Jasmine Court Independent 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

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good.

This key question has been rated as good. This meant people were safe and protected from avoidable harm.

The service was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

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.

The service had a proactive and positive culture of safety based on openness and honesty in which concerns were listened to. Patient safety incidents were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

All staff knew what incidents to report and how to report them. We spoke with 8 members of staff. An incident of abuse between patients was discussed at a team meeting and learning was shared among staff to ensure this did not happen again.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong.

There had been no serious incidents in the last 12 months.

Staff feedback and clinical governance meetings demonstrated that learning from incidents was regularly shared and that processes had been embedded. For example, staff and managers described being involved in learning and participating in staff meetings, supervision, clinical governance and training.

The service worked with people and partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The service ensured continuity of care, including when people moved between different services.

We sought feedback from commissioners and bed managers who placed patients at Jasmine Court, to obtain their view of the hospital systems, pathways, patient flow, safety and quality. We received feedback from 2 commissioners. They said they worked well with the hospital and communication was good, with staff being very open to support and advice. They spoke highly of staff and the environment and whilst there had been previous concerns regarding reviewing 1:1 observations, the service had been responsive to this following feedback.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. The service used a comprehensive preadmission process. Care plans evidenced that the multi-disciplinary team assessed dynamically, ensuring continuity of care. During our inspection staff told us about a patient referral they were unable to accept as the patient’s needs could not be met at the service. Patients were always reviewed by the service in person to ensure the service would be able to provide the correct care.

Staff involved all the necessary health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Care plans were comprehensive, and person centred and there were multiple examples of patients being referred to external providers such as GPs, Dentists and secondary care specialists.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The service had a safeguarding policy and clear processes in place for staff to follow. Staff received training on how to recognise and report abuse, appropriate for their role. All staff completed mandatory safeguarding training and compliance was at 97.3%.

The hospital had a safeguarding lead, and staff knew how to raise safeguarding concerns. Between August and October 2025, staff had made 3 safeguarding referrals. Safeguarding concerns related to a variety of incidents including violence and aggression between patients and historic allegations of sexual abuse.

The safeguarding lead ensured that the service had a robust system for tracking the progress of safeguarding referrals. Referrals were reviewed monthly, and staff liaised with the Local Authority when appropriate. The safeguarding log was up to date and included details about safeguarding incidents.

Staff followed safe procedures for children visiting the service. Children were not allowed to be on the ward; however, arrangements could be made for them to visit patients using the conference room within the hospital.

There were 6 deprivation of liberty safeguards applications made in the last 12 months to protect people without capacity to make decisions about their own care.

We spoke with 3 carers. All carers told us they felt their loved one was safe at Jasmine Court and they knew how to raise concerns if they needed to. One carer stated that he slept well at night knowing his family member was safe.

We reviewed 4 staff files, in 1 of these the most recent DBS check for the member of staff was 2019. We reviewed the policy that Barchester had in place, and this did not dictate a requirement for staff members to have their DBS reviewed at set timed intervals after employment. The service told us that they can re-check staff when they deem it necessary. The service relied on staff to tell them if they were questioned, arrested, charged or cautioned with any criminal or driving matters.

The service worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that matter to them. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Assessment of patient risk

We looked at 3 care plans. In each one staff completed risk assessments for each patient on admission using a recognised tool, and reviewed this regularly, including after any incident. Risks were reviewed by the multidisciplinary team each day.

Management of patient risk

Staff knew about any risks to each patient and acted to prevent or reduce risks. Potential risks for patients included risk of falls, self-harm and self-neglect. Some patients were vulnerable and were at risk of exploitation from others. Staff had a good understanding of patients’ histories and significant risk incidents that had occurred in the past.

Staff involved patients in care planning and risk assessment. Staff told us that care plans were co-produced with patients and were discussed in ward rounds and reviews.

All patients had access to an Independent Mental Health Advocate (IMHA) during their stay at the hospital. Information about how to access the advocate was displayed around the ward and given to patients on admission.

Staff enabled patients to give feedback on the service they received. There were regular community meetings held for patients, and carers told us they were satisfied they could easily provide feedback to the service.

Use of restrictive interventions

The service had a Restrictive Interventions policy which was reviewed in February 2024. The policy described the service’s commitment to minimising the use of restrictive interventions and use of force. The policy outlined arrangements for authorising and reviewing restrictive practices, including ‘blanket restrictions’ and included guidance to involve service users where possible.

Restrictive interventions were discussed in bi-monthly clinical governance meetings. Rules, policies and restrictive practice were discussed in patient community meetings.

In August 2025 there were 2 incidents of restraint compared to 1 in July. 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. There were 100 incidents of de-escalation in July and 53 in August, this is a decrease of 47 from the previous month. This significant fall raised concerns that there was a risk of under reporting from staff. Managers had noted this immediately and raised the importance of recording every incident in a team meeting.

People were cared for in safe environments that were designed to meet their needs. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care.

We toured the ward and observed that it was airy and spacious, very clean and well-maintained, well-furnished and fit for purpose.

Staff could not observe patients in all parts of the wards and outside space. However, the service had fitted convex mirrors to monitor communal areas and used enhanced observations to support patients with additional risks.

The ward complied with guidance and there was no mixed sex accommodation. The service only admitted male patients.

Staff had access to alarms, although one member of staff we spoke with did not have a personal alarm yet; patients had easy access to nurse call systems.

The clinic room was clean and fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly.

There was a comprehensive ligature risk assessment and appropriate furnishings to mitigate risk. However, there was no easy to read one page ligature hotspot/heatmap available for staff to see.

Facilities that promote comfort, dignity and privacy

Each patient had their own bedroom, which they could personalise. Bedrooms were clean and bright with ensuite facilities. Bedrooms were not locked and one patient we spoke with raised concerns about other patients being able to go into his room.

Staff used a range of rooms and equipment to support treatment and care. The ward had a clinic room, and rooms that could be used for group work, art therapy and activities.

The service displayed the names and photos of all staff so that patients and visitors were aware of the staff working on the wards.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who receive effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the time of the inspection the service employed 5 registered mental health nurses and used 9 bank nurses to cover holidays and sickness. The service employed 23 support workers and used 9 bank support workers. There were currently no vacancies for Nurses or support workers. Managers had calculated the number and grade of nurses and healthcare assistants required.

The service was currently recruiting for a hospital director and there was a deputy manager currently in the onboarding process. Otherwise, the multi-disciplinary team was fully staffed.

Nurses at the service were all reasonably new in post and whilst they were all settling into their role they were being well supported by the clinical lead. The service employed 2 doctors.

Within the last three months shifts were filled by bank nurses 3% of the time and 1% of the time by agency nurses.

Within the same period, bank support workers were used 2% of the time and agency support workers were used 1% of the time.

During this period enhanced observations were covered by bank support workers 38% of the time and agency support workers were used 1% of the time.

Managers told us they were now fully recruited for nurses and support workers, and they would be moving to zero usage of agency staff.

During the inspection we could see the ward was fully staffed, although there was a high number of patients on 1:1 observations. Patients we spoke with said there were always staff visible on the wards, however 2 patients told us their leave was not always granted due to short staffing.

Mandatory training

Staff had completed and kept up to date with their mandatory training. Overall, staff compliance with mandatory training was 96.9%. There was no mandatory training with a compliance rate of less than 75%. The lowest compliance was in Induction-common induction standards or home induction 89.4%. The mandatory training programme was comprehensive and met the needs of patients and staff.

Managers gave each new member of staff a full induction to the service before they started work.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean.

All ward areas and clinic areas were clean and well maintained.

Ccleaning records were up to date and demonstrated that all areas of the hospital were regularly cleaned.

Staff followed infection control policy, including handwashing. Hand gel was available at the ward entrance. Compliance levels for mandatory training in infection control was at 97.3%.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely.

Patients’ medicines were reviewed as part of an overall review of their progress at ward rounds. Patients were involved in discussions about medication and care planning.

Staff completed medicines records accurately and kept them up to date. We reviewed the medicines charts for 4 patients. Records we looked at were clear, up to date and accurate.

Staff stored and managed all medicines and prescribing documents safely. All medicines were stored in locked cabinets, or in the medicine fridge in the clinic room.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. None of the patients were receiving doses of medicine above the level recommended in the British National Formulary (BNF).