Thornford Park

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained the same becausethe provider’s systems and processes were not robust enough to mitigate risks. There were a number of concerns that we found on this assessment that had not been picked up or discussed by the provider. Improvements needed to be made to ensure that the governance processes were robust enough to manage or mitigate against risks to patients using the service.This was a breach of regulation 17: Good governance.

However,

The hospital director and the senior management team had a clear vision for what they wanted to achieve at the service and were developing and implementing processes focussed on supporting staff wellbeing and ensuring everyone promoted a culture of good practice, good quality, and safe care and treatment. All staff we spoke with said that the leaders were kind and approachable and that there had been significant improvement and change since they came into post, particularly around the ward security and creating a safe therapeutic space for patients.

Good practice was recognised and celebrated.

We have not awarded this service a score for Well-led.

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

We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of patients and our communities.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff. Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. They could explain what the provider values were with the acronym “KITE”, which stood for kindness, integrity, teamwork and excellence.

Leaders ensured that there was a flow of information from floor to board and vice versa. For example, staff meetings, multidisciplinary meetings, ward rounds and handovers fed into the monthly clinical governance meetings.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.

Staff could explain how they were working to deliver high quality care within the budgets available. Managers told us they had some level of autonomy to ensure their wards were safely staffed.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Leaders were visible in the service and approachable for patients and staff. The hospital manager informed us that the senior management team tried to visit every ward at least once a week. However, 2 patients said they did not know who the hospital managers were. They said they do see patients coming onto the wards but that they never really introduce themselves or have a chat with them.

Staff were given opportunities to develop skills and pursue leadership and management qualifications. For example, 2 ward managers informed us they have recently completed level 5 leadership and management training.

Quality Statement Score: 3

We create a positive culture where patients feel that they can speak up and that their voice will be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The provider collected feedback from patients and their carers around their care and treatment including whether they knew how to complain, whether they liked the food and whether they have worked collaboratively with staff to agree a care plan.

Although managers and staff told us they had access to the feedback from patients, carers and staff and used it to make improvements, there were still actions from the survey that had not been completed. For example, 35% of patients disagreed or strongly disagreed they had an agreed care plan. This was consistent with the feedback we received directly from patients on this assessment. The provider’s service user survey action plan showed they aimed to address this issue by March 2025.

Patients and carers were involved in decision-making about changes to the service. The provider ensured that patients could give feedback through a variety of mediums including through surveys, community meetings, share your experience questionnaires as well as via the complaints and compliments forms.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. There were experts by experience champions who met directly with the senior leadership team to share patients’ experiences.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for patients who work for us.

The provider undertakes equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patients group.

Staff received training in equality, diversity and inclusion.

Managers told us that staff were able to apply to work flexibly. However, some staff reported they would love to work flexibly due to their personal circumstance but had been refused.

Managers put reasonable adjustments in place for staff members to help them carry out their role.

We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

While there was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed, there were still areas where improvement was required. For example, we saw that the issues around the seclusion room cleanliness had been discussed at multidisciplinary, but no clear actions were taken.

The provider reported on its risk register that the hospital was an old site and that many of their systems and structures were depreciating rapidly, including the backup generator. While there was a five year plan in place with a capital bid for improvement and remedial works, we were concerned patients were or could be at risk if work was not done sooner. For example, at the time of this inspection, we saw that when it rained water was dripping onto the extension lead in the ward manager’s office in Kingsclere ward. There was a process around ward security and fire, but staff were not aware they could not easily access the firefighting equipment in a fire emergency, and this was not picked up within the environmental risk audits.

Patients we spoke with raised concerns around food, including portion sizes, lack of options, quality and taste. At the time of the inspections, more than 50% of patients reported that the provider did not always meet their nutritional needs. The provider informed us that they have been working hard to improve the food and people’s experience. This included a implementing a nutritional steering group and nutritional champions, and the launch of a new menu. The provider had developed an action plan following the previous service user survey to improve on the food. However, feedback we received directly from patients on this inspection showed that more improvements needed to be made to ensure that people’s nutritional and dietary needs were consistently met.

While there were improvements required to ensure an improvement in the overall service performance, the provider had a clear approach to achieving a good and effective service, and the future outlooked appeared positive. For example, the senior leaders were very open and transparent and wanted to do a good job. They were consistently looking for ways to improve and innovate and encouraged and supported staff to do the same.

Staff understood the arrangements for working with other teams, both within the organisation and externally, to meet the needs of patients.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and staff felt this was useful to improve the quality of care.

The provider had a robust information governance system which included treating patients’ records confidentially.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patients’ care.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for patients. We share information and learning with partners and collaborate for improvement.

Thornford Park and Elysium Healthcare no. 2 ltd were a part of the Partnership Board of the provider collaborative and were actively involved in the strategy planning events including chairing some of the meetings. They worked with system partners to ensure patients’s care and treatment needs were being met.

There was a weekly collaborative Clinical Activity Panel which considered new referrals into secure services and monitored the patients who were placed out of area and consulted on their planned pathway including repatriation to their local area.

Directorate leaders engaged with external stakeholders such as commissioners, Healthwatch and the Ministry of Justice.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for patients. We actively contribute to safe, effective practice and research.

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. Innovations were taking place in the service. For example, the provider actively encouraged patients to take up roles as Experts by Experience involvement champions to form key connections between patients in services, providers and commissioners.

Staff had opportunities to participate in research. For example, staff had written a paper on the adverse effect of antipsychotics on the increasing risk of metabolic diseases.

Staff used quality improvement methods and knew how to apply them. For example, the provider undertook a quality improvement project between September 2022 and June 2024 to improve safety and stability by reducing incidents through patients engagement and building therapeutic relationships. The provider reported a reduction in the levels of incidents by 25% following the quality improvement programme.

Wards participated in accreditation schemes relevant to the service and learned from them. For example, managers told us they were working towards being accredited by the Royal College of Psychiatrists quality network for forensic mental health services.