Berkshire Healthcare NHS Foundation Trust

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• 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 people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 2. The evidence showed some shortfalls. Staff did not record all incidents on the provider’s incident reporting system.

There had been no serious incidents requiring investigation in line with the patient safety incident response framework (PSIRF) in the 12 months prior to the inspection. Staff had reported 433 incidents in total over the last 12 months. The most common incident types were assault (165), non-physical assault (135) and self-harm (53).

The service had an incident reporting system in place. However, staff did not report all incidents that they should. In some instances, staff had reported details of incidents in patients’ progress notes or risk assessments but not reported these on the incident reporting system. These included incidents of self-harm, verbal aggression and physical aggression. This meant that data on the overall number of incidents/themes was incorrect as not all incidents had been logged as they should have been in line with the provider’s policy. Leaders were aware of this and staff were involved in a quality improvement project around incident reporting. By 31 July 2026 they were aiming to have over 95% of incidents being reported within 24 hours, and over 90% of these meeting a specific competencies standard.

Staff understood the duty of candour. They were open, transparent, and gave patients and families a full explanation if and when things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff discussed incidents in handover meetings and also had a daily safety huddle with the wider multidisciplinary team (MDT) where they reviewed any feedback from incidents and immediate concerns. The provider also sent out monthly bulletins to share wider learning across the organisation.

There was evidence that changes had been made as a result of incidents. For example, the light switches on the ward had been replaced with alternative fittings following incidents where patients were able to break these.

We scored the service as 4. The evidence showed an exceptional standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. The Trust had an Intensive Support Team (IST) who accepted referrals from the community learning disabilities teams for people who were reaching crisis and may need an admission to hospital. The IST worked with patients to try and prevent hospital admissions and also supported patients following discharge from hospital. When a patient was admitted to the ward, the IST and ward staff worked seamlessly to ensure comprehensive information sharing and risk assessment. The speech and language therapist and occupational therapist had split roles across the inpatient service and the IST. Other IST staff regularly visited their patients on the wards to provide reassurance and continuity of care.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. All patients had a comprehensive discharge plan and if there was a delayed discharge, the reason for this was documented, as well as any actions being taken to address this.

Patients who were in the process of transitioning to another care provider had clear plans in place to support their discharge. Staff gave patients easy read information about the place they were being discharged to. Staff from placement providers visited patients on the ward and took them out to visit their new placement, gradually building up the time they spent there. IST staff facilitated training for placement staff to support them with working with patients and staff had received positive feedback in relation to this.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Safeguarding adults level 2 or 3and safeguarding children level 3 training were mandatory for all staff.

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 and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. The ward manager was the designated safeguarding lead and staff could also seek safeguarding advice and support from the Trust’s safeguarding team. The most frequently reported safeguarding concerns were patient on patient assaults.

Staff followed safe procedures for children visiting the service. Children were not permitted to visit patients on the wards. Visits from children took place at other areas in the hospital.

Mental Capacity Act

Ninety-seven percent of staff had received training in the Mental Capacity Act.

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 from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions, including providing information for patients in easy read formats that they could understand.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies. There were no deprivation of liberty safeguards applications made in the last 12 months.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion rarely and only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff knew patients well and were aware of any risks they posed to themselves, to each other or to the environment. Staff knew what strategies to use to minimise and manage risks. All staff were trained in Positive Range of Options to Avoid Crisis and use Therapy– Strategies for Crisis Intervention and Prevention (PROACT-SCIPr-UK). This is a programme that equips staff with the practical skills and knowledge to support people who may be struggling to communicate their needs. Staff told us that this training was very beneficial in helping them understand the theory behind the interventions they use, rather than just focusing on physical restraint techniques.

We reviewed risk assessment and management plans for all 4 patients admitted to the ward at the time of our inspection. All the risk assessments were up to date and staff had reviewed these weekly, or more frequently if indicated. However, we found that risk mitigation plans were not always implemented in line with provider policies. For example, the provider’s ‘safe and supportive observation of and engagement with patients’ policy stated that intermittent observations should be carried out 4 times an hour, at random times. However, when we reviewed observation records, we saw that some staff were completing these at regular15 minute intervals, which meant there was a risk patients could predict the times staff would check on them.

Staff ensured that restraint was used only when other less restrictive interventions had not been successful. Restrictive intervention reduction summary reports for the last 5 months showed a significant reduction in the use of PROACT-SCIPr-UK interventions between October 2025 (36) and February 2026 (10). The interventions used included non-restrictive interventions including verbal re-direction. Staff rarely used physical restraint, and prone restraint had not been used within the last 12 months. Rapid tranquilisation had been administered once in the last 3 months. However, it was clear that other interventions and oral medicines had been attempted prior to rapid tranquilisation being given. Seclusion was also rarely used. There had been 4 episodes of seclusion in the 12 months prior to the inspection. The Reducing Restrictive Practice operational group met monthly to review restrictive interventions, including restraint, seclusion and rapid tranquilisation. This group reported into the Trust’s Reducing Restrictive Practice oversight group.

Staff involved patients and the wider MDT in care planning and risk assessment. Care plans were very personalised and reflected patients’ preferences. However, some of the easy read care plans in patient’s folders had not been updated as frequently as the care plans logged on the electronic records system. This meant that patients may not have accessible versions of their most up to date care plans.

Behaviour therapists developed positive behaviour support plans (PBS) for patients to equip staff with strategies to recognise when a patient was becoming distressed and to know how they could best support patients in these situations. PBS is a person-centred, proactive strategy to understand and manage distressed behaviours, focusing on improving quality of life for individuals with learning disabilities or autism. We saw that all patients had individualised PBS plans. However, one patient’s plan had not been updated during their current admission to the ward.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties, such as using easy read materials, choice boards and pictorial aids. Staff developed care plans that met the needs identified during assessment. Care plans were personalised, holistic and recovery-oriented. Care plans were also provided in an easy read easy read, pictorial version to give to patients. However, one patient's easy read care plans were not up to date. The team rectified this immediately to ensure that all easy read care plans were up to date. The speech and language therapist completed comprehensive communication assessments for patients and produced grab sheets for staff summarising their findings and strategies they thought would be helpful. However, the grab sheets in patient’s folders were not always the most up to date versions that were available.

Staff enabled patients to give feedback on the service they received in a range of different ways. Staff ran a weekly community meeting for patients to give feedback about the ward environment, activities or catering. Patients were also offered weekly one to one sessions with their named key members of staff to discuss things such as emotional wellbeing, upcoming MDT reviews and prescribed medications. Staff also invited patients to attend daily Huddle Board meetings, during which they were supported to make meaningful contributions regarding potential environmental changes and other areas for improvement within the service. During these sessions, patients were supported to discuss and review any issues or tickets they had raised and were provided with updates on actions taken or progress made. This enabled patients to see how their feedback had contributed to service development.

There was a blanket restriction in place on the ward around access to drinks and snacks. Managers told us this was because one patient was at risk of over-consumption. Details of the restriction were recorded on the log of blanket restrictions, which was monitored via the Trust’s restrictive practice meetings. Mitigations for minimising the impact on other people were in place, including, placing jugs of water or squash in their bedrooms if risked assessed as safe to do so.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The ward environment was clean, well-decorated and well-maintained.

Staff could not observe patients in all parts of the wards and outside space. However, the service had fitted convex mirrors and used enhanced observations to support patients with additional risks. Closed-circuit television (CCTV) was in place in communal areas. Staff did not have direct access to the footage, but the service manager could request to view this.

Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Staff completed an annual ligature audit.

The ward complied with guidance on eliminating mixed-sex accommodation. The ward was configured so that corridors could be allocated for specific genders. Each corridor had toilets, a bathroom and shower facilities. However, at the time of our inspection the shower in the male corridor was out of use due to legionella having been identified in the water supply. Patients had access to an alternative shower and bathroom facilities while the provider was working to resolve this. Female patients had access to a female only lounge. Each patient had a wristband which enabled them to access the relevant parts of the ward, including their bedrooms. This also enabled them to store belongings securely in their bedrooms.

Staff carried portable alarms and patients had easy access to nurse call buttons in their bedrooms.

The seclusion room allowed clear observation and 2-way communication. It had toilet facilities and a clock. Patients had access to anti-ligature clothing and bedding where necessary.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The service displayed the names and photos of all staff on each ward, so that staff and visitors were aware of the staff working on the wards.

All rooms throughout the ward had a large sign with a picture on to help patients navigate their way around the ward.

We scored the service as 4. The evidence showed an exceptional standard. The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs. The service had low vacancy and turnover rates. Their compliance with mandatory training was very high.

The ward had low vacancy rates. They were fully recruited for qualified nurses and had vacancies for 2.6 whole time equivalent healthcare assistants.

The ward was fully staffed during our inspection, with 3 qualified nurses and 5 healthcare assistants working on the ward. The ward manager told us they always have 2 qualified nurses on shift but that they aim to have 3 due to the high volume of meetings requiring a qualified nurse to attend. People told us that the ward was rarely short staffed. In the 3 months prior to the inspection 6% of shifts had been unfilled, the majority of these were requests for healthcare assistants.

The ward manager could adjust staffing levels daily to take account of case mix. If more than one patient was on enhanced observations, then extra staff would be brought in to support the shift.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. The ward used regular bank staff and had not used any agency staff in the 3 months prior to the inspection. Staff turnover rate in the 12 months prior to the inspection was very low at an average of 0.5%.This was significantly lower than the Trust target of 10%.The average staff sickness rate was 7%, which was higher than the Trust target of 3.5%.

Staffing levels allowed patients to have regular one-to-one time with their named key members of staff.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. There was a vacancy for a consultant psychiatrist, but this post was being covered by a locum psychiatrist. There was also a speciality doctor on the ward.

Staff had received and were up to date with appropriate mandatory training. The overall compliance rate with mandatory training was 96%.The training was appropriate for the patient group using the service. Staff were trained in Makaton. Managers monitored mandatory training and alerted staff when they needed to update their training. Where training had gone out of date, staff were booked to complete this in most cases.

Staff told us they felt extremely well supported in their roles. All staff had received an appraisal within the last year. The results from the 2025 NHS staff survey showed that 91.3% of respondents from Campion unit felt supported to develop their potential. This was over 30% higher than the national peer average score for this statement.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. All ward areas were clean, had good furnishings and were well-maintained.

Staff adhered to infection control principles, including handwashing. Staff completed a monthly hand hygiene audit which showed 100% compliance for the last 12 months.

Staff identified individual infection control risks and documented these in risk assessment and mitigation plans.

Staff detected infection risks and escalated these appropriately. Staff had recently identified legionella bacteria in one of the shower rooms on the ward. This room had been put out of use and weekly meetings were taking place to review the situation.

The provider’s infection control team disseminated important information to staff. For example, a staff member had recently been signed off work with an infectious disease, and the team had sent all staff an email offering them advice. We observed staff discussing this in their team meeting.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff stored medicines, including controlled drugs (CDs), securely, with appropriate temperature monitoring. However, staff stored medicines keys in an unlocked box in the nursing station. Staff rectified this immediately during the inspection. CD balances were accurate.

Emergency medicines were available and checked regularly.

People received their medicines as prescribed. All patients had the correct consent to treatment forms easily accessible at the point of administration. Prescribing was in line with national guidance and no patients were receiving High Dose Antipsychotic Treatment (HDAT).

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance. A GP held a virtual clinic once a week where they reviewed any outstanding monitoring requirements. We observed this during our inspection and saw that a patient was identified as requiring a blood test to monitor one of their medicines.

Staff ensured that unused or expired medicines were removed. However, we found some cream that stated it should be used within 3 months of opening that had not been labelled to indicate the date it was opened.