All Saints Hospital

Date of assessment: 24 and 25 September 2025

We assessed this service due to the age of the previous ratings.

All Saints Hospital provided specialist care and treatment for 20 men with mental health needs who are also deaf or have impaired hearing and use British Sign Language (BSL) to communicate. All Saints Hospital delivered 2 assessment service groups across 2 wards: forensic inpatient or secure wards and long stay or rehabilitation mental health wards for working age adults.

All Saints Hospital had 1 forensic inpatient or secure ward:

Appleton ward - providing care and treatment in a low-secure environment for up to 6 male patients.

At this assessment we assessed all quality statements across all 5 key questions.

At this assessment we identified 1 breach of regulation in relation to governance in the service.

We rated the service as good. The ward was generally safe, clean, well equipped and fit for purpose. Staff assessed and managed risks to patients and themselves well. Patients were involved in their care planning and risk assessments and staff actively sought patient feedback on the quality of care provided.

However, governance processes did not always operate effectively, and performance and risk were not always managed well or with appropriate oversight. There were processes that had been implemented which had not been reviewed to ensure that they were embedded effectively. The service had further work to do to ensure the culture of the service was improved.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. 93.1% of staff had received training in the Mental Health Act.

Staff had 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. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had access to information about independent mental health advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. 89.7% of staff had completed their mandatory 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. 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. Managers gave examples of how capacity was considered and the processes that were followed within the service.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

Date of assessment: 24 and 25 September 2025

We assessed this service due to the age of the previous ratings.

All Saints Hospital provided specialist care and treatment for 20 men with mental health needs who are also deaf or have impaired hearing and use British Sign Language (BSL) to communicate. All Saints Hospital delivered 2 assessment service groups across 2 wards: forensic inpatient or secure wards and long stay or rehabilitation mental health wards for working age adults.

All Saints Hospital had 1 forensic inpatient or secure ward:

Appleton ward - providing care and treatment in a low-secure environment for up to 6 male patients.

At this assessment we assessed all quality statements across all 5 key questions.

At this assessment we identified 1 breach of regulation in relation to governance in the service.

We rated the service as good. The ward was generally safe, clean, well equipped and fit for purpose. Staff assessed and managed risks to patients and themselves well. Patients were involved in their care planning and risk assessments and staff actively sought patient feedback on the quality of care provided.

However, governance processes did not always operate effectively, and performance and risk were not always managed well or with appropriate oversight. There were processes that had been implemented which had not been reviewed to ensure that they were embedded effectively. The service had further work to do to ensure the culture of the service was improved.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. 93.1% of staff had received training in the Mental Health Act.

Staff had 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. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had access to information about independent mental health advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. 89.7% of staff had completed their mandatory 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. 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. Managers gave examples of how capacity was considered and the processes that were followed within the service.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

Date of assessment: 24 and 25 September 2025

We assessed this service due to the age of the previous ratings.

All Saints Hospital provided specialist care and treatment for 20 men with mental health needs who are also deaf or have impaired hearing and use British Sign Language (BSL) to communicate. All Saints Hospital delivered 2 assessment service groups across 2 wards: forensic inpatient or secure wards and long stay or rehabilitation mental health wards for working age adults.

All Saints Hospital had 1 long stay or rehabilitation mental health ward for working age adults:

Braidwood ward - a specialist high-dependency rehabilitation ward for up to 14 male patients. The ward included four self-contained flats and four bedsits to help facilitate the recovery journey of patients.

At this assessment we assessed all quality statements across all 5 key questions.

At this assessment we identified 1 breach of regulation in relation to governance in the service.

We rated the service as good. The ward was generally safe, clean, well equipped and fit for purpose. Staff assessed and managed risks to patients and themselves well. Patients were involved in their care planning and risk assessments and staff actively sought patient feedback on the quality of care provided.

However, governance processes did not always operate effectively, and performance and risk were not always managed well or with appropriate oversight. There were processes that had been implemented which had not been reviewed to ensure that they were embedded effectively. The service had further work to do to ensure the culture of the service was improved.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. 93% of staff had received training in the Mental Health Act.

Staff had 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. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had access to information about independent mental health advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. 90% of staff had completed their mandatory 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. 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. Managers gave examples of how capacity was considered and the processes that were followed within the service.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

Date of assessment: 24 and 25 September 2025

We assessed this service due to the age of the previous ratings.

All Saints Hospital provided specialist care and treatment for 20 men with mental health needs who are also deaf or have impaired hearing and use British Sign Language (BSL) to communicate. All Saints Hospital delivered 2 assessment service groups across 2 wards: forensic inpatient or secure wards and long stay or rehabilitation mental health wards for working age adults.

All Saints Hospital had 1 long stay or rehabilitation mental health ward for working age adults:

Braidwood ward - a specialist high-dependency rehabilitation ward for up to 14 male patients. The ward included four self-contained flats and four bedsits to help facilitate the recovery journey of patients.

At this assessment we assessed all quality statements across all 5 key questions.

At this assessment we identified 1 breach of regulation in relation to governance in the service.

We rated the service as good. The ward was generally safe, clean, well equipped and fit for purpose. Staff assessed and managed risks to patients and themselves well. Patients were involved in their care planning and risk assessments and staff actively sought patient feedback on the quality of care provided.

However, governance processes did not always operate effectively, and performance and risk were not always managed well or with appropriate oversight. There were processes that had been implemented which had not been reviewed to ensure that they were embedded effectively. The service had further work to do to ensure the culture of the service was improved.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. 93% of staff had received training in the Mental Health Act.

Staff had 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. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had access to information about independent mental health advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. 90% of staff had completed their mandatory 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. 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. Managers gave examples of how capacity was considered and the processes that were followed within the service.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.