Holybourne Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

Most staff we spoke with were positive about the culture and morale on their wards, and the support they received from their teams.

Staff said they felt able to raise concerns without fear of retribution. Staff said their views and opinions would be listened to and acted on. Staff knew how to use the whistle-blowing process. Posters detailing who to contact if staff needed to speak up were on display in staff areas.

Senior leaders told us they were focused on building a culture at Holybourne reflecting the Active Care Group behaviours and had been developing this and staff awareness with a view to this being evident in all that they do in terms of patient and staff experience

The annual staff survey took place in March 2025, with Holybourne Hospital achieving a 32% response rate. Leaders told us that the survey had to be completed through the company’s app. Which caused a hindrance to staff completing the survey as they had to download the app. At the time of inspection, the senior leadership team was analysing the results and creating an action plan.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide care. Throughout our engagement meetings and during our inspection the registered manager demonstrated a good understanding of patients, the staff team and all matters relating to the provision of acute mental health services.

All staff we spoke to stated that leaders were visible and approachable.

Leadership development opportunities were available, including opportunities for staff below team manager level. Managers supported staff to develop their skills and take on more senior roles. For example, one health care support worker had been supported to complete their nurse training.

The service had a comprehensive training programme.

All staff we spoke to stated that they knew who their freedom to speak up guardian was. Staff stated that they felt that they could raise concerns without fear of retribution.

The provider worked towards an inclusive and fair working culture. All staff we spoke to stated that they felt respected and valued.

Staff received training on equality, diversity and inclusion.

Since the last inspection the service had successfully embedded several areas of improved governance processes. We saw there were still a small number of areas to continue working on. For example, consistent and clear medicines optimisation procedures and consistency in ensuring all staff escalated high NEWS scores. We also identified lack of detail in physical health care plans for some patients and practice relating to prn medicines that the service had not picked up through their own audit processes.

Positive findings included that the service held a range of meetings at which staff shared issues and concerns, identified actions and monitored progress. Agendas for meetings were standardised across the service and covered learning from incidents, complaints and safeguarding cases. Daily operations planning meetings were held every morning. These involved ward managers and senior managers. The purpose of these meetings was to assess occupancy, risk, acuity, safeguarding and staffing.

Monthly audits were undertaken on each ward with different staff responsible for audits. Regular audits undertaken included safeguarding, physical health and care plans. Findings from these audits were discussed during clinical governance. For example, following an inquest held for a patient in March 2025 a focus around physical health was highlighted. Staff were reminded to monitor food and fluid charts on a daily basis and to focus on the quality of the forms completed.

Managers maintained a risk register for the hospital. The risk register for the hospital included details of the risk, a risk rating and an action plan explaining how the risk was being addressed and a deadline for the completion of these actions. Significant progress had been made in recruiting more permanent nurses. There was ongoing work being completed to improve the wards appearance.

Staff collected and analysed data about outcomes and performance and engaged actively in local and national quality improvement activities.

Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. Staff had received additional training in de-escalation skills and physical health monitoring. Managers told us that one staff member was supported to complete their leadership training.

Managers recognised poor performance, could identify the reasons and dealt with these.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. Staff said they had sufficient computers to carry out their roles.

Information governance systems included confidentiality of patient records. All computer systems were assessed by individual usernames and passwords.

Staff made notifications to the relevant external bodies as needed. Staff sent notifications in a timely manner to the Care Quality Commission in relation to patients sustaining injuries, allegations of abuse and incidents reported to the police.

Managers engaged other local health and social care providers to ensure that an integrated health and care system was provided to meet patient needs. The hospital had a daily bed planning meeting with a local trust to review upcoming referrals and possible discharges. Staff at the hospital said this agreement was working well.

Staff were engaged in decision making about the ward through discussions at team meetings and clinical governance meetings.

Teams had access to the information they needed to provide safe and effective care and used that information to good effect

The hospital management team were clearly committed to continuous improvement of the service. There had been a particular focus on the recruitment of permanent staff. The service had plans in place to make improvements to the environment.

A quality improvement project was underway to introduce green light torches at night as a response to complaints made by patients about bright lights. Staff told us that they were keen to begin further improvement project in the future. Ward managers told us that the service was involved in a national project called Mental Health Act Quality Improvement and Safe Wards quality improvement