Thornford Park

Overall

Requires improvement

Updated 15 September 2025

Thornford Park is a 141 bedded hospital providing medium and low secure forensic mental health services including two wards for people with learning disabilities and one ward for people with autism. It also has two psychiatric intensive care units and three rehabilitation flats which can accommodate up to 8 people.

Bucklebury, is a 12 bedded male acute medium secure unit Tadley, is a 10 bedded male medium secure unit for people with a learning disability
Adbury ward (formerly called Hermitage), is a 14 bedded male medium secure unit
Kingsclere, is a 13 bedded male rehabilitation low secure unit
Donnington, is a 14 bedded male low secure unit for people with autism
Headley, is a 11 bedded male acute low secure unit
Highclere, is a 17 bedded male low secure unit for older people
Theale, is a 9 bedded male enhanced low secure unit
Oakley, is a 12 bedded female integrated secure setting for people with a learning disability
Crookham, is a11 bedded male psychiatric intensive care unit
Curridge, is a 10 bedded female psychiatric intensive care unit
Midgam, is a 2 bedded male low secure flat
Ashford, is a 5 bedded male low secure flat
Donnington Flat, is a 1 bed male low secure flat for people with autism

We undertook this assessment following a series of serious incidents and increased safeguarding concerns. We also received a number of complaints from people and relatives which included lack of person-centred care and that the service did not always meet people’s dietary needs. Due to the nature of these concerns and previous concerns raised following CQC’s Mental Health Act review visit in January 2025, we made a decision to conduct an assessment.

We last inspected this service in September 2021 when we rated the service Requires Improvement. Following this inspection our rating of the service stayed the same as we rated it Requires Improvement, this was because:

There were issues with the environment across the hospital
In the forensic and secure ward people told us they did not always feel involved in their care and people report not having access to their care plans or being involved in developing them
Not all ligature risks were identified on the ligature audit
Managers had not ensured the wards were always cleaned to an appropriate standard
People reported that the wards were uncomfortable with alarms sounding regularly and that staff often woke at night while doing their observations
People told us the food was not always tasty, filling and did not meet their dietary requirements
The providers governance systems had not identified the issue we found on this inspection

However:

There was a robust complaints and incident management system in place
There was a clear pathway for people for people to be discharge and people had discharge plans in place
The senior leadership team had a clear vision for the service
In the Acute and PICU ward people being supported to make decisions about their care and being given copies of their care plans

Acute wards for adults of working age and psychiatric intensive care units

Good

Updated 22 January 2025

We rated the service as good. At the previous inspection issues raised included low rates of staff supervision, problems with care records and physical health care monitoring. There were also issues around checks and audits of emergency equipment. At that assessment we found a limited range of therapeutic activities for patients. The clinical governance structure was also lacking in timeframes for completion of activities.The service had made improvements and is no longer in breach of regulations. Staff now assessed and mitigated risks. The service now performed regular checks on emergency equipment and there was evidence of this being audited. The provider now ensured staff had regular supervision. Patients were now able to access a range of therapeutic activities on the wards. The clinical governance on the wards had also improved with clear goals and timelines for completion of projects.

Staff supported patients to have choice and control and involved patients in the planning of their care. For example, patients were asked about their goals for their admission and what staff could do to help them achieve these. Patients were involved in writing their care plans and were offered a copy of them.

However, on Curridge ward the environment and furnishings were worn and in a poor state of repair. Staff told us this was being addressed and there was an ongoing maintenance plan in place.

Forensic inpatient or secure wards

Requires improvement

Updated 22 January 2025

During this assessment, we found that:

There were a number of significant environmental safety issues that the provider needed to address including a leaking roof in one of the wards, damaged walls and ceilings, as well as lack of a dedicated entrance to Headley ward in line with the Health Building Notes 03-01 Supplement 1: Medium and low secure mental health facilities for adults. While the provider informed us that there was a capital bid in place, and there were some ongoing repairs to address these issues, we were concerned that patients could be at risk. This was a breach of Regulation 15, Premises and equipment.

The provider did not take all practicable steps to ensure that care and treatment provided to patients was consistently appropriate, met their needs and reflected their preferences. More than half of patients we spoke with said they either did not have a care plan, or they were not involved in developing their care plan. Staff did not always ensure the areas used for long-term segregation were kept clean. The environment was dirty and littered with take away boxes and left over food. The ensuite bathroom in the seclusion room was very dirty. This was a breach of Regulation 9 Person Centred Care.

Ward managers completed environmental and ligature audits with the estates manager. While most of the potential ligature points were identified with actions to mitigate the risks, we identified areas on the wards that were potential fixed ligature anchor points and blind spots, including on Bucklebury, Headley and Oakley wards. Managers told us that there was no specific training for how to complete ligature risk assessments.

The roof on some wards was easily accessible through the garden. The rear garden fence on Headley ward was easily scalable and this was not included on the provider’s risk register. Although, staff told us if a person was at risk of absconding, that area would be on enhanced monitoring by staff.

The wards were not always cleaned to a high standard. Patients we spoke with said that the wards could be cleaner. We saw that areas were littered with food and the ensuite bathrooms were dirty. The walls were stained on Bucklebury and there were watermarks on the ceiling. This was a breach of Regulation 12: Safe Care and Treatment.

Patients reported that the wards were very loud and uncomfortable because of the emergency alarms going off on other wards. While some wards had quiet rooms, during our assessment we observed, for example, Bucklebury ward was very noisy with alarms sounding for long periods of time and lights flashing on the ward outside of bedrooms even though the alarm was activated on another ward in the hospital.

Patients across 5 wards including Adbury, Donnington, Bucklebury, Kingsclere and Headley said that staff did not always treat them kindly or behave appropriately towards them.

Patients told us that when staff did nighttime observation, the rays from the torches usually woke them up. In addition, some patients reported that they did not always have one to one time with their named nurse. This was a breach of regulation 10: Dignity and respect.

Patients told us that the food was not always of good quality, tasteful and of good portion sizes. Some patients said that the food was not always fresh. Patients said that there were not always vegetarian options. Patients reported that the food was not always tasteful, and the portion sizes were small and not filling. Patients said they often get takeaways to meet their dietary needs. This was a breach of regulation 14: Meeting nutritional and hydration needs.

Staff did not always ensure that patients had a care plan that was developed collaboratively with them. Care plans were not always holistic and personalised. In addition, staff did not always ensure that there were clear plans to manage and support patients with additional care needs such as managing their hygiene or physical health condition.

Staff did not ensure that information was always readily available that met the Accessible Information Standard such as easy read for patients in the learning disability and autism wards.This was a breach of regulation 9: Person-centred care

The provider’s governance systems and processes were not robust enough to mitigate risks. There was significant remedial work required to make the ward environments safe and fit for purpose. For example, there were damaged walls with the plaster coming off, a leaking roof, and a lack of dedicated access to some wards with no clear timeframes when these issues will be addressed.

Staff had not realised that they could always access the firefighting equipment on some wards, and the environmental risk and security audit had not identified this issue.This was a breach of regulation 17: Good governance.

However,

There was a robust process around complaints and incident management. Patients we spoke with said they knew how to make a complaint, and staff supported them to do so. Patients received feedback on complaints and there was learning from incidents to improve the service.

Staff completed a comprehensive risk assessment for patients on admission and regularly reviewed risks.

There was a clear pathway for patients in line with the model of care for forensic services. Patients had a discharge plan or moving on plans to ensure that discharges were successful.

The service had an effective multidisciplinary team including doctors, nurses, allied health professionals and support staff who worked well together.

The hospital director had a clear vision for what they wanted to achieve at the service and was developing and implementing systems and processes focussed on supporting staff wellbeing and ensuring everyone promoted a culture of safe, good quality, person centred care and treatment. All staff spoken with were positive about the new leadership team and said they had made a significant impact and positive change. The leadership team were working towards addressing the concerns we raised following the assessment, and when we made another unannounced visit to the service on 13th March 2025, we saw that there was work in progress to fix the leaking roof.

Staff said that they would recommend Thornford park as a good place to work. Staff felt there were opportunities for growth and career development. Leaders actively encouraged innovation, and the teams were working to improve outcomes for patients.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Wards for people with a learning disability or autism

Good

Updated 8 December 2021

This was the first time we rated this service. We rated it as good because:

The care provided to patients was of a very high standard.
Ward managers had an excellent understanding of their services and of patients’ needs. They were visible and approachable for patients and staff.
Care plans, risk assessments and Positive Behavioural Support (PBS) plans were clear and informative.
Individual needs were met and staff demonstrated skill and kindness. Patients said that they were listened to, could ask for help, were able to participate in their care plans and planning their future. Staff helped them achieve their goals and supported them to make decisions.
Patients stated they were happy with their care and treatment and the support offered.
Staff were confident in being able to express their thoughts and on the whole felt really well supported by the ward managers. They felt they were given opportunities to improve their skills and develop.
The provider had worked with a local university to develop an adapted Sexual Offender Treatment Programme (SOTP).
Staff ensured physical health was well monitored and documented.
Discharge plans were discussed and documented as achievable goals for individuals’ needs.
Staff used verbal de-escalation to manage patient incidents and there was low use of restrictive interventions.