Thornford Park

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

This means we looked for evidence that patients were protected from abuse and avoidable harm.

At our last assessment we rated this key question as good. At this assessment the rating has changed to requirement improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that patients could be harmed.

The service was in breach of legal regulation in relation to regulation 15 because the provider did not ensure that the premises where care and treatment was delivered was well maintained, and suitable for the intended purpose. For example, staff did not always have access to fire fighting equipment in the event of a fire and the roof on one of the wards was leaking when it rained. Regulation 15: Premises and equipment.

The service was in breach of legal regulation in relation to regulation 12 because the provider did not ensure ligature risks were managed well and the environment were sufficiently cleaned to reduce the risk of infection. This was a breach of Regulation 12: Safe Care and Treatment.

However,

Staff knew what incidents to report and how to report them.

Staff understood the duty of candour. They told us it was about being open and transparent, and giving patients and families a full explanation when things went wrong.

Patients said they knew how to complain.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults at risk of, or suffering, significant harm.

Staff made appropriate referrals to the local authority safeguarding teams. Staff were aware of lessons learned from safeguarding concerns, and these were discussed at handover and multidisciplinary meetings. The provider also sent a weekly newsletter to all wards which included lessons learned.

The provider encouraged the least restrictive approach to managing patients who could be at risk to themselves or others. Medicines stocks were correct, and staff completed medicines records appropriately

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Staff knew what incidents to report and how to report them. The provider had an incident reporting system and staff were trained on how to use it. Staff reported all incidents appropriately including to the relevant bodies such as CQC, the local authority and the police where applicable. Incidents were investigated and we saw evidence of learning following investigation. For example, following the increase in ingestion of foreign objects on the wards the provider had implemented a new process to manage the risk of swallowing including enhanced monitoring of remote controls and batteries.

Staff discussed feedback from investigation of incidents at handover, multidisciplinary meetings and staff team meetings. The provider shared a weekly newsletter with staff across the hospital which included incidents across the wards and learning from the incidents.

Staff understood the duty of candour. They told us it was about being open and transparent, and giving patients and families a full explanation when things went wrong. The provider reported 4 serious incidents between January and March 2025 that met the threshold for duty of candour. We saw that staff followed the duty of candour procedure.

Staff were debriefed and received support after a serious incident.

We work with patients and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when patients move between different services.

The provider had clear criteria for patients they would offer a service for in line with the model of care for low and medium secure forensic services. The service’s referral and admission processes ensured that all essential information about patients was received to determine if their needs could safely be met. The provider received 104 referrals between March 2024 and February 2025. Fifty percent of the referrals were declined because the provider could not safely meet their needs or there were no beds available.

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 or transfer.

The service strived to repatriate patients to services in other localities including being closer to home. They held planning meetings with the respective localities as well as other stakeholders including organisations such as the Ministry of Justice and the Multi-Agency Public Protection Arrangements (MAPPA), a system in the UK designed to manage risks posed by certain sexual and violent offenders to the public, to ensure discharges were safe and effective. Of the 160 discharges between March 2024 and February 2025, 92 of the patients were repatriated to services in other localities including those closer to home.

We work with patients to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Patients told us they felt safe on the ward. Most patients said they would speak to staff if they felt unsafe and that staff managed safeguarding concerns well such as patients to patients altercations. However, one person reported that they did not feel safe raising concerns with staff as they were more concerned about the staff attitude towards them. Another person reported they were hurt during a restraint. We reviewed CCTV footage of this incident involving restraint and saw that staff employed the right techniques, were reassuring, and that they were professional at all times.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff followed safety procedures for patients visiting the service.

Staff made appropriate referrals to the local authority safeguarding teams. Staff were aware of lessons learned from safeguarding concerns, and these were discussed at handover and multidisciplinary meetings. The provider also sent a weekly newsletter to all wards which included lessons learned.

The provider encouraged the least restrictive approach to managing patients who could be at risk to themselves or to others. Staff told us they would always try to manage behaviours that challenge through de-escalation first by talking to the person and reassuring them. Some wards such as Donnington and Kingsclere had not reported any episodes of restraint in the last three months. Across the hospital, only 25% of patients had one or more episodes of restraint in the last three months.

Staff worked in line with the provider’s restrictive practice policy and procedure which was regularly reviewed. The wards kept a register of the restrictions which was risk-based and individualised, including restricting patients’ access to community. For example, there was a clear security process in place to support patients’ access to the community depending on their legal and leave status. All patients accessing the internet were individually risk assessed.

We work with patients to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Most patients we spoke with said they felt safe and supported to understand and manage risks. For example, one person told us how managers dealt with an incident with another person in a supportive and reassuring way.

Patients and their carers knew who to contact when patients might be at risk, or their health condition might be worsening. While most patients reported that their care was discussed at ward rounds, some patients felt they were not always empowered to make decisions about their care and treatment. Patients reported staff, including the doctors, did not always explain their treatment options to them.

Staff we spoke with knew patients well and could describe their risks. They told us that they worked with patients to manage risks and to keep them safe from harm. For example, staff told us they will firstly use verbal de-escalation to manage patients’ risk to themselves, and others and they could also offer these patients oral PRN (as required) medication.

Staff completed risk assessment on admission. Staff told us they took practicable steps to mitigate patients’ risks. For example, patients with a known risk of falls were placed on one to one enhanced observation.

Staff had access to radios and alarms to keep patients safe. Patients had bedside call bell systems to notify staff when they needed support.

Staff told us they supported patients to understand their rights. Staff told us best interest meetings were held by the multidisciplinary team for patients who lacked capacity. Patients, family members and care coordinators were invited to these meetings.

Staff ensured that patients could access advocacy. There were notices on all wards showing how to contact the advocates. At the time of our inspection, we saw that the advocates could meet with their clients without any restrictions.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

The provider did not ensure that the premises where care and treatment was delivered was well maintained, and suitable for the intended purpose. For example, staff did not always have access to the cupboards where the firefighting equipment was stored on the ward. The roof on Kingsclere ward was leaking. At the time of the inspection, we saw that the rain drops coming through the roof were dripping on the extension socket in the ward manager’s office.

On Bucklebury ward, the plasterboard was coming off the walls and there were exposed metal angle beads which could be potential ligature points. There was paint coming off the wall, and stains in some areas. The ceiling in Kingsclere ward had water marks and discoloration, potentially from the rain.

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 ward 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.

There was no dedicated entrance to Headley ward. Patients going into the ward had to pass through Kingsclere ward to get to Headley ward. The Health Building Notes 03-01 Supplement 1: Medium and low secure mental health facilities for adults 2023 requires that all new developments including refurbishments have a dedicated access to the wards. The provider informed us that Headley ward has not been refurbished or reconfigured since it was established and they have not recorded any patient safety incident regarding this set up. However, we did not see a specific risk assessment or protocol relating to use of Kingsclere ward to access Headley ward that provided sufficient assurance that the safety of staff, patient or visitors would not be compromised.

While staff said these environmental issues had been reported, there were no clear timeframes for when they would be addressed. We raised these concerns with the provider following the inspection, and the provider informed us that action was being taken to address the environmental concerns which included a capital bid. When we attended a site visit on 13th of March 2025, we saw that there were workers undertaking some repairs including fixing the leaking roof.

The roof on some wards was easily accessible through the garden. While we had concerns about the height of the fence on Headley ward, the provider assured us that the fence was anti-climb fence. Staff told us if a person was at risk of absconding, that area would be on enhanced monitoring by staff. The provider informed us following the inspection that works have commenced to fix the roof.

The windows in the green seclusion room did not have blinds. We raised the concerns with the provider following our Mental Health Act review visit in January 2025 that work needed to be done to improve on the seclusion facilities. However, on this assessment we saw that the seclusion suite did not have blinds.

Ward managers completed the ligature risk assessment with the estates manager. Managers knew and could describe where the risks were. However, staff members could not always identify where potential ligature points were on the wards. Staff told us they used the ligature heat maps (a map that shows all the potential ligature points) if they had any concerns.

All staff were informed of potential ligature risks at start of their shift and throughout the day. Induction forms for new staff contained information on ward ligature points and mitigations. Managers displayed a heat map in the office.

Staff did regular risk assessments of the care environment. There was a daily security check overseen by the ward manager with a dedicated security lead on all shifts.

The ward complied with guidance on eliminating mixed-sex accommodation. Staff had easy access to alarms and patients had easy access to nurse call systems (in wards where this was necessary). Seclusion rooms allowed clear observation and two-way communication and had toilet facilities and a clock.

During the inspection, we saw that the clinic rooms did not always have all the recommended equipment in line with the guidance: Improving the physical health of adults with severe mental illness: essential actions 2005. For example, Highclere ward did not have an examination couch. The provider informed us following the inspection that there was a full GP treatment room which was fully equipped for the needs of service users managed by the provider’s physical health team in conjunction with a contracted GP service. All clinic rooms had easily accessible resuscitation equipment and emergency drugs which were checked regularly.

We make sure there are enough qualified, skilled and experienced patients, who receive effective support, supervision and development and work together effectively to provide safe care that meets patients’ individual needs.

The provider reported very low vacancies for nurses and healthcare support workers across all wards. The provider reported that the overall turnover of staff was reducing and currently 4% as of February 2025. There was a 2% fall in sickness rates for administrative staff and 2% increase in sickness rates for medics between December 2024 and February 2025.

Managers had calculated the number and grade of nurses and healthcare assistants required. The number of nurses and healthcare assistants matched this number on all shifts. Ward managers could adjust staffing levels daily to take account of case mix with authorisation from senior managers.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. However, at the time of this inspection, the provider was using a high number of agency staff due to the need for increased staffing numbers to facilitate enhanced observations of patients who presented as a risk to themselves or others.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

Patients said that some staff were always available in communal areas and willing to engage with them. For example, we saw on Adbury ward that the staff were playing pool with patients. However, some patients reported that some staff do not engage with them and that they stayed in the office. Patients told us sometimes it is difficult for them to get hot drinks as staff were too busy.

While staff told us that staff shortages rarely resulted in staff cancelling escorted leave or ward activities, some patients reported that their leave had been cancelled due to staff shortages or because staff on the ward had to deal with incidents on another ward. Patients told us that on most occasions, staff apologised and tried to reschedule the leave. Patients reported that there were not always enough staff on weekends, especially on Sundays.

There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely (and staff had been trained to do so).

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the group of patients using the service.

There was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency. However, patients said they only met with their responsible clinician once a month during ward rounds. This was not in line with the NICE guideline which recommends that patients should have a minimum of 20 minutes of one to one time with their responsible clinician every week.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

While some wards such as Oakley and Highclere were visibly clean and in good state of repair, other ward such as Bucklebury, Oakley and Kingsclere were not cleaned to a high standard or well maintained. The furniture in the communal area on Bucklebury ward appeared worn. While patients told us there were cleaners on the wards daily, they felt that the cleaning could be better.

However, staff kept the clinic rooms clean and free of clutter.

We make sure that medicines and treatments are safe and meet patients’ needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

The service had a pharmacist that visited weekly. Medicines reconciliation was done by the doctors. Staff told us they did not use any covert medication.

Medicines stocks were correct and there was a robust process around recording of medicines. However, staff did not ensure that medicines were correctly labelled and dated when opened. In addition, staff did not always ensure that unused medicines were disposed of in a timely way. For example, on Bucklebury ward, we saw 5 bottles of liquid medicines opened in the cupboard and 2 out of the 5 did not have labels indicating when they were opened. When reviewing the clinic room fridge, we saw 13 loose insulin injectors had been opened. Staff we spoke with were unable to identify which insulin injector was in use, and which was the PRN in use. Staff reviewed these and noted that 9 of these injectors did not have adequate dosage and should have been disposed of, which they then disposed of.

Staff reviewed the effects of medication on patients’ physical health regularly in line with NICE guidance, including for patients who were prescribed a high dose of antipsychotic medication.

Staff managed clinic room keys well. The medication key was kept by the person assigned to medicines on each shift.