The Care Quality Commission
  • Mental Health
  • Independent mental health service

Rhodes Wood Hospital

Overall: Good read more about inspection ratings

Shepherds Way, Brookmans Park, Hatfield, Hertfordshire, AL9 6NN (01707) 291500

Provided and run by:
Elysium Healthcare Limited

Important: The provider of this service changed. See old profile

All Inspections

During an assessment of Child and adolescent mental health wards

Rhodes Wood Hospital registered with CQC in October 2016 to provide the following regulated activities; assessment or medical treatment for persons detained under the Mental Health Act 1983, diagnostic and screening procedures and treatment of disease, disorder or injury. The hospital accommodates male and female young people, between the ages of 8-18 with a primary diagnosis of an eating disorder. There were 37 beds across 3 wards: Rainbow, Shepherd and Cheshunt wards.

We completed a responsive unannounced inspection of this service on 5 June 2025 due to concerns about patient safety. During our on-site visit we did not find any concerns relating to safety of young people on observations or sexual safety.

Our last inspection of Rhodes Wood Hospital was in May 2022, where we found a breach of Health and Social Care Act (Regulated Activities) Regulations 2014, relating to premises and equipment. The service was told they must ensure all areas of three wards were redecorated, maintained and visibly clean. At this inspection there were no infection prevention control issues with flooring or walls, as found at our last inspection. However, some areas of the environment needed improvement, such as holes in ceilings and walls, that were in the process of being resolved.

During an assessment of the hospital overall

Rhodes Wood Hospital is a registered location under the provider Elysium Healthcare Limited. This assessment looked at Child and Adolescent Mental Health wards, which we rated as good. As part of this assessment, we looked at the key questions of Safe and Well Led.

The service provided safe care. There was a proactive learning culture, where incidents were recorded, appropriately investigated and lessons learned were shared with the team. The service worked with partners to establish safe systems of care, including community teams. There were effective systems, processes and practices in place to ensure that young people were protected from abuse and neglect. The hospital had access to a range of specialists to meet the needs of young people. This included doctors, nurses, psychology and dietetics teams. Staff had received training relevant to their roles. Leaders were visible within the service and staff told us they felt supported. There was good governance. Multi-disciplinary meetings had a clear framework, where essential information was shared. 

However, some areas of the hospital were not well maintained, although there had been some improvement since our last inspection. There were areas where paint had peeled from walls, doors and skirting boards were marked. We also observed two water leaks that had left large holes in the wall of the kitchen on Rainbow ward and in the ceiling of the corridor. Following our inspection, the provider shared their re- decorating schedule.

Some staff were not able to tell us how they could access ligature cutters on an upstairs landing on Shepherd ward. Following our inspection, leaders took action to ensure that staff knew how to access ligature cutters in an emergency. 

Some bedrooms were shared. We raised this as an enquiry with the provider. Following our inspection, the provider had asked young people their opinions on bedroom sharing, with most young people preferring to share. 

24 May 2022 to 25 May 2022

During a routine inspection

Rhodes Wood hospital is a registered location under the provider of Elysium Healthcare Limited. The hospital comprises of three different wards: Shepherd, Cheshunt and Rainbow wards. Shepherd and Cheshunt wards can accommodate males and females, between the ages of eight and 18 years, who have a primary diagnosis of an eating disorder. Rainbow ward provides care and treatment for young people who may have more complex presentations and can accommodate males and females, between the ages of 12 to 18 years.

Following the last inspection, a number of breaches in regulation were identified. This resulted in conditions being imposed and a warning notice being issued. The provider subsequently took appropriate actions and the conditions were removed. The aim of this inspection was to review the breaches in regulation identified following our last inspection which were contained in the warning notice, and to ensure that the actions previously taken had been fully addressed and embedded in practice.

Our rating of this location improved. We rated it as good because:

  • The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • The ward teams had access to the full range of specialists required to meet the needs of the young people on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients, families and carers in care decisions.
  • Staff made sure children and young people had access to opportunities for education and work and supported them. Staff also encouraged the young people to maintain relationships and links with their local home community.
  • There was compassionate, inclusive and effective leadership at all levels. Leaders had the skills knowledge and experience to deliver high quality personalised care. Leadership development was embedded into the service and there was a strong culture of staff development across all levels of service.
  • There were robust and effective governance processes in place which were embedded into the service and enabled leaders to effectively manage the service.

However:

  • Not all ward areas were clean or well maintained although all were well furnished and fit for purpose.

19 February 2020

During an inspection looking at part of the service

We did not rate this inspection. The ratings from the inspection which took place 09 to 11 April 2019 remain the same.

At the inspection in April 2019, we issued enforcement action because the provider failed to provide safe care and treatment to young people.

We carried out a focused inspection in October 2019 to check against the enforcement action taken in April 2019. Following this inspection, we issued urgent enforcement action because the provider was failing to provide safe care and treatment to young people. The provider was required to make improvements in the use of seclusion and long term segregation. These, specifically were:

  • Patients did not have care plans to reflect that seclusion and segregation was required as part of their care.
  • Staff confirmed they had received training on seclusion and long-term segregation. However, there was noticeable confusion as to what they were, and the differences.
  • Significant numbers of seclusion paperwork were incomplete and not comprehensive.
  • We were not assured that staff understood or followed the Mental health Act Code of Practice in relation to seclusion and long term segregation.

This inspection looked specifically at these areas of concern. The inspection was focused and unannounced. We do not revise ratings following inspections of this type. Following this inspection, we issued further enforcement action. We found the following during our focused inspection:

  • Staff that we spoke with had received training on seclusion and long-term segregation. Only seven out of ten frontline staff were able to clearly explain the meaning of seclusion and six out of ten frontline staff were able to explain long-term segregation. Staff knowledge varied considerably, and staff remained uncertain on the meaning of long term segregation. We were therefore not assured that all staff had retained their knowledge of the training or that they would be competent in implementing seclusion or long term segregation.
  • Data received during the inspection indicated that 80% of permanent staff had received training on seclusion and long term segregation however we did not gain clarity on the figures for agency staff.
  • During the inspection we received a copy of the seclusion and long term segregation policy. This was incomplete as it was still under review and was not therefore ready for use by the staff.
  • On the morning of the inspection, we requested the nursing and medical reviews for long term segregation as they were not recorded in the patient records. They were provided to us after further requests. The medical reviews were not in line with the Mental Health Act code of practice. The record showed a log of the Doctor’s signature each day. We noted that medical reviews had not always been undertaken at the weekends and those that had been done were completed over the phone and not face to face.
  • The nursing reviews were not in line with the Mental Health Act code of practice. The records showed a question had been posed for staff to complete within the daily shift checklist (and not a separate long term segregation record). The question read: "Is the LTS care plan being followed?" In some instances, this was left blank or recorded as not applicable. This checklist commenced in February 2020 one month after the period of long term segregation had started.

However:

  • The provider had submitted a weekly update on any patients with restrictions on their movements. There were none until mid-January 2020.There had been no episodes of seclusion and on reviewing the patient records for Mymwood we were assured that this was the case.
  • We received a submission from the provider that a young person on Mymwood ward had commenced long term segregation in mid-January 2020. The records that we reviewed during the inspection stated that the plan was discussed at the Multi Disciplinary Team Meeting in early February 2020 and then shared with the Local Authority social worker and NHSE.
  • During the inspection we reviewed the long term segregation care plan which was detailed. We reviewed the records and the long term segregation was reviewed weekly by the multi disciplinary team starting on 16 February 2020 and weekly thereafter. We saw from the patient records that staff were making regular efforts to engage the young person in appropriate activities and that the young person went out on leave with their parents and with nursing and occupational therapy staff.

17 - 18 October 2019

During an inspection looking at part of the service

We did not rate this inspection. The ratings from the inspection which took place 09 to 11 April 2019 remain the same. This was a focused, unannounced inspection, to follow up on enforcement action we issued to the provider after our last inspection.

At the last inspection, we issued enforcement action because the provider was failing to provide safe care and treatment to young people. The provider was required to make significant improvements in different areas. These, specifically were:

  • the safe management of ligature risks
  • staff knowledge, understanding and implementation of seclusion
  • staff response to alarms
  • thorough checking of emergency bags
  • infection control
  • timeliness and completeness of individual patient risk assessments
  • the safe management of Section 17 leave.

During this inspection, we found some areas of significant improvement. The provider had acted upon previous concerns raised. Therefore the warning notice has been lifted. However, we did serve an urgent notice of decision, around the management of seclusion and long-term segregation.

Ligature risk assessments identified all potential ligature risks across the hospital. Each risk contained mitigation, so staff knew how to manage identified risks. Staff knew where ligature risk assessments were, and could refer to them easily.

The provider had invested in a new alarm system across the hospital. All clinical staff carried personal alarms. Alarms were routinely tested and charged to ensure they were in full working order. When an alarm was activated, it sounded across the hospital. Viewing panels had been installed in all three wards, which directed staff to the location of the alarm.

Nursing staff checked all three emergency bags across the hospital regularly. All equipment and medicines which should have been present, were present. Staff had recorded contents accurately.

Staff adhered to infection control when disposing of both general, and clinical waste across all three wards. Nursing staff had appropriately labelled sharps bins, used these appropriately, and they were not over filled.

Staff completed an individual risk assessment of each young person upon, or shortly after admission. Risk assessments contained appropriate and up to date information around risks, to include how staff managed these as safely as possible.

Doctors recorded the parameters of authorised leave clearly.  Specific duration of leave was stipulated for all young people. Staff recorded the names of escorts in most instances. Staff, where appropriate, had identified and recorded details of the home address for when young people were to reside with parents. Staff recorded episodes of leave, including views on how the leave went, from young people, staff or family members / carers as appropriate. Staff had implemented and discussed contingency plans with young people, in case leave did not go as well as expected.

However,

Staff were not clear as to what seclusion and long-term segregation was, and could not clearly explain the differences between the two. Seclusion and segregation paperwork had been put in place so staff could record any instances. However, the paperwork was incomplete and not comprehensive. We found a lack of care planning, and limited records to show reviews of young people in seclusion or long term segregation had taken place. We could not ascertain, in a number of records viewed, the length of time the seclusion or segregation had lasted. Secluding or segregating young people for any longer than absolutely necessary is an infringement of their human rights. We were not assured that staff understood or followed, the Mental Health Act Code of Practice, in relation to seclusion and segregation safeguards.

09 -11 April 2019

During a routine inspection

Summary of findings

We rated Rhodes Wood hospital as inadequate because:

  • Staff did not assess, monitor or manage risks to people who use the services appropriately. Ligature risk assessments did not identify all potential ligature risks. Mitigation was not robust. Ligature risk assessments were not held on the wards. Risk assessments were not always completed in a timely way following admission. Formal risk assessments were not comprehensive. Some patients did not have risk management plans.
  • The hospital did not take sufficient action to minimise risk to patients and staff. We identified numerous reportable incidents involving the police, paramedic assistance, and patient transfers to general hospitals which had not been reported to CQC. Staff had not consistently informed CQC when they had raised safeguarding concerns. There were three mandatory training courses with compliance of 60% or under. Conflict resolution (60%); breakaway (59%) and basic life support at only 53%.
  • Systems were not always reliable or appropriate to keep people safe. Staff did not routinely test or carry personal alarms, although there were call bells in most rooms. When an alarm was pressed, it only sounded in office areas. Staff reported that there would often be a delay in response when needed. Nursing staff checked emergency bags daily. However, we found discrepancies in what was recorded as being present, against what was present. This included emergency medication.
  • Staff did not always adhere to the Mental Health Act Code of Practice. We identified two instances where staff had secluded patients for a short period of time. Staff did not recognise this as episodes of seclusion. It was therefore not reported as seclusion. We identified staff had not been managing section17 leave robustly. Staff were not always certain of the parameters of leave granted and recording of leave was often brief. Not all patients had contingency plans if things went wrong while on leave.
  • The wards were dusty, unclean and poorly maintained. Some areas needed re-decoration. Some walls were scuffed in one area and had been written on by patients. Staff did not report or address maintenance issues consistently or in a timely way. There were significant gaps in the cleaning records. They did not indicate when Mymwood Place had last been properly cleaned. Staff used clinical waste bags for general rubbish. Nurses had disposed of rubbish in sharps bins. We were not assured that staff viewed infection control as a priority.
  • There were gaps in management and support arrangements for staff. Managers were not providing nurses and therapeutic care workers with regular clinical supervision.
  • Records sampled confirmed this. Not all eligible staff had received an appraisal. Some staff had not been supported following incidents.

However:

  • There was an adequate number of staff and staff were a visible presence on all wards. Most bank and agency staff had worked at the hospital frequently and so knew the patients.
  • Managers shared learning from incidents, investigations and complaints with all staff. They did this during team meetings, multi-disciplinary meetings, supervision (when it occurred) and through emails and posters. There was emphasis upon lessons learnt and striving to improve patient experience.
  • Staff ensured that patients had easy access to independent advocates and supported patients as needed. Staff encouraged patients to keep in contact with families, carers and appropriate others. Staff accommodated visits at the hospital if patients were too ill to leave the hospital grounds.
  • Patients and carers described staff as caring and helpful.
  • Staff understood the individual needs of patients. Staff facilitated young people’s access to education throughout their time on the wards. Each patient had a weekly individual time-table. This included education, therapy and leisure activities.
  • Leaders had the skills, knowledge and experience to perform their roles. They were visible and approachable for patients, staff and carers.

14, 15 and 29 March 2017

During an inspection looking at part of the service

We rated Rhodes Wood Hospital as good overall because:

  • The environment was visibly clean and homely. Furnishings had been chosen to create a child friendly atmosphere.
  • Risks relating to ligatures had been identified and mitigated against. Staffing levels were based upon occupancy and acuity levels which were monitored regularly by ward managers and senior staff.
  • All staff had received level 3 safeguarding training and there was a designated safeguarding lead social worker who had established links with the local authority safeguarding officer (LADO) to review all safeguarding referrals and concerns.
  • The service offered specialist training on eating disorders to all staff.
  • There were robust reporting systems in place for staff to learn lessons from serious incidents and to respond to complaints.
  • Comprehensive risk assessments and care plans were completed pre-admission through to discharge and reviewed weekly and when an individual patient’s presentation changed.
  • There was a large multi-disciplinary team which offered family therapy, psychology, psychotherapy, dietetics, nursing and psychiatry. The MDT attended a daily handover to have up to date information on patients.
  • The care model was clearly defined and followed National Institute for Health and Care Excellence guidance for eating disorders including the use of the Junior MARSIPAN (management of the really sick patient with anorexia nervosa under 18's).
  • Feedback from patients and their families was generally positive. There were support groups offered for families fortnightly.
  • Following discharge the service routinely offered a 12 week follow-up package of care which supported the patient and their family to adjust to the community setting and allowed weekend access to the service for more intense support where appropriate. Patients were routinely offered an innovative therapeutic intervention called cognitive remediation therapy (CRT) to all patients during their admission at Rhodes Wood hospital. This intervention had been published in a psychology journal.

However:

  • We found some medical equipment to monitor physical healthcare was not recently calibrated or was out of date. This was resolved at the time of the unannounced visit.
  • We found that prior to January 2017 not all qualified staff had received regular supervision.