Holybourne Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

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

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

There was one area where improvement was needed. The service was in breach of regulation for having clear, up-to-date and detailed care plans for some physical health conditions.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff completed a comprehensive mental health assessment of each patient either on admission or soon after. This included a review of mental state, capacity, section, presented risks, and physical health issues. When patients were admitted they were reviewed by a doctor for an initial assessment, which included an assessment of their risk. Staff supported patients to make decisions on their care for themselves. However, capacity assessments were not always recorded clearly for patients who might have impaired mental capacity.

All patients had their physical health assessed soon after admission and regularly reviewed during their time on the ward. Staff carried out blood tests and electrocardiogram tests shortly after a patient was admitted to the ward. Physical health assessments that were completed on admission were audited monthly. However, physical health care plans were not always up to date or sufficiently detailed. For example, current physical health issues were not consistently up to date and we saw diabetic care plans did not always indicate how often staff should carry out blood glucose monitoring.[NA1]

At our last inspection, staff did not always escalate physical health concerns appropriately. Staff were using a national early warning signs (NEWS) form to record checks of patients’ vital signs daily. The form is used to record the physical health of a patient. Staff collect a range of indicators to produce a score which shows when a patient’s health may be deteriorating. Depending on the score, staff should escalate to the nurse in charge, a doctor, or emergency services. Since the last inspection, the provider had completed a lot of work with staff to escalate risks, and a new governance system was now in place. During this current inspection, we saw that in most instances, staff escalated concerns so that actions could be taken to prevent further deterioration. We identified 1 record where there was no evidence to suggest high NEWS scores were escalated to the appropriate professional. The service should continue to embed practice around escalating NEWS scores appropriately.

Personal emergency evacuation plans (PEEP) were in place for all patients in the hospital. The aim of a PEEP is to provide people who cannot get themselves out of a building unaided with the necessary information and assistance to be able to manage their escape to a place of safety and to ensure that the correct level of assistance is always available.

The provider monitored the use of restrictive interventions. Between January 2025 and May 2025 there was a total of 83 incidents that resulted in the use of physical intervention. Staff participated in the provider’s restrictive interventions reduction programme. Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe. All staff that we spoke to told us that restraint would only be used as a last resort. During the inspection staff we spoke to stated that they would use distraction techniques to de-escalate incidents of aggression.

Staff did follow NICE guidance when using rapid tranquilisation. Patients were given rapid tranquilisation (RT) medicines intramuscularly to help reduce agitation and aggression. Post dose physical health monitoring was completed in line with provider policy and staff recorded this. However, where more intensive monitoring was required beyond standard times, staff were not always clear where to document results. The service was in the process of rolling out non-contact observation forms to monitor patients that required extended period of observation following RT.

Most care plans were personalised, holistic and recovery oriented However, we found that 4 care plans where this could be more specific to the patients. We saw in some care plans the voice of patients and patients having choice in what activities they participate in.

Staff provided a range of care and treatment suitable for the patients in the service. Most patients were admitted to the wards with psychosis, schizo-affective disorder, bi-polar affective disorder or schizophrenia. Some patients were experiencing an emotionally unstable personality disorder. Treatment predominantly involved the use of medicines. Therapies offered included art therapy, music therapy and CBT. Staff we spoke to stated that they use NICE guidance when planning patients care and treatment. Staff also stated that they ensured that patients were supported to make decisions for themselves.

Patients we spoke to stated that they were supported to maintain contact with their loved ones.

Staff held weekly multidisciplinary meetings to discuss patient care. These meetings were attended by the patient, consultant psychiatrist, speciality doctor, assistant psychologists and a member of the nursing team. At the meetings we observed, staff gave clear information about patients and ensured any changes in their care was shared, both within the team, and with other teams external to the organisation.

All wards had access to a psychologist. Assistant psychologists also provided support to patients on the wards, including 1 to 1 and group sessions.

Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. The ward teams had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.

Records were stored securely. Staff accessed the electronic patient record system using a personal username and secure password. Patient notes were mostly comprehensive, and staff could always access them easily.

Staff helped patients live healthier lives by supporting them to take part in programmes or giving advice. For example, staff encouraged to utilise their leave, patients would go on walks in Richmond Park which was a short distance from the service. Staff directed patients to other services and supported them to access those services if they needed help. However, we noted that two patients who had a high BMI score were not referred to dietitians.

Staff used recognised rating scales to assess and record the severity of patients’ conditions and care and treatment outcomes including Core-10 which is a 10-item questionnaire used to measure psychological distress.

Patients we spoke to stated that they were supported to the gym if they wanted to.

Staff monitored people’s care and treatment in several ways and reported these internally and to external organisations, where needed.

Patients we spoke to stated that they were informed about their rights, Patients had easy access to information about independent mental health advocacy and patients who lacked capacity were automatically referred to the service.

An advocate would attend the wards once a week. At the time of our inspection the provider had not received any reports from the advocate which would be used in clinical governance meetings. Since the inspection, leaders informed us that this would be addressed.

Informal patients knew that they could leave the ward freely, however the service did not clearly display posters telling them this.

Staff knew who their Mental Health Act administrator was and when to ask them for support. The service had clear, accessible, relevant and up-to-date policies and procedures that reflected all relevant legislation and the Mental Health Act Code of Practice.

Staff explained to each patient their rights under the Mental Health Act in a way that they could understand, repeated as necessary and recorded it clearly in the patient’s notes each time.

Staff made sure patients could take section 17 leave (permission to leave the hospital) when this was agreed with the Responsible Clinician.

Managers and staff made sure the service applied the Mental Health Act correctly by completing audits and discussing the findings