Woodbourne Priory Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last inspection we rated this key question requires improvement. The service was in breach of legal regulation in relation to person centred care (regulation 9) in relation to support for autistic patients. At this inspection and assessment, the rating has changed to good. The service had made improvements and is no longer in breach of regulations in relation to supporting autistic patients. The service understood the diverse health and care needs of people and their local communities, the service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs and people were supported to plan for their future.

However, the service did not always make sure people were at the centre of their care and treatment choices, the service did not always make it easy for people to share feedback and ideas and the service did not ensure equity in access for all people.

We have not awarded this service a score for Responsive.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People who used the service and those close to them (including carers and dependants) were not regularly involved in planning and making shared decisions about their care and treatment. We spoke with 10 patients across the 4 acute and PICU wards. Five told us staff had not involved them in planning their care. Eight told us staff had not involved them in managing their risks. We spoke with 2 carers, 1 said staff had not invited them to reviews of their relative’s care. We reviewed 9 care records across the 4 acute and PICU wards. Staff had not recorded evidence of patient involvement in 4. We saw examples of staff cutting and pasting information in 2 of the care records. In 1 care record the documentation did not reflect the feedback from staff on the steps being taken to support a patient. Staff told us about the measures used to reassure the patient, which included singing and dancing. Senior leaders were aware of these issues and introduced a quality audit which included checking that staff were involving patients in planning their care. Ward managers told us they implemented weekly contact with carers to improve engagement.

We saw evidence that the service made reasonable adjustments for some patients. These included accessing interpreters for patients and families whose first language was not English.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Patients received care and treatment from services that understood the diverse health and social care needs of their local communities. Staff told us about linking in with social services for patients with poor social support, although they expressed difficulties in accessing section 117 (aftercare) funding for patients.

Patient’s care and treatment was delivered in a way that met their assessed needs from services that were co-ordinated and responsive. The service worked closely with commissioners to ensure a smooth transition from the service. We heard from one family how the service had intervened to ensure their loved one was not moved from the service inappropriately.

The provider reported 34 delayed discharges from 1 October 2024 to 30 September 2025. This was out of a total of 299 admissions. We requested reasons for delayed discharges, but this was not provided.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Patients could get information and advice that was accurate, up-to-date and provided in a way that they understood, and which met their communication needs. We asked 6 patients if they were provided with information about their care and treatment in a way they could understand. All said yes and 1 told us there was lots of information on the noticeboards. The service provided a range of information leaflets in different languages. During our visit we observed posters displayed with information relating to advocacy, complaints (including CQC MHA complaints), carers information and safeguarding. We noted that patient bedroom doors included the names of their consultant and named nurse. Senior leaders told us that Elm and Beech Wards, as part of the Culture of Care initiative, led improvements in carer engagement. Maple Ward and other wards were adopting these strategies. Weekly calls remained the most successful engagement method, with monthly on-site gatherings continuing as an additional option for carers. However, one carer voiced concerns to CQC that information shared with them was sometimes confusing due to miscommunication between nurses and consultants.

Patient’s individual needs to have information in an accessible way were identified, recorded, highlighted and shared. These needs were met and reviewed to support their care and treatment in line with the Accessible Information Standard. The provider had a policy on ‘Accessible Information’ which was followed by staff. We saw staff highlighted patient specific communication needs on the front page of their care records. We saw examples of communication needs being met through the provision of interpreters and information in easy read formats.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make it easy for people to share feedback and ideas.

Patients knew how to give feedback about their experiences of care and support including how to raise any concerns or issues. We asked 9 patients if they knew who to speak to if they were not happy. Seven patients said they would talk to the ward manager and 1 told us they had complained and it was sorted out. One patient said they knew who to talk to but wouldn’t be listened to and another patient said they would complain externally as the provider would try and cover it up.

The provider reported receiving 19 complaints between 1 October 2024 and 30 September 2025. Maple ward reported the highest number with 9. The provider reported 18 of the complaints received reached a resolution. Of these, 0 were upheld, 1 was partially upheld and 17 were not upheld. The most common type of complaint related to quality of therapy and treatment with 6 cases referring to this. Complaints were received from patients and carers. Examples included a carer complaining about best practice not being followed in relation to medication prescribing, and allegations of abuse from a patient that had not been ticked as a safeguarding on the complaints spreadsheet reviewed. Wards displayed information on how to complain, including to CQC. Staff spoken with told us they would try and resolve any concerns for patients, before escalating.

Learning from complaints and concerns was seen as an opportunity for improvement. The provider shared monthly patient safety bulletins with staff. These included a section on learning from complaints. Identified learning about the importance of involving family and carers was a repeated lesson in patient safety bulletins issued between 1 October 2024 and 30 September 2025. Although learning was identified, there was limited detail on what needed to be done to make improvements.

The provider reported 33 compliments were received between 1 October 2024 and 1 September 2025. Elm ward received the most with 20. Compliments were received from patients, students and carers. Examples included “Elm ward was a brilliant experience and helped me out loads with my journey” (patient) “thank you for a great year, I have truly cherished my time learning laughing and growing” (student) and “the staff on Elm ward were just incredible with not only my son but with me too” (carer).

Patients were not always kept informed about how their feedback was acted on. We reviewed community meeting minutes for Elm ward and Maple ward. We found that community meetings were not an opportunity for patients to have their say, they were an information giving meeting. Patients were only asked for feedback on food. There was minimal follow up on previous meetings and no evidence of encouraging patients to share concerns or ideas for improvements. We noted the ‘you said, we did’ display on Maple ward was empty.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

Not all patients could access services when they needed to. Physical premises were not always accessible. On Maple ward, we observed and the ward manager advised the ward was not accessible for patients using wheelchairs, so they would not accept these referrals. Acer ward manager also advised they would not be able to accommodate patients in wheelchairs. The head of facilities advised that although doorways were wide enough to accommodate a patient using a wheelchair, there were no accessible bedrooms on site and plans were in place to create accessible rooms on an empty ward. Following the inspection the provider advised that Maple ward had an accessible bedroom. Patients on Elm and Acer wards (located on the first floor) expressed concerns that they were not always able to access the garden.

Staff made reasonable adjustments for other patients, including accessing interpreters when required and adapting care for autistic people. Examples of this included provision or headphones, dimming the lights and tailoring support for a nonverbal patient. The wards were equipped with adequate rooms for therapies and activities to take place. There were also quiet areas on the wards for patients.

The service had a clear referral and admission process for each ward. This included clear inclusion and exclusion criteria, in line with expectations for acute and PICU wards, for example, a requirement for patients admitted to the PICU to be detained under the appropriate assessment or treatment section of the MHA.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Patients’ care, treatment and support promoted equality and removed barriers. Staff across all wards told us about supporting patients and families whose first language was not English by accessing interpreters. Staff on one ward described how they removed barriers for an autistic patient by involving their family and adapting how they communicated. OT staff created a pictorial care plan and used social stories to support the patient. Doctors on Aspen ward said additional input was brought in to support patients with sensory needs, including mindfulness, art therapy and breathing exercises.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage. Staff were trained in equality, diversity, inclusion and human rights, the provider reported a compliance rate of 100% for this training.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

When patient’s future care preferences were for greater independence professionals worked together to help them achieve their goals. Staff told us how they supported patients discharge or step down through assessments of daily living skills, overnight leave, working with the home treatment team and finding accommodation. Doctors described how community treatment orders can enable discharge for some patients. A community treatment order (CTO) is an order made by the patient’s responsible clinician (RC) to provided supervised treatment in the community. This means the patient can be treated in the community for their mental health problem, instead of in hospital. But the RC can recall the patient back to hospital for immediate treatment, if necessary. We checked 6 care records for discharge plans and staff completed these for all patients.

However, not all patients were aware of their future plans for discharge or step down from the service. We asked 9 patients across the 4 wards if they had a discharge plan. Four patients said yes, 3 said no and 2 didn’t know what a discharge plan was.