Rhodes Wood Hospital

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

The service provided safe care. The service had a proactive learning culture, where incidents were recorded and appropriately investigated. There was an incident log in place, which detailed incidents and actions taken following the incident. For example, incidents where young people were not able to manage their food orally and restraint was used were appropriately recorded. This helps to maintain safety for young people.

The service worked with partners to establish and maintain safe systems in care. We reviewed young people’s records and found good evidence of planning for discharge, including communication with community teams. Joined up working with community teams and external agencies is essential for safe discharge.

There were effective systems, processes and practices in place to make sure young people were protected from abuse and neglect. Staff were able to tell us steps they would take to safeguard young people, including discussing concerns with the nurse in charge and completing a safeguarding referral.

Risks were assessed and staff understood them. Risk assessments were regularly updated and recent incidents were clear within the risk assessment. Clear recording of current risk means that appropriate mitigation can be put in place.

The hospital had access to a range of specialists to meet the needs of young people. This included a therapies team, dietetics team, nursing staff, support staff and consultants. Staff had received training relevant to their role.

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.

There was an effective approach to assessing and managing the risk of infection. Infection prevention and control audits were completed. The environment mostly met the needs of young people. There were convex mirrors where there were blind spots to mitigate risks to young people.

However, we observed that the environment was not always well maintained and there were some areas that were not visibly clean. We observed paintwork peeling from walls or doors and skirting boards were marked. Since our inspection the provider has shared a redecoration schedule, which outlined areas that had been redecorated and areas that were due to be painted. Some bedrooms did not have call bells, and some young people were not able to get the attention of staff when needed. Since our inspection the provider has given assurance around processes in place for young people in bedrooms without call bells. This included closed- circuit television (CCTV) reviews to ensure that staff were present and a night co-ordinator check was implemented.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a proactive culture of safety and learning. The service had an incident log in place. Themes included incidents relating to restraint during nasogastric feeding of young people. Staff used the hospital therapy dog to support young people following nasogastric feeding under restraint. Staff knew what incidents to report and how to report them. Staff told us they would report any incidents to the ward manager, record the incident and if there was a safeguarding concern, this would be picked up by the safeguarding lead. Staff told us there would be a debrief for both staff and young people following an incident. After incidents managers identified immediate actions, lessons learned and put action plans in place. An example of this was lack of oversight of section 17 leave, where an allegation was made against a member of staff. Appropriate immediate actions were identified and lessons learned were shared with the team. This included changes in processes, such as no lone opposite sex escorts.

We reviewed a summary of complaints at the hospital. From March to June 2025 the hospital had received 2 complaints relating to the same young person. The complaints related to communication and clinical decision making, which were both fully investigated.

Parents and carers of young people that we spoke with told us that they had raised concerns with the hospital. Concerns raised by parents included concerns about self-harm. Parents told us their concerns had been listened to and acted on appropriately by staff. For example, one parent told us that their loved one's observation levels were increased following them raising concerns with staff.

We requested duty of candour records, however there had been no duty of candour for the last three months.

The service worked with partners to establish and maintain safe systems of care. Managers told us that a pre-admission assessment was completed with young people, parents and community teams. This meant that all essential information about the young person was gathered prior to admission to ensure a safe pathway.

We reviewed 6 young people’s records and found evidence of good planning for discharge. We saw evidence that community services were involved in discharge planning. We also attended a multi-disciplinary meeting, where planning for discharge was discussed and included the involvement of families and community teams. This is essential to ensure a smooth and safe transition for young people.

Staff involved all necessary professionals to ensure that young people had a continuity of care. Staff told us that a multi-disciplinary team were involved in assessing the young person and there had been occasions where referrals had been declined if the young people’ needs could not be met. Staff were able to identify signs of young people needing further support. Staff told us they would complete health checks such as blood or urine tests if they were concerned. Staff told us that nasogastric feeding was used as a last resort.

Most parents and carers told us they felt involved in treatment and were invited to multi-disciplinary meetings every other week and parent feedback forums.

Young people told us things were not always explained well on admission. For example, a young person told us they were not aware of when to go to the table for a meal or when they could access their bedrooms. Staff told us young people were given a welcome pack on admission. Young people told us they felt safe at the hospital.

Most staff were trained in safeguarding and knew how to raise safeguarding concerns. At the time of inspection safeguarding compliance was 92.8% for all staffing groups. There were 10 staff that were non-compliant with safeguarding training, as it had expired the day after inspection. Leaders had requested that outstanding training was completed. We spoke with 4 staff nurses and 5 support workers. They were able to tell us the steps they would take to safeguard young people. Most staff told us that they would discuss any safeguarding concerns with the nurse in charge and would complete a safeguarding referral. Staff were able to give examples of a time when they had needed to safeguard. One staff member told us that a young person made allegations against a staff member and as a result a safeguarding referral was completed. Understanding safeguarding procedures is essential to protect young people from abuse and neglect.

We reviewed restrictive practice records and found the use of restraint and reason for restraint was clearly documented. We found evidence that de-escalation techniques were used before restraint and recording of restraint was clear. The service had a local policy in place for hand support, which outlined clear expectations for young people requiring support at meal times.

Prior to our inspection at Rhodes Wood, we had concerns relating to sexual safety of young people. During our inspection we reviewed the providers sexual safety policy, which outlined responsibilities of staff. Most staff we spoke with were able to tell us that they had sexual safety training within their safeguarding training. Children and young people we spoke with told us they felt safe at Rhodes Wood and told us they did not have any concerns about sexual safety.

Risks were assessed and staff understood them. During our inspection we reviewed 6 care records. We found that risk assessments were regularly updated and clearly documented the risks for the young person. Any recent incidents were clearly highlighted within the risk assessment.

Staff used recognised scales such as Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), which is a tool to assess severity of mental health needs in young people and the Children’s Global Assessment Scale (CGAS), which is used to assess psychological and social functioning. Approved rating scales can help identify appropriate intervention.

There was a balanced and proportionate approach to risk. We reviewed restraint records and found recording of incidents was clear, including the staff members involved, length of time of restraint and actions taken after restraint. Levels of restrictive practice were proportionate. Young people were risk assessed to have items such as mobile phones in their possession.

We reviewed 6 young people’s care plans. Young people’s care plans were detailed, however they were not always person centred. Young people had their physical health monitored regularly and there was also evidence of a dietetics assessment within 2 days of admission.

Following an inspection of Rhodes Wood hospital in May 2022, the provider was told they must ensure all 3 wards were well decorated, maintained and visibly clean.

Although there had been some improvement observed in relation to the May 2022 findings. We observed that some areas of the environment were not always well maintained and there were areas of some wards that were not visibly clean. On Rainbow ward we observed rooms and corridors where paint was peeling from walls. We also observed a dirty window sill in the de-escalation room. On Shepherd ward we observed paintwork was worn, doors in communal areas and skirting boards looked dirty and were marked. There were also parts of the hospital where maintenance was needed. For example, there was a large hole in the ceiling on Rainbow ward and a large hole in the wall of the kitchen due to a leak. This was in the process of being fixed. However, managers had a redecoration schedule in place, which identified areas of the hospital that were due redecoration. Following our inspection the service was able to evidence maintenance works that had taken place in the hospital, such as toilet refurbishment on Cheshunt ward.

Most bedrooms had call bells, apart from the first-floor bedrooms on Rainbow ward. Parents and carers told us that there had been occasions were young people had wanted to speak to staff members while they were in their rooms, however there were no staff members present on the landing. Since our inspection senior leaders gave assurances around processes in place for children and young people in bedrooms without a call bell. Random closed-circuit television (CCTV) checks have been completed and confirmed that staff members have been present. Leaders have also told us that a night co-ordinator check had also been implemented to ensure that staff were present as per the staffing model.

Not all staff were aware of ligature risks downstairs on Shepherd ward or were able to tell us how to access ligature cutters on the 2nd floor landing during an emergency. Following our inspection, action had been taken to ensure that all staff members were aware of potential ligature anchor points and how to access ligature cutters in an emergency. The provider told us that following our visit, correspondence was sent to all staff members reminding them how to access ligature cutters. Managers also spoke with staff members to confirm their knowledge on location of ligature maps and access to ligature cutters.

Some bedrooms were shared. We reviewed the providers policy on bedroom sharing, which stated that young people sharing should be similar in age and young people that share should be of the same biological gender. Following our inspection a patient survey was completed, where 7 young people said they were happy to share a room, 2 young people had no preference, and one young person reported that they did not enjoy sharing a room. Shared bedrooms have been added to the agenda for the carer’s forum for further discussion.

Staff could observe children and young people in all areas of the wards. There were convex mirrors in place on stairwells where there were blind spots, to mitigate risk to young people.

The hospital had access to a range of specialists to meet the needs of the children and young people. This included nursing staff, a therapy team, dietetics team, safeguarding team and a medical team consisting of 3 consultants and 3 associate specialist doctors. Young people told us there were enough staff to keep them safe.

Staff received training appropriate and relevant to their role. Most staff were up to date with mandatory training, with overall compliance being 98.4%. Mandatory training in paediatric immediate life support was 95.1% and safe and therapeutic management of violence and aggression (SMTVA) training was 99.1%. We reviewed competencies and training of agency staff. Agency staff members that were not up to date with their competencies were not offered a shift until training was completed. Young people told us staff had received the appropriate training to keep them safe.

Staff received the support they needed to deliver safe care. Supervision compliance in May 2025 was 91%. Managers supported staff through appraisals, with compliance in May 2025 being 99.3%. Staff told us they had a robust induction before starting work at Rhodes Wood, which involved training and shadowing other staff members. Staff told us that they felt appropriately trained to do their roles.

Sickness rates for the last 6 months were low at 1.7%, absence was 2.5% and staff turnover was 8%.

Young people told us there were enough staff and they did not have any concerns around safe staffing. Young people told us that agency staff were not as familiar with them as regular staff were.

Cleaning was not entirely effective in all areas. We observed that most of the environment was visibly clean, although there were some areas that did not look clean. The windowsill in the de-escalation room on Rainbow ward was dusty.

Children and young people told us that the environment was mostly clean. A young person told us, although the floors were regularly mopped, they still looked dirty.

However, infection prevention and control audits were completed. Most audits were 100% compliant, however the kitchen servery and clinic environment were 96% compliant. We reviewed cleaning records, which were up to date and demonstrated that ward areas were cleaned regularly. Compliance for infection prevention and control training was 97% at the time of inspection. There was a comprehensive infection prevention and control policy in place.

Staff followed systems and processes to ensure medicines were prescribed, stored and administered safely. This included the secure storage of all medicines, including controlled drugs (CDs), which are subject to additional safeguards due to their potential for misuse.

We reviewed the medicines administration charts for 9 young people and found that medicines were prescribed and administered in line with the appropriate consent to treatment documents. Staff routinely monitored the impact of medicines on young people’s physical health. This included undertaking baseline assessments such as ECGs prior to prescribing, in line with guidance from the National Institute for Health and Care Excellence (NICE).

The service ensured that young people’s behaviour was not controlled by excessive and inappropriate use of medicines. ‘When required’ (PRN) medicines were administered appropriately and clearly documented on the young person’s medicines administration charts. In rare cases where rapid tranquilisation (RT) was necessary to manage episodes of acute agitation or aggression, we saw that staff recorded and carried out post-administration physical health monitoring in line with the provider’s policy.

The service had an external pharmacy team to ensure the hospital had safe and effective systems in place to manage young people’s medicines. Weekly pharmacy audits were undertaken, and the service demonstrated a responsive approach to audit findings. In addition to external audits, the service also conducted its own monthly medicines audits to maintain oversight and ensure internal standards were consistently met. Lessons learned from both internal and external audits were shared with the clinical team and used to drive improvement. Audit trends showed a reduction in the number of issues raised, indicating sustained learning and improvement over time.

Nursing staff responsible for the administration of medicines were appropriately trained and assessed as competent on an annual basis. In addition to mandatory training, staff received ongoing input from the external pharmacy, including specialist training on mental health medicines and associated Mental Health Act documentation.