronic physical health needs had a visual flashing flag on their electronic record. This flagging system ensured staff were immediately alerted to any specific physical health risks and were directed to the relevant care plan for guidance on safe and appropriate management.

Staff used the Medical Emergencies in Eating Disorders (MEED) guidance to risk‑assess all patients. Each patient had a completed MEED risk assessment in place. This supported the clinical team to determine each person’s level of medical risk and informed the required frequency of physical‑health observations, the level of monitoring and any necessary escalation. Physical health observations included risks such as a BMI below 13, electrolyte imbalance or abnormal ECG. To strengthen oversight across the service, Orri maintained a live care board within the Orri Hub, displaying each patient’s current MEED risk rating. This enabled the clinical team to review risk levels across the entire caseload in real time, identifying patients who may require further assessment, and ensure timely, coordinated responses to emerging concerns.

The service also carried out an assessment of whether the patient was at risk of re-feeding syndrome. Re-feeding syndrome is a potentially fatal condition caused by initiation of re-feeding quickly after a period of not eating.

Patients attending the in-person day care and outpatient programme had their physical health monitored by the nursing team. The service ran planned physical health clinics and physical health drop-in sessions throughout the week. For online patients', physical health monitoring was carried out by the GP or another healthcare provider. Risks were clearly identified in patient records and were updated after a change in risk or incident, including any safeguarding concerns. Medical risk was also reviewed through regular MDT discussions with oversight from the consultant psychiatrist and ongoing monitoring of the live care board, ensuring that any changes in risk were identified and acted upon promptly. For example, patients were referred to the acute hospital if they had significant electrolyte abnormalities, bradycardia (Low pulse), hypotension, postural instability, significant weight loss or concerns regarding re-feeding syndrome. For patients accessing in person day care the service also used National Early Warning Score 2 (NEWS2) to monitor for acute physical deterioration.

Staff responded promptly to any changes in risks to patients and sudden deterioration in a patient’s health, for example the service had referred a patient for urgent medical assessment at the local acute hospital due to a very low pulse. Staff discussed patient risk in the daily flash meeting, morning and evening handover meetings. This was for all service lines. The evening handover meeting ensured that staff were able to discuss any patient risks or concerns before the service closed for the evening. The service did not have a waiting list, so there were no patients waiting to be seen where risks were unknown.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

We scored the service as 4. The evidence showed an exceptional standard. The service was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

Patients spoke very positively about the environment. We observed patients using the therapy rooms, reception area and the dining room.

The environment had been purposefully co‑designed with patients to ensure it was both safe and therapeutically supportive. The service had robust health and safety and compliance arrangements in place for managing the environment, maintenance, and staff training. We reviewed monthly meetings where the environment was discussed. These showed discussions were comprehensive, clearly identified any shortfalls, and outlined the actions and arrangements in place to address them.

Staff carried out regular risk assessments of the care environment to ensure it remained safe for patients, staff and visitors. All staff knew the locations of ligature cutters and had been trained in their correct use. Quality and safety drills were undertaken quarterly, including emergency simulation exercises such as responding to a collapsed patient or managing a ligature incident, to ensure staff were confident and prepared for real‑life scenarios. Staff requested additional opportunities to practise cardiopulmonary resuscitation (CPR) to ensure they maintained their confidence and competence. In response, the service purchased a resuscitation manikin and introduced regular practical CPR sessions to support ongoing emergency preparedness.

All therapy rooms were locked when not in use.

Nurse call wall alarms were available throughout the building. These were also portable alarms and staff could carry them when supervising patients on the roof terrace garden.

The service had closed circuit television (CCTV) in all communal and corridor areas. Managers used CCTV for reviewing incidents that occurred as part of their investigations. CCTV signage was displayed to inform patients and visitors that CCTV monitoring was in operation.

The premises were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. There was an Automated External Defibrillator (AED) machine in the clinic room. Staff checked this regularly to ensure that it worked. There was appropriate signage, so staff knew where it was located. Nursing staff completed daily checks of EpiPens for patients with allergies to ensure they were in date, accessible, and ready for immediate use.

Fire safety arrangements were in place. Of eligible staff, 100% were up to date with day service fire safety training. Fire escapes were clearly signposted on each floor. Fire equipment was regularly checked to ensure it was fit for purpose. For patients with mobility difficulties fire evacuation chairs were available. Where required, staff completed personal emergency evacuation plan (PEEP) for patients who had mobility difficulties. The service conducted regular fire drills four times a year. The most recent fire drills took place in February 2026.

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.

Patients told us there were enough staff available.

The service had enough staff of different disciplines, who knew the patients and were appropriately trained to keep them safe from avoidable harm. The service had a range of clinicians, administrative staff, therapists, dietetic staff, and eating disorder associates. Managers ensured that vacancies were covered with regular contracted agency staff, who were fully inducted into the service before they started work.

There was adequate medical cover within the service. The service had enough medical staff with two consultant psychiatrists and a physician associate in post.

Staffing for both in person and online services was reviewed at the daily operations meeting. Capacity planning was carried out a patient group level. Each patient group accommodated 8 patients. Groups operated with fixed, protected hours for occupational therapy, nursing, dietetics, psychiatry and individual one‑to‑one sessions.

The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed.

The service had a comprehensive programme of mandatory and specialist training, with all mandatory modules tailored to specific staff roles. Completion rates were monitored through an online compliance system. Managers notified staff when updates or refresher training was due. Staff had completed and remained up to date with all required training, achieving a 91% compliance rate. The training provided was appropriate for the needs of the patient group.

We saw that there were staff trained in first aid, basic and intermediate life support who could attend to physical health emergencies.

Managers had developed a bespoke mandatory eating disorder course for all staff. This enabled staff to deepen their knowledge and skills in treating eating disorders using evidence‑based approaches. The course was competency‑based, ensuring that learning outcomes were measurable and that staff were equipped to deliver safe, effective care.

The service carried out employment checks on staff, including criminal background checks, qualifications and right to work at the time of recruitment and on an on-going basis where appropriate.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. ‘Clean’ stickers were visible and in date.

The environment was clean, well‑maintained and appropriately furnished, supporting both safety and infection‑prevention standards. High‑touch surfaces were cleaned frequently throughout the day, reducing the risk of cross‑contamination and helping maintain a hygienic setting for patients, staff and visitors. A guide dog was present on the premises to support a visually impaired patient, and staff ensured this was managed in line with infection‑control procedures.

Cleaning records were up to date and demonstrated that all areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing. Staff had access to personal protective equipment (PPE), handwashing facilities and training in infection control to keep themselves and patients safe. Training rates for infection control were 100%. Teams followed a bespoke ‘hands up’ hand washing dance to learn handwashing techniques.

Staff followed hand hygiene guidelines and regularly completed hand hygiene and infection, prevention and control audits, where shortfalls were identified action plans were in place, for example new signage and disinfectant wipes had been placed beside sensory and fidgety toys for neurodiverse patients.

The service had an Infection Prevention and Control lead that staff could contact for support and guidance.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service told us they did not routinely prescribe medicines and that direct prescribing was only allowed in exceptional situations. Prescribing was normally carried out by the individual’s GP.

During our inspection we found that two psychiatrists had not been following this policy and prescribed medicines more frequently than intended under the service's policy for day and outpatients. Following the inspection, the service immediately reviewed prescribing practices. Senior leaders initiated a rapid review to understand the scope of the issue and ensure safe, compliant practice. Clear actions were implemented, including reinforcing policy expectations with all prescribers, audit of all prescriptions issued, additional training, clinical oversight, review of medicine processes and ensuring all prescriptions were subject to appropriate checks. The rapid review found there had been no impact on the patients because the prescribing doctors had been liaising with the patients GP. Prescribing compliance was being monitored through regular audits, and clinical governance meetings. This area of risk was added to the service risk register.

Patients aged 18 and over were permitted to bring in any required medicines. Although the service did not routinely store medication, nursing staff could make appropriate arrangements when clinically necessary, including refrigeration or measures to manage associated risks. For patients under 18 nursing staff carried out individual risk assessments to determine whether medicines could be kept on their person or stored safely by the service.