- Independent mental health service
Thornford Park
Assessment report published 15 September 2025
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
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.
People's experience of this service
An Expert by Experience was part of the inspection team. This enabled us to engage with patients on a peer basis on the wards. The Expert by Experience also contacted several relatives of patients by phone to get their feedback.
Overall the feedback was positive and patients were happy with the care they received.
The Expert by Experience spoke with 14 patients across the 2 wards.
Patients said they felt safe and that staff were available and supported them to meet their needs.
Patients felt staff listened to them and involved them in their care. However, some patients were unhappy about smoking rules and did not feel able to influence these decisions. These decisions were made in line with national policy and guidance and not by the hospital.
Patients knew who their named nurse was and met with them to discuss their care. Care plans were available and offered to each person. . However, not everybody had accepted a copy of their care plan.
Ward staff made patients welcome and gave them an introduction to the ward on admission.
Patients said there were a range of activities on and off the ward to participate in. These included the gym, basketball, table tennis, football and pampering sessions. The Occupational Therapists (OTs) ran a programme of activities. However, sometimes the weekends were quieter without many activities taking place.
Religious leaders regularly visited the ward and a priest and Iman supported patients, there was also a multi-faith room available.
Patients felt staff were respectful towards them and helped them keep in touch with family and friends.
Advocacy services were available and patients said they had used them and they had been helpful.
Patients knew how to complain about the service and said there were also posters on the ward with details of how to complain. Most patients told us they would speak to the nurse in charge or ward manager in the first instance.
Mental Health Act and Mental Capacity Act Compliance
Mental Health Act
94% of staff across the hospital had received training in the Mental Health Act. The remaining staff were due to attend but had periods of sickness and leave when training was offered. All staff were due to complete the training.
Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.
Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.
The provider had relevant policies and procedures that reflected the most recent guidance.
Patients had easy access to information about independent mental health advocacy and there were posters on ward informing patients who to access this.
Staff explained to patients their rights under the Mental Health Act (Section 132) in a way that they could understand and repeated it as required. We saw evidence that staff informed patients of their section 132 rights appropriately and recorded this in the persons health records.
Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) once the responsible clinician had approved the persons leave.
Staff requested an opinion from a second opinion appointed doctor when necessary. We saw evidence of a completed second opinion doctor request forms.
Staff stored copies of patients detention papers and associated records correctly, so they were available to staff when needed.
The service displayed a notice to tell informal patients that they could leave the ward freely.
Staff did regular audits to ensure that the Mental Health Act was used correctly and there was evidence of learning from those audits. For example, a S17 leave audit took place quarterly.
Mental Capacity Act
93% of staff across the hospital had training in the Mental Capacity Act. The remaining staff were due to complete their training and some had been impacted by sickness and leave.
Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. We saw examples of completed MCA assessments for patients.
The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.
Staff knew where to get advice regarding the Mental Capacity Act, including deprivation of liberty safeguards.
Staff took all practical steps to enable patients to make their own decisions.
For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately on a decision specific basis.
When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. We saw examples of completed MCA assessments.