CQC places Ivetsey Bank Hospital into special measures following inadequate inspection

The Care Quality Commission has rated the child and adolescent mental health wards at Ivetsey Bank Hospital as Inadequate and placed the service into special measures following inspections in March and April.

The hospital, run by Active Young People Limited, provides inpatient mental health care for young people aged 12 to 17 with diagnosed mental health conditions.

CQC carried out the inspection in response to incidents where young people had experienced harm following episodes of self-harm and the use of restraint.

Inspectors issued two Warning Notices and identified five breaches of regulations relating to person-centred care, safe care and treatment, premises and equipment, governance, and staffing.

The inspection resulted in the overall rating being downgraded from Good to Inadequate. The safe and well-led domains also fell from Good to Inadequate, while the caring domain was downgraded from Requires Improvement to Inadequate. The effective and responsive domains remain rated Requires Improvement.

As part of the regulatory action, CQC has placed the service into special measures. This means the hospital will be subject to enhanced monitoring while improvements are made and must demonstrate progress within a defined timeframe.

Inspectors found significant concerns regarding the management of safety and quality across the service.

Leaders did not have effective systems to oversee care, meaning recurring risks were not being adequately identified, addressed or reduced. Inspectors also found repeated incidents of self-harm and concerns about the use of restraint. During the inspection, CCTV footage reviewed with staff highlighted incidents that inspectors considered required further investigation.

The inspection also found that not all staff had the necessary training or qualifications to carry out their roles safely. Following Maybo restraint training, almost half of the staff who attended required additional refresher training before they could safely use restraint techniques.

Inspectors also identified concerns about the ward environment, finding that potential risks to young people’s safety were not always being managed or reduced appropriately.

In addition, some staff told inspectors they did not feel respected or supported and were reluctant to raise concerns because they feared repercussions. CQC said this limited opportunities to learn from incidents and improve practice.

Despite the concerns, inspectors found some positive practice. Staff were praised for supporting young people with discharge planning, with some patients reporting they felt involved in planning their next steps. CQC also found leaders worked openly with commissioners and partner organisations, who described the service as transparent and collaborative.

Commenting on the findings, Gemma Berry, CQC Deputy Director of Mental Health in the West Midlands, said young people receiving care at the hospital deserve to feel safe and confirmed that CQC will continue to monitor the service closely while improvements are made.

The full inspection report is available on the CQC website.

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