Holybourne 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good, although there were aspects of care that needed improvement around the safe storage or medicines, prn (as required) medicines and quality of physical health care plans.

The service was in breach of regulation for the way people’s medicines were managed and mechanisms to ensure safe storage.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

Staff reported all incidents that they should report and included lessons learned. Staff across the hospital reported incidents such as medicines errors, patients going absent without leave and incidents of self-harm. Staff recorded the details of incidents on the electronic incident record. Between January 2025 and April 2025 there were 256 incidents reported, 212 resulted in no harm or injury, 39 resulted in minor injury, 4 resulted in moderate harm and 1 was an unexpected death. The most common type of incident were disruptive interactions between patients or patient and staff, equipment failure, and patients absconding after a period of leave.

Staff met to discuss lessons learned and look at improvements to patient care. There was evidence that changes had been made as a result of lessons learned from incidents. As part of the inspection, we reviewed minutes of team meetings held on the wards for the previous 3 months. Lessons learnt was a standing agenda item for all of the meetings. We saw changes included practice around ECGs and the introduction of a reflective practice group for staff.

Managers debriefed and supported staff after any serious incident. For example, staff told us that after a physical incident they had experienced managers would check in with them regularly.

Managers investigated incidents where necessary. Patients and their families were involved in these investigations where appropriate.

Staff received feedback from investigation of incidents, both internal and external to the service. for example, following discussions in February 2025 on Richmond Ward they launched a “discharge messages” and “positive words as a part of the Safe Wards initiative.

Staff understood their responsibilities under The Duty of Candour. They were open and transparent, and they gave patients and families a full explanation when things went wrong

Staff provided a range of care and treatment suitable for the patients in the service. Treatment predominantly involved the use of medicines. Therapies offered included art therapy, music therapy and CBT.

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.

Staff did not regularly move or discharge patients at night or very early in the morning. However, one relative told us that their partner was admitted in the early hours of the morning. When patients went on leave there was always a bed available when they returned.

A local NHS trust had a contract in place with the hospital. Staff told us that they mostly had good links to patients’ care co-ordinators in the community and they would always be invited to attend ward rounds. Senior leaders attend an external meeting with local NHS trust. A monthly compliance report was submitted to the trust to inform the trust of performance. The report reflected a variety of care delivery indicators which were discussed at the monthly contract meetings.

Managers regularly reviewed length of stay for patients to ensure they did not stay longer than they needed to. In May 2025 the average length of stay was 36 days.

Managers monitored the number of patients whose discharge was delayed, knew which wards had the most delays, and took action to reduce them. Leaders told us that there had not been any recent delay to discharges of patients. Barriers to discharge were reviewed with clinical teams within Holybourne, and with the community services of referring trusts. The most common barrier to discharge was in relation to finding suitable accommodation.

Staff carefully planned patients’ discharge and worked with care managers and coordinators to make sure this went well. There was a multidisciplinary meeting with community health team and home treatment team to review discharges, admissions and overall patient flow. Care co-ordinators were regularly invited to the weekly ward round meetings to offer their input and provide updates on any possible barriers to discharge.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Flowcharts were visible in the nursing offices on how to escalate safeguarding concerns. Between January 2025 and April 2025, 15 safeguarding records had been created by staff. All safeguarding concerns were discussed in the daily professionals meeting.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff gave details of when they had raised safeguarding concerns.

Patients we spoke to stated that they felt safe on the wards.

Staff followed clear procedures to keep children visiting the ward safe. The hospital had a family room that was off the ward, this would be used for visiting children and families. People under the age of 16 were not allowed onto the ward

Staff kept up to date with their safeguarding training. Safeguarding training was mandatory for all staff. 94% percent of staff were up to date with safeguarding children and safeguarding adults training.

Managers took part in serious case reviews and made changes based on the outcomes. All safeguarding matters were discussed in clinical governance meetings.

Staff involved patients and gave them access to their care planning and risk assessments. Patients were able to attend ward rounds, and their views were recorded when they did so. Carers and relatives were actively encouraged to attend ward rounds this could be done remotely or in person with the permission of the patient involved.

Most patients and carers we spoke to stated that they were involved in the planning of their treatment plans.

Staff stated that patients had the opportunity to do things that matter to them. For example, we saw spiritual needs being me as one patient was able to attend a local church.

Staff made sure patients understood their care and treatment and found ways to communicate effectively. Staff told us that they would use an interpreter where appropriate.

Staff used technology to support patients, teleconferencing facilities were used during ward rounds to ensure family and community teams remained involved in-patient care.

Staff and patients were aware of the policies and procedures in place to ensure a safe environment. We identified one area that needed improvement. Staff were not carrying out engagement and observation in line with the provider policy. Staff were using predictable and fixed times within an hour to carry out the observations, when the policy outlined that unpredictable time should be used. Since the onsite inspection, senior leaders they told us that staff had changed this practice to be in line with the policy. They have completed a piece of work around this including staff following policy procedures.

Staff completed and regularly updated thorough risk assessments of all wards areas and removed or reduced any risks they identified. Daily checks of the environment were carried out by a designated member of staff.

Staff could observe patients in most parts of the wards. There were some areas on the wards that staff were unable to observe from the nursing office. Staff were aware of the blind spots that were present on the wards and mitigated the risk by being present in the communal area at all times. Staff identified and responded to any changes in risks to, or posed by, patients. If staff were concerned about a change in a patient risk, they would increase the level of observation. Staff also told us they would move a patient closer to the nursing office if their risks were escalating.

Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. The service had introduced a new ligature risk assessment form since our last inspection and we saw this had been completed for all wards in March 2025. There were anti-ligature fittings in the bathrooms.

Staff checked, maintained, and cleaned equipment. Cleaning records were maintained and up to date. Since our last inspection in March 2023, blood glucose monitoring machines were calibrated on a weekly basis.

Staff we spoke to stated that they felt safe on the wards. Patients told us that they felt safe on the wards.

Staff followed provider policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. Staff searched patients for prohibited items when they returned from leave. This involved asking patients to empty their pockets and allow staff to look in any bags. Staff could also check for concealed metal items using a handheld metal detector. Staff told us that they would conduct random searches of patients’ bedrooms if they were concerned about possible contraband on the ward.

Staff had easy access to alarms and radios. Patients had easy access to nurse call systems. Staff alarms were tested and issued at the beginning of each shift.

The ward complied with guidance and there was no mixed sex accommodation.

Seclusion rooms were not in use at this service. A de-escalation room was available. The staff used the de-escalation room for managing patients exhibiting volatile behaviour.

Clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly. The emergency bag on the wards were checked daily.

On Richmond ward an oxygen cylinder was available in the clinic room for use in an emergency. There was no spare cylinder present in the clinic room, there was a spare oxygen cylinder located on the same floor on Barnes Ward. Spare oxygen cylinders were available on all the other wards.

The service had a full range of specialists to meet the needs of the patients on the wards. Each ward team included a ward manager, registered nurses, support workers, a speciality doctor and a consultant psychiatrist. The wards also had access to occupational therapists, psychologists, assistant psychologists and activity co-ordinators. Leaders told us that since the last inspection there had been a recruitment drive to fill vacant posts.

There were sufficient staff to support escorted leave and ward activities. Managers had calculated the number and grade of nurses and healthcare assistants required. The ward managers could adjust staffing levels according to the needs of the patients. No staff that we spoke to told us that they felt the reduction in support workers on each ward had made it more challenging to facilitate section 17 leave. Staff told us that there was enough staff to facilitate escorted leave and ward activities. Should they require more staff, managers were able to request additional staff.

Patients we spoke to stated that they felt there was enough staff. All staff we spoke to stated that they felt that there was enough staff.

There were enough staff to carry out interventions (for example, observations and restraint) safely and staff had been trained to do so. All staff had received training in the use of physical intervention. None of the staff we spoke with said there had been insufficient staff to carry out physical interventions when required.

At our last inspection the service had a 50% vacancy rate for nursing staff, there were 17.4 vacant posts at the service. At the time of this inspection the service had a vacancy rate of 0.22% for nursing staff. At our last inspection, the service had 6 healthcare support worker vacancies, this was an overall vacancy rate of 14%. At the time of this inspection the service had a vacancy rate of 1.5% for healthcare support staff. This meant that agency use for support worker staff was very low. We found that 1% of healthcare support worker shifts were covered by agency staff.

At our last inspection, 50% of nursing shifts were covered by agency staff and 42% of duty nursing shifts were also covered by agency staff. At the time of this inspection 0% of nursing shifts were covered by agency staff.

The service had low turnover rates. Overall staff turnover was 0.8% in April 2025.

The service had enough daytime and nighttime medical cover and a doctor available to go to the ward quickly in an emergency. As of April 2025, there were 9 WTE medics employed by the service and there were no vacancies. On call out-of-hours cover was provided by the ward doctors and consultants. This was through a 7 day on call rota. Managers had a process in place to get medical staff locum cover if this was needed.

Staff had completed and kept up to date with their mandatory training. At the time of inspection, the overall training compliance was 93.8%. Training compliance was monitored weekly by the senior management team and department leads. Staff were required to be compliant with their mandatory training as a requirement for working in the hospital and being retained on the bank.

Most staff stated that the training available was good. The mandatory training programme was comprehensive and met the needs of patients and staff. Mandatory training courses included fire safety, infection control, managing medicine, personal safety and conflict management, care notes, Prevent, safeguarding, equality and diversity and basic life support. There were some mandatory training courses that were role specific, for example positive behaviour support and sepsis awareness.

Managers supported staff through regular, constructive clinical supervision of their work. At the time of the inspection the overall supervision rate was at 83%. Most staff that we spoke to told us that they had received clinical supervision. Staff told us that supervision covered any recent incidents, training, competencies and wellbeing. The service kept a record of supervision and appraisal compliance.

Managers made sure staff attended regular team meetings or gave information from those they could not attend. These team meetings followed a fixed agenda. At the meetings, staff discussed incidents, lesson learnt, physical health, patient feedback and complaints and compliments. However, these meetings were not minuted.

Staff were required to have a formal appraisal once a year. As of April 2025, the overall appraisal rate for the hospital was 86%. Therapy staff had the lowest appraisal rate at 75%. Osman Ward had the lowest appraisal rate at 85%.

Weekly reflective practice sessions were provided to the multidisciplinary staff members by the hospital in collaboration with a nearby university. However, on Osman Ward some staff that we spoke to told us that they would like reflective practice to resume.

Managers gave each new member of staff a full induction to the service before they started work. All staff that we spoke to told us that they had received a comprehensive induction before starting on the ward. Managers had a system in place to ensure that agency staff members had received an induction.

Managers supported staff who needed time off for ill health. On 25 occasions nurses and support workers were unable to attend their shift due to sickness. This accounted for 2.5% of all shifts.

The service had policies and completed audits surrounding the environment. Since our last inspection the service staff who were responsible for cleaning made sure cleaning records were up-to-date and the premises were clean. All the premises we observed appeared clean, well maintained, well-furnished and fit for purpose.

Staff followed infection control principles including appropriate handwashing techniques, use of equipment including aprons and gloves, and hand sanitiser was readily available. Handwashing audits were carried out monthly.

Staff stated that patients could raise any concerns during the weekly ward community meeting.

Patients we spoke to did not raise any infection control issues. However, if they had to raise any concerns, they knew how to do this and who to speak to.

We noticed on Richmond and Kingston wards that clean and used linen was not stored in separate areas. This was highlighted in audits, and we were told this was due to limited space on the wards.

Staff did not always follow systems and processes to prescribe and administer medicines safely[NA1] .

We reviewed 8 medicine administration charts. We saw PRN (as required) medicines were not always reviewed as the patient’s condition changed. We also saw PRN medicines being used to treat symptoms which were not what the prescriber had intended. For example, we saw medicines prescribed for agitation being used for sleep. Where multiple PRN medicines were prescribed, we saw they were sometimes used together. This was not in line with the services de-escalation guide, which stated first line and second line PRN medicines. This could lead to adverse events or increased risks of side effects if multiple PRN medicines were given at the same time.

Staff did not always store and manage all medicines and prescribing documents safely. On Kingston Ward, the fridge temperate was above the desired range on the day of inspection. On Barnes Ward, we identified that the fridge temperature had been out of range for a period of 6 days, and although the staff had temporarily moved the medicines to another fridge, they had not escalated this issue appropriately at the time. Since the inspection leaders have informed us that they have a new temperature management system that monitors the fridge temperature and alerts managers if the temperature is out of range.

There were also areas of good practice identified. Staff reviewed the effects of each patient’s medicines on their physical health according to NICE guidance. Side effects of medicines were monitored through regular checks of patients’ pulse, blood pressure, respiration and oxygen saturation. Any side effects were discussed at the daily multidisciplinary team handover. Patient’s received routine physical health monitoring. Where results were out of range staff escalated concerns so that actions could be taken to prevent further deterioration. Patients at risk of developing blood clots had venous thromboembolism (VTE) risk assessments completed.

The service ensured people’s behaviour were not controlled by excessive and inappropriate use of medicines. We reviewed 8 medication charts; most patient medication was within BNF limits.

Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines.

Carers and patients that we spoke to told us that they felt well informed about the medications administered by staff.