The Care Quality Commission
  • Mental Health
  • Independent mental health service

Thornford Park

Overall: Requires improvement read more about inspection ratings

Crookham Hill, Thatcham, Berkshire, RG19 8ET (01635) 860072

Provided and run by:
Elysium Healthcare No.2 Limited

All Inspections

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

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.

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

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.

During an assessment of Forensic inpatient or secure wards

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.

During an assessment of Forensic inpatient or secure wards

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.

During an assessment of the hospital overall

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

14 & 15 September 2021

During a routine inspection

Thornford Park is a 129 bedded hospital providing inpatient medium and low secure forensic mental health services including a ward for people with learning disabilities and a ward for people with autism. It also has two psychiatric intensive care units (PICUs) and three rehabilitation flats.

Our rating of this location went down. We rated it as requires improvement because:

  • There were high nursing vacancy rates at the service. The hospital utilised agency staff to fill these gaps, however this was not always possible. This meant that the wards were sometimes short-staffed and on the forensic wards this had an impact on patients being able to take leave. This had an impact on patient’s wellbeing and could impact on their recovery. At our previous comprehensive inspection in 2017 we told the hospital it must make improvements to ensure it always has enough appropriate staff to meet patients’ needs; this was, and remains a breach of the Health and Social Care Act regulations.
  • Governance and oversight processes at the hospital required improvement. The quality of care records on the forensic and PICU wards was variable. Kingsclere ward had very thorough and comprehensive records, while records on Bucklebury ward were less personalised and did not include adequate mitigation plans for identified risks. Care records did also not reflect the patient voice.
  • The forensic wards looked very tired and required refurbishment. These were due to be renovated, with a programme of works due to commence in 2022.
  • Staff utilised the National Early Warning System (NEWS 2) to monitor the physical health of patients. However, on the forensic and PICU wards it was not always documented what action had been taken when indicated which meant that the physical health needs of patients may not have been acted upon, placing them at risk.
  • Some patients on Bucklebury and Hermitage wards told us they did not feel safe due to the risk of violence from other patients. Violence and aggression was the most common incident type reported on the wards.
  • On Headley ward a patient had two T2 forms signed by two different approved clinicians in place authorising different medicines (a T2 form confirms that a patient is capable of understanding the nature, purpose and likely effects of a treatment and that they have consented to receiving this). This could have led to a patient receiving the wrong medicine, or not receiving medicine they should have.
  • On Curridge ward we found that a defibrillator wasn’t working. This had not been identified because the relevant audits of emergency equipment had not been carried out.
  • Patients on the PICUs told us that there were not enough activities to occupy them during evenings and weekends.
  • Staff on the PICUs did not always receive regular individual supervision. Compliance rates for individual supervision in the quarter prior to the inspection were 68%.

However:

  • The learning disability and autism wards were rated as good overall. Staff demonstrated a commitment to providing person-centred care for patients and we saw some excellent use of communication methods.
  • Staff had handled the COVID-19 pandemic very well. None of the patients at the hospital had tested positive since April 2020.
  • The senior leadership team had a good understanding of the key challenges the service faced. The hospital director was a visible presence throughout the hospital and approachable for patients and staff.
  • The provider had worked with a local university to develop an adapted Sexual Offender Treatment Programme (SOTP).
  • Patients we spoke with gave excellent feedback about the way staff treated them. They said they were always kind and compassionate.
  • Patients were involved in their care and developments in the hospital. There was a patient council made up of representatives from each ward and patients also attended ward-based and hospital-wide clinical governance meetings.
  • Staff were supported to develop in their roles. For example, all ward managers were able to complete level five leadership training.
  • The hospital had robust safeguarding procedures in place. Staff had good knowledge of these procedures and the provider had supported 11 staff members to complete level four safeguarding training.
  • Patients had good access to physical healthcare and were supported to make healthy lifestyle choices, e.g. offered nicotine replacement therapy and weight management programmes. The hospital also had an onsite gym and ran exercise classes to encourage patients to exercise.
  • Staff had recently begun hosting a monthly online carers’ forum which provided an opportunity for carers to learn more about the hospital.

23 June and 3 July 2020

During an inspection looking at part of the service

Thornford Park Hospital provides forensic inpatient services across ten wards and two shared flats within the secure perimeter of the hospital.

We undertook an unannounced focussed inspection following concerns received through the CQC website about poor infection control measures relating to Covid 19 procedures across the hospital.

We visited Currdige and Tadley wards due to concerns raised about quality of care delivered to patients and about the increasing number of incidents that the provider had sent us notifications about alleged abuse and significant injuries.

This inspection was a focussed inspection so therefore did not provide a change to the existing rating.

During this inspection we found:

  • Records lacked detailed guidance for staff on how to manage patient risks and on how to manage incidents that placed patients and others at risk of harm.

  • The provider had not developed or implemented a procedure on when to administer medicines prescribed to be taken “when required” (PRN). This meant there were inconsistencies between staff on when to administer PRN medicines. Patients were not having these medicines consistently as prescribed.

  • The staff we spoke with as part of this inspection including feedback prior to the inspection expressed a lack of confidence with the organisation which had an impact on their performance. For example, lack of experienced staff, delays in introducing COVID procedures and specialist training. A clinician said that in “Curridge morale has been low but Tadley has varied.”

However:

  • Overall, there were effective system to provide safe care and treatment to patients. The provider had improved communication and introduced measures to prevent the spread of infection.
  • The wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose.

21-23 November 2017

During a routine inspection

We rated Thornford Park as good because:

  • Risk assessments and risk management plans were detailed, thorough and up to date and patients had been involved in the development of the plans. The assessment of patients’ needs and the planning of their care was thorough, individualised and had a focus on recovery. Physical healthcare assessments and associated plans of care were thorough and consistently delivered to a high standard. Care plans had either a National Institute for Health and Care Excellence (NICE) guidance reference to an identified intervention or another nationally recognised intervention such as from the Quality Network for Forensic Mental Health led by the Royal College of Psychiatrists.
  • There were enough suitably qualified and trained staff to provide care to a safe standard. We consistently saw respectful, patient, responsive and kind interactions between staff and patients. Staff displayed a high level of understanding of the individual needs of patients. There were innovative practices used consistently across the service to engage and involve patients in the care and treatment they received, for example, the recovery star. There was a confident and thorough understanding of relational security among all of the staff. Relational security is how staff use their knowledge and understanding of their patients to ensure the ward environment is kept calm and any conflict is kept to a minimum.
  • Bed management processes were effective and there was a clear care pathway through the service from medium secure wards to the least restrictive environments, such as the shared flats. The service model optimised patients’ recovery, comfort and dignity. The needs of patients were considered at all times.
  • The service had clear guidance in place to report incidents and we saw evidence that staff learnt from when things had gone wrong. The service was responsive to listening to concerns or ideas made by patients and their relatives to improve services. We saw that when staff where able to, these ideas were taken on board and implemented.
  • Staff monitored patients’ physical healthcare and they could access specialist physical health services when needed. A GP provided regular physical health monitoring. Patients attended a well-man clinic.
  • We observed many positive engagement and interaction between staff and patients. Staff demonstrated a clear understanding of individual patient’s needs.

However:

  • Staff were not always available to facilitate section 17 leave on the forensic wards and leave was often cancelled.
  • The number of staff having access to regular supervision was below the provider’s target of 90%.
  • Not all patients were always reminded of their rights when their circumstances changed, such as on renewal of detention.
  • The seclusion room did not have a two-way intercom to ease communication between staff and patients.  Gym equipment was worn . All of these facility issues had been identified for refurbishment and upgrade in 2018
  • The recording of seclusion was documented differently across the wards. Staff made the required checks however, some was recorded electronically and some in paper form.

30 June, 7-9 and 23 July 2015

During a routine inspection

We rated Thornford Park as good because:

  • The wards were kept clean and well maintained and patients told us that they felt safe.
  • There were enough, suitably qualified and trained staff to provide care to a good standard.
  • Patients’ risk assessments were robust and person-centred.
  • The service had clear mechanisms to report incidents of harm or risk of harm and we saw evidence that the service learnt from when things had gone wrong.
  • The assessment of patients’ needs and the planning of their care was thorough, individualised and had a focus on recovery.
  • We found evidence of best practice and that all staff had a good understanding of the Mental Health Act 1983 (MHA), the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).
  • Throughout all of the wards the multidisciplinary teams were consistently and proactively involved in patient care and that everyone’s’ contribution was considered of equal value.
  • Staff were caring and motivated and we saw good, professional and respectful interactions between staff and patients during our inspection. We saw evidence of initiatives to involve patients in their care and treatment. These included the ‘my shared pathway’ recovery approach to care planning and daily ward briefings with all patients and staff.
  • Staff had a confident and thorough understanding of how good relationships between patients and staff can support a secure environment.
  • Bed management processes were robust and effective. The service model optimised patients’ recovery, comfort and dignity. There was a clear care pathway through the service from medium secure wards to the least restrictive environments, such as the shared flats.
  • The needs of patients were considered at all times. There was a varied, strong and recovery orientated programme of therapeutic activities available over seven days, every week.
  • The service was particularly good at listening to concerns or ideas from patients and their relatives to improve services, with the exception of their feedback about the inconsistent quality of the food. When staff where able to; these ideas were implemented.
  • Staff morale was good and staff felt well supported and engaged with a highly visible and strong leadership team, which included both clinicians and managers. Governance structures were clear, well documented, adhered to by all of the wards and reported accurately. This meant that the hospital had clear controls in place to know that the service was being delivered to a good standard.

However

  • The use of plastic bin liners was inconsistent across the wards and no clear rationale was given as to why this was. (Plastic bin liners could be used as a means of suffocation if used to self-harm.)
  • We received mixed comments from patients about how kind the staff were towards them.
  • The quality of food remained inconsistent despite patient feedback about this.

24, 25 February 2014

During a routine inspection

We inspected three of the eight wards at the hospital. Chievely ward, a medium secure unit; Theale ward an acute unit; and Highclere a low secure ward for men with physical health problems who tended to be older.

Where people did not have the capacity to consent, the provider acted in accordance with legal requirements. Patients had been supported to make advance directives for their future care should they lose capacity to make decisions. Wherever possible patients' consent to their care and treatment was sought and their choices respected. Where necessary a second opinion appointed doctor was involved.

Patients had individualised care plans and we saw that some patients had a high level of input into their plans whilst other patients had refused to participate. Each patient had been asked for their views and these had been recorded. Patients had access to physical healthcare both within the hospital and could also access community health services, dependent upon risk.

The provider cooperated with other providers in order to manage patients' health, safety and welfare.

The premises were safe, secure and fit for purpose. we saw that a program of refurbishment was taking place.

Staff felt supported by management and there was an effective system of supervision and training in place. Following incidents staff had the opportunity to attend debriefs.

The provider had an effective quality monitoring system and demonstrated learning from incidents

6 February 2013

During a routine inspection

We conducted this inspection on Bucklebury Ward. We found that staff respected people's rights, involved them in their care where possible and were thoughtful about the care provided. Staff we spoke with demonstrated a good understanding of people's needs and the ethical issues involved in treating people who were detained. However, one person told us “They don't speak to me with respect”. Other records and information looked at did not support this view.

There was a programme of activities which took place daily that people could choose to participate in. One person said “The activities are OK, and you can stay on the ward and play games”. Information was displayed at several points around the ward to inform people about a range of topics. Some of this information was out of date. Meetings were held with people three times a week to discuss how the ward operated. One person told us “I leave the meetings because it's a one-way conversation”. However records seen did not support this view.

Staff felt supported in their role and had access to regular recorded one to one supervision meetings. There were regular team meetings, role specific meetings, debriefing sessions and reflective practice discussions.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.