Ellern Mede Ridgeway

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The care and treatment records we reviewed demonstrated that care planning was personalised and there was clear evidence of patient involvement throughout. Plans were written in the first person. For example, for one young person this included theirs and their carers’ views on discharge goals and transition planning. Another young person had documented their comments and opinions on their positive risk-taking strategies. Young people told us that staff supported them to understand and manage their own risks better.

There were activities on offer to suit different interests, available in one-to-one or group settings. Young people were positive about the choice of activities. In addition to ward-based activities, there were trips to the cinema, football matches and opportunities to interact with animals. School staff visited some young people on the ward in line with their individual needs.

Staff empowered young people to make their own decisions about their care and treatment. Young people gave their feedback at their ward rounds and staff discussed and addressed it in detail.

The service understood the diverse health and care needs of patients and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff ensured that young people could continue accessing school or other learning while at hospital. Carers we spoke with were positive about the school provision. They told us about good communication with the young people’s local schools, clear plans and individual needs being met well. For example, school staff visited some young people on the wards and supported young people to build up from attending part-time to full days.

Staff supported young people to maintain contact with their families and friends. Some young people were admitted out of area. Their carers could join ward rounds virtually. Staff also told us about the provider’s charitable fund available to help with carers’ travel costs.

Staff involved other relevant services as appropriate, including the local acute hospital, GPs, schools, community eating disorder services and NHS commissioners.

Stakeholders we spoke with were positive about how the service facilitated continuity of care. One stakeholder described the pre-admission meetings as very helpful in joint goal setting between the young people, carers, referrers and community teams.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff provided information to young people in accessible formats if required, in line with their communication needs and preferences documented in the care plan.

Staff ensured that people could obtain information, such as treatments, their rights, key contacts, independent advocacy and how to complain. This information was available in booklets tailored for patients and carers and displayed throughout the hospital. However, there was no activity timetable displayed, and some young people reported not always knowing when activities or meetings were due to start.

Most young people and carers told us they were satisfied with their level of involvement in care and treatment. Carers were positive about communication from the service and said they received clear and regular updates. One carer told us how staff called them even at weekends to update them. Carers said staff were prompt in responding to their queries. This feedback was echoed in the hospital’s 2025 patient and carer survey results, where most respondents reported receiving enough information before and during admission. However, 2 carers thought that their feedback slot at MDT meetings could be longer.

Staff kept commissioners and other relevant professionals regularly updated. Stakeholders we spoke with were positive about the way staff communicated and shared information with them and their teams.

The service made it easy for patients to share feedback and ideas, or raise complaints about their care, treatment and support. They involved patients in decisions about their care and told them what had changed as a result.

Carers we spoke with knew how to complain, if needed, and believed that changes would be made as a result. Carers said there were regular opportunities to give feedback to the service, for example through weekly feedback forms and surveys.

The provider’s patient inclusion lead and expert by experience were accessible to staff and young people.

Young people could raise queries or concerns at weekly community meetings. However, not all young people attended those, and there was some variation in the feedback we heard. For example, one young person said they would go to their parent with any concerns, another to a consultant or therapist, and another that they would likely not tell anyone. One young person said they did not know how to make a complaint. This indicated that the process could benefit from better clarity. Additionally, the anonymous feedback box for patients was in a staff-only area, which we highlighted to staff during out site visit.

The service conducted annual patient and carer surveys. The most recent surveys were completed in 2025. Staff acted on the feedback received, for example work had started on improving the hospital environment. Weekly carer drop-in sessions were organised in response to requests for more practical family support. Staff involved young people through community and patient co-production meetings, and carers through family governance meetings. Additionally, staff planned to involve young people and carers in improving the design of future survey questionnaires.

Staff and managers handled complaints appropriately, in line with the provider’s policy. During the previous quarterly reporting period, the hospital received 7 compliments and 4 complaints. At the time of our inspection, 2 complaints were open. Both were from carers and related to care provision.

Staff discussed feedback and complaints in daily meetings and clinical governance meetings. Staff told us that learning from complaints was cascaded and workshops were run on the themes identified.

The service made sure that people could access the care, support and treatment they needed when they needed it.

Stakeholders from partner agencies told us the service was very quick to respond to new referrals. Two stakeholders shared their positive experiences of referring young people who went on to be successfully treated at the hospital and discharged without lengthy stays.

The service was accessible for people with mobility needs. The hospital was equipped with a lift and equipment such as a hoist was available.

There was adequate medical cover day and night and a doctor could attend quickly in an emergency. Senior managers and doctors were part of the on-call rota out of hours.

Staff ensured young people had access to appropriate care post-discharge and planned for this jointly with them, carers and relevant professionals. There was evidence of effective discharge planning in the care and treatment records we reviewed. Due to the level of complexity often involved, lengths of stay at hospital varied. Staff recorded and regularly reviewed provisional discharge dates for each young person.

The service occasionally admitted patients aged 18 and over when there were no vacant beds at the provider’s nearby hospital for young adults. Staff ensured that young and adult patients did not mix and put appropriate safeguards in place. At the same time, this meant that adult patients had restricted access and limited interactions within the hospital. The service recently admitted one young adult to the Cottage ward, pending a vacant bed at the provider’s adult site, who remained there approximately a month later. Shortly after our inspection, a second adult patient was admitted. We heard that this enabled both adults to interact with one another, and that both had begun attending the provider’s adult hospital daily for therapeutic activities and engagement with peers.

At the time of our inspection, the provider was reviewing the service model to include adult patients in its provision.

Staff and leaders actively listened to information about patients who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which patients and carers felt empowered to give their views. Carers and most young people we spoke with knew how to complain or raise concerns, although there was some variation in how some young people said they would do this.

Staff completed mandatory training in equality, diversity and inclusion (EDI), with 100% compliance. There was information displayed on the wards to make diverse groups of people welcome and included, for example an EDI calendar. Staff and patients celebrated religious festivals together.

Staff we spoke with told us about making personalised adjustments for people with protected characteristics under the Equality Act 2010. All staff had completed LGBTQ+ awareness training and the Oliver McGowan Tier 2 mandatory training on learning disability and autism. Staff told us about supporting transgender and non-binary patients with respect and dignity.

Carers were consistently positive about the dedicated family provision on offer, such as weekly carer groups, and good opportunities for peer support. One carer told us about a drop-in where they could discuss behavioural strategies with staff, describing it as a great forum for family support.

Patients were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

Staff actively involved young people and their families in making decisions about their care. We saw evidence of effective discharge planning in the care records we reviewed. Care planning included young people’s and carers’ views on discharge goals and transition planning. Discussions about discharge plans started at pre-admission meetings.

Staff ensured that all relevant teams and professionals were involved in planning the care and treatment of patients with complex needs, for example when young people were admitted from far out of area. These included local authorities, GPs, schools, community teams and NHS commissioners. For example, community teams were invited to weekly MDT meetings to help with planning step-down care. The provider’s school staff supported young people to build up to attending school full time and liaised with their local schools effectively.

Staff recorded provisional discharge dates, which they regularly reviewed with the young people, carers and professionals throughout the treatment journey.

Feedback from partner agency stakeholders demonstrated that the service worked well jointly with them in planning complex care and achieved positive outcomes for patients. One stakeholder described the pre-admission meeting process as excellent and very helpful. Some stakeholders thought that joint working could be further strengthened by providing clearer expectations on admission, involving community teams sooner and more assertive discharge planning.