- Independent mental health service
Pathfinder Ashness House
Report from 9 July 2025 assessment
Contents
Ratings - Long stay or rehabilitation mental health wards for working age adults
Our view of the service
We carried out a comprehensive assessment of Ashness House on 6 to 7 August 2025.
We rated this service as Good.
Ashness House is a 26-bed inpatient service for males with severe and enduring mental health illness, co-morbid physical health problems and complex needs. Tide Ward has 19 inpatient rehabilitation beds and Coast Ward 7 High dependency beds.
This service was last inspected in December 2022, and the service was rated good overall. At that inspection, we found that some legal requirements were not met. We had concerns that the service did not always explain the Mental Health Act to patients in a way they could understand, and the service must provide more ways to help patients understand their rights. This was a breach of Regulation 9(1)(3)(b).
At this assessment we rated the service as Good.
We spoke with 8 members of staff, 6 patients and 5 carers. We also reviewed the care and treatment records of 6 patients.
We identified several areas of good practice during this inspection. Staff had a good understanding of incident reporting processes, knowing what incidents to report and the process for doing so. Staff told us they avoided using restraint by using de-escalation techniques. Most staff were up to date with their yearly appraisals. Patients could access a range of interventions and activities in line with national guidance. Patients told us staff were kind and treated them well. All staff told us they felt respected, supported and valued by their colleagues and managers. Staff were using CAMS monitoring tool (Co-operations, Anti-social behaviour, Mood/Anger, sexually inappropriate behaviour), which has seen a decrease in incidents.
However, we did find areas for improvement.
We observed some gaps in employment records and mandatory training records.
The ward areas appeared mostly clean, however there was a malodour, some areas and the cleaning records were not up to date. Staff did not always follow best practice in infection and prevention and control in relation to ward signage.
The provider was unclear who was providing Independent Mental Health Act Advocacy (IMHA) services and information about accessing these services was not clear for patients or staff. Care plans did not always consistently reflect the views of the patient, in their own words.
The service had identified that additional meeting rooms were needed, to support the functioning of the ward.
At this assessment we identified breaches of regulations under 12 Safe Care and Treatment, 15 Premises and Equipment, 17 Good Governance, 18 Staffing. We found four breaches of regulation in relation to cleanliness and infection prevention and control, personal emergency evacuation plan documentation and employment documentation, and mandatory training records.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
We spoke with 6 patients and 5 carers.
Patients gave positive feedback, praising staff for their friendliness and helpfulness, and appreciating regular meetings with their named nurse.
Carers told us staff had positive attitudes and did a good job, although at times communication with the service could be better.
The service collected feedback from patients about their care through surveys and community meetings.
Mental Health Act
All staff had completed training in the Mental Health Act and the Mental Health Act Code of Practice.
Patients had access to information about advocacy services, although at the time of inspection, the service did not have a clear contract in place for patients to access an Independent Mental Health Advocacy (IMHA), although if needed, the patients could access this via another service.
Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. The Mental Health Act administrator for the service was based on site and shared they send regular reminders to ensure that patients’ Section 132 rights were upheld. Section 132 rights are legal rights that give information about a person’s detention under the Mental Health Act.
Staff consistently informed patients of their rights under the Mental Health Act, with records showing this information was repeated as needed, and most patients demonstrated awareness of their rights.
Staff requested an opinion from a Second Opinion Appointed Doctor (SOAD) when they needed to.
Staff properly stored and managed detention papers, ensuing accessibility for relevant staff, and demonstrated a clear understanding of section 17 procedures (permission for patients to leave hospital). Staff did regular audits to ensure that the Mental Health Act was being applied correctly.
Mental Capacity Act
Staff received training in the Mental Capacity Act and deprivation of liberty safeguards. Compliance rates were 87%.
For patients who may have had impaired mental capacity, staff assessed and recorded capacity to consent to decisions appropriately.