• Mental Health
  • Independent mental health service

Holybourne Hospital

Overall: Requires improvement read more about inspection ratings

Holybourne Avenue, London, SW15 4JL (020) 8780 6155

Provided and run by:
Active Adult Limited

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

All Inspections

14 March 2023, 15 March 2023 and 11 April 2023

During a routine inspection

Our rating of this service went down. We rated it as requires improvement because:

  • Staff did not always escalate physical health concerns appropriately. This meant there was a risk that deteriorating patients may not receive timely medical support.
  • Staff did not always follow the procedure for seclusion set out in the Code of Practice.
  • Blood glucose machines were not regularly calibrated. This meant that the machines could give incorrect readings that could lead to staff giving incorrect doses of medicines.
  • Staff did not always follow NICE guidance when using rapid tranquilisation. For example, we identified one record of rapid tranquilisations where staff did not record the patient’s physical health observations 4 times within the first hour as per NICE guidance.
  • Governance processes were not sufficient to ensure all risks were identified and managed.
  • Cleaning records were not fully completed by all staff.
  • Staff did not always store and manage all medicines and prescribing documents safely. On Barnes ward we identified 3 different types of medicines that had exceeded their expiry date. When patients were discharged with short notice, medicines for the patient to take away with them did not come with important warning labels.
  • The wards were previously psychiatric intensive care units and the ward environments reflected this. The ward environment lacked colour and had limited furnishings.
  • We identified one record where a patient was deemed to not have capacity however the evidence behind this decision was not recorded.


  • The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. Staff followed good practice with respect to safeguarding.
  • Staff provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients 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.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.