Woodbourne Priory Hospital

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 people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. The service was in breach of legal regulation in relation to safe care and treatment (regulation 12) and safe premises and equipment (regulation 15). At this inspection and assessment, the rating has changed to good. The service had made improvements and is no longer in breach of regulations. This meant all wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well.

However, the service did not always work well with people to understand and manage risks and did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

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 scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Safety was a top priority that involved everyone, including staff as well as people using the service. There was a culture of safety and learning. Staff told us they learnt from incidents through de-briefs, reflective practice and briefings on lessons learnt shared by the provider, including from incidents at other locations. We reviewed patient safety bulletins issued by the provider between February 2025 and September 2025. These bulletins were issued monthly and included a breakdown of incident numbers on each ward, key learning from safety events and details of any action required. Staff told us about implementing changes to checking patients post following a serious incident that occurred at another provider. Managers told us there was a lessons learned section on incident reports and these lessons would be shared across the location. Staff told us they would speak to patients after incidents and support them to reflect on what had happened, including what went well and what could be done better.

Risks were not overlooked or ignored. They were dealt with willingly as an opportunity to put things right, learn and improve. Examples included changing to hot water dispensers after an incident where a patient threw hot water at a member of staff; improving procedures following an incident where staff were unable to locate the key for the anti-barricade doors and introducing a minimum of hourly checks for all patients following a serious incident of patient harm. Staff were encouraged and supported to raise concerns, staff told us they were confident to raise any safety concerns and said they would be listened to. Ward managers met daily with healthcare assistants (HCA’s) to discuss any safety concerns they may have.

Lessons were learned from safety incidents or complaints, resulting in changes that improved care for others. Senior leaders analysed incidents across the service to identify trends and make improvements, examples included actions taken after leaders identified an increase in absent without leave (AWOL) incidents on Aspen (PICU). Actions included working with families, patients and staff to understand section 17 leave and the importance of keeping to prescribed leave arrangements. AWOL incidents for Aspen were previously 3-4 a month and reduced to 1 per quarter.

The provider reported 1038 incidents across this service between 1 October 2024 and 30 September 2025. Maple ward reported the most with 385 incidents; 1 was a severe harm incident, 1 was an incident of moderate harm and the rest were no or minor harm. The severe harm incident related to a previous patient and occurred at a different provider. Aspen ward reported 366 incidents; 1 was graded as moderate harm, the rest were low or minor harm. Acer ward reported 153 incidents; 2 were graded as moderate harm, the rest were no or minor harm. Elm ward reported 134 incidents; all were graded no or minor harm. However, incidents were not always appropriately reported. We reviewed incident reports on Acer and Elm wards. We reviewed 5 incident records for Acer ward. Staff were not recording all required information in the records reviewed. This included staff not recording section 17 leave start time, duration and expected and actual return times in 2 AWOL reports and staff not recording actions taken in response to the incidents or post incident checks for patients. Staff had not updated the patient’s risk assessment or care plan in 2 records. We reviewed 3 incident reports on Elm ward. Two incidents related to violence and aggression towards staff. We were unable to find evidence that staff updated either patient’s care plan or risk assessment after these incidents. Whilst speaking to staff about this they stated they do not date risk assessments and care plans. This was unsafe as staff may not always be aware of patients’ current risks. The other incident related to a ligature attempt by a patient. Staff did not record any actions taken following this incident, for example, removal of ligature risk items. Staff did not update the patient’s care plan or risk assessment following this incident.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was 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. Staff told us they received information about new admissions prior to their arrival on the ward. Information was shared in handovers, weekly multi-disciplinary team (MDT) reviews and in care records. Staff on Acer ward told us they gained patient consent to speak with their families to gather more information. HCAs told us the nurse in charge would ensure they were up to date with relevant information about a new admission at the start of their shift. A nurse on Elm ward told us potential admissions would be discussed with the MDT to ensure they were suitable for the ward.

There was a strong awareness of the risks to people across their care journeys. Ward managers were aware of the risks to patients’ timely discharge, including funding delays and patient immigration status. Acer ward manager told us about supporting a patient who was traumatised by previous hospital admissions and how they successfully supported them back into their community. Medical staff told us they would review the history and safety of a referred patient and ensure any provisions were made to keep them safe once admitted to the service.

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. This included working with commissioners, case managers, GP’s and local authorities.

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.

There was a strong understanding of safeguarding and how to take appropriate action. The provider reported an overall compliance rate of 94% for levels 1-3 of safeguarding adults and safeguarding children training completed by staff. Staff spoken to were able to describe different safeguarding scenarios and the action they would take. Examples included escalating to the nurse in charge or ward manager, referring to the local authority, making sure the patient was safe and completing safeguarding incident reports.

Most patients were supported to understand safeguarding, what being safe meant to them, and how to raise concerns when they didn’t feel safe, or they had concerns about the safety of other people. We asked 9 patients if they felt safe on their ward. Seven said they felt safe and would speak to staff if they felt unsafe. One patient on Acer ward said they didn’t feel safe all the time as other patients could hurt them, although they did not report any incidents of harm. One patient on Aspen ward said they didn’t feel safe from themselves. We spoke with 2 carers, 1 told us their relative felt safe, the other said their relative was physically safe but not psychologically safe due to staff behaviour that caused paranoia, including shining torches through their relative’s door and teasing.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. The service had an identified safeguarding lead who completed level 4 safeguarding training and provided advice and guidance to staff. Staff reported all safeguarding concerns internally and would refer directly to the local authority safeguarding team, when needed. Leaders discussed safeguarding concerns in daily ‘flash’ meetings and monitored safeguarding trends through clinical governance meetings. However, managers shared concerns that external safeguarding processes took a long time, and patients were often discharged before these were completed. We saw evidence of managers following up with external partners to try and improve this.

The service took a proportionate approach to imposing restrictions on patients. The provider reported 26 incidents involving the use of seclusion between 1 October 2024 and 30 September 2025. Aspen PICU recorded the highest use at 25, Maple ward reported 1 and the other wards reported 0. Aspen PICU was the only ward with a seclusion room as acute wards are not required to have seclusion rooms. We reviewed seclusion records on Aspen ward and identified 1 patient was secluded in their bedroom in April 2025 as the seclusion room was in use. The provider advised use of bedroom seclusion had significantly reduced. We found seclusion care plans were in place for patients who were secluded. The provider reported no use of long term segregation between 1 October 2024 and 30 September 2025. The provider reported 72 incidents involving the use of rapid tranquillisation between 1 October 2024 and 30 September 2025. Maple ward recorded the highest use at 30, Acer ward reported the lowest with 0.

Mental Capacity Act

• The provider reported 98% of staff completed training in the Mental Capacity Act.
• Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. Staff told us that they would assume capacity and ensure any capacity concerns were clearly documented. Medical staff told us they would assess patients’ capacity on admission. They told us they had improved on the recording of capacity assessments and that the first (functional) test of a capacity assessment must be person specific and not a generic statement.
• 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. In care records reviewed we saw staff assessed patients capacity on a decision specific basis, when required.
• When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. On Elm ward we reviewed the care record of a patient staff assessed as lacking capacity. There was evidence of best interest meetings taking place in relation to the patient’s treatment plan. However, staff had not recorded how they consulted with others or involved the patient in the decision-making process.
• Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies.
• The service had arrangements to monitor adherence to the Mental Capacity Act. Responsible clinicians were overseeing capacity assessments completed by doctors and the MDT reviewed all capacity assessments.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks.

Patients were not always informed about risks and how to keep themselves safe. We spoke with 10 patients across the 4 acute and PICU wards. Eight told us staff had not involved them in managing their risks. We reviewed 10 care records across the acute and PICU wards. Staff recorded patient involvement in their risk assessments in 3 records. Following the inspection, the provider shared documentation that evidenced staff involving patients in managing their risk for 2 other patients.

Risks were assessed and staff understood them. Staff told us they assessed risk as follows; risks that required immediate attention, for example, self harm; risks that required continuous monitoring and risks that required attention post discharge. We reviewed 10 care records across the acute and PICU wards and staff completed comprehensive risk assessments in 9 of them. Staff regularly reviewed and updated these risk assessments. The MDT created risk formulations for patients with input from psychology. However, 2 members of staff told us they rated self harm and suicide risks as high, medium and low. This was not in line with current NICE guidance.

We reviewed observation records for 10 patients. Staff completed observation records as required and included relevant details, for example, what the patient was doing. Staff recorded good detail in the observation records, especially when the patient was asleep; noting that breathing was observed for 2 cycles. Staff completed intermittent observations in line with National Institute of Health and Care Excellence (NICE), by ensuring prescribed checks were randomised across the time period.

Staff ensured the correct procedures were followed when patients accessed their prescribed section 17 leave. Section 17 of the Mental Health Act (MHA) allows a patient’s responsible clinician (RC) to authorise a leave of absence from the ward for a specific occasion or occasions and/or specific period. The patient’s RC may also place other conditions on a patient’s leave of absence, including whether they need to be accompanied by staff. We reviewed section 17 leave paperwork. Staff recorded details of prescribed leave including duration, location and family involvement. Staff completed the 5 point risk assessment prior to the patients going on leave. Staff included a description of what the patient was wearing and confirmed the patient’s mobile phone was fully charged.

Staff told us restraint was only ever used as a last resort after de-escalation attempts had failed. The provider reported staff physically restrained patients 208 times between 1 October 2024 and 30 September 2025. Aspen PICU recorded the highest use at 98, Acer ward reported the lowest with 10. The provider reported that none of these restraints were in the prone position. However, 1 patient on Aspen ward told us they thought staff used restraint too quickly, without trying other things first. They said staff were ok in how they restrained, and they had not been hurt. Staff told us everyone involved in a restraint incident, including the patient, would be debriefed afterwards.

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.

Patients were cared for in safe environments that were designed to meet their needs. We asked 9 patients across the wards if they thought their ward environment was safe for them and they all said yes. Six patients told us broken items were repaired or replaced quickly, 3 described situations when it had taken a long time for broken items to be repaired or replaced, including a broken tv controller. A carer told us that the ward their relative was on was clean and tidy which contributed positively to their experience. Leaders regularly assessed the wards and identified potential risks, for example, blind spots and ligature anchor points. Leaders mitigated these risks through staff observation, closed circuit television (CCTV) and curved mirrors. Staff spoken with were aware of risks in their ward environment and the mitigations in place to manage them. We reviewed the seclusion room. The room environment was compliant with the MHA code of practice, and allowed clear observation, two-way communication, had toilet facilities and a clock. Staff had easy access to alarms and patients had easy access to nurse call systems.

Facilities and equipment were well-maintained and consistently supported staff to deliver safe and effective care. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. However, the provider did not always ensure completion of calibration checks of medical equipment was clearly recorded. This was a breach of regulation at the previous inspection. On Maple and Acer wards the calibration checks recorded on the ward were out of date for some medical equipment. Following the inspection, the provider shared a medical equipment test report dated September 2025 which recorded that all medical equipment was checked and passed for the acute and PICU wards. We reviewed the emergency bag checks on Aspen ward. Whilst the records showed staff checked the emergency bag, there was no records to show that individual items in the bag had been checked. After the inspection the provider shared documentation evidencing that, although individual items were not consistently signed as checked, emergency equipment was present, accessible, and available for use at the time of inspection.

There were effective arrangements to monitor the safety and upkeep of the premises. The head of facilities implemented a new ‘live’ system for staff to log audits and maintenance requests. Staff spoke highly of this new system and said the maintenance team were very responsive. The head of facilities introduced new procedures and processes to ensure the service complied with fire safety requirements. This included improved training for staff, fire drills, managers monthly walk arounds and clinical governance oversight. A previous Fire Risk Assessment (FRA) identified 60 improvement requirements, the most recent FRA identified 4.

Leaders and staff considered how environments could keep people safe from psychological harm as well as physical harm, for example in relation to sexual safety. Maple ward was a mixed gender acute ward. There was 1 main bedroom corridor which was separated into 3 zones. The first zone was female beds, the last zone was male beds and the middle zone was either female or male depending on the need. All bedrooms were ensuite and staff were able to observe the corridor. There were CCTV cameras in each section. There was a small female only lounge. This arrangement met the requirements of mixed gender accommodation guidance.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider reported no vacancies across the acute and PICU wards due to low occupancy levels. The provider reported 13% of qualified shifts were filled by agency staff and 3% by bank staff between 21 October 2024 and 6 October 2025. Aspen PICU reported the highest use of agency qualified staff at 25%. The provider reported 3% of HCA shifts were filled by agency staff and 3% by bank staff between 21 October 2024 and 6 October 2025. The provider reported no shifts were unfilled between 21 October 2024 and 6 October 2025. The provider reported an average sickness rate of 5% between 1 October 2024 and 30 September 2025. Aspen ward reported the highest rate at 9%. The provider reported a turnover rate of 26% across the service.

There were mostly appropriate staffing levels and skill mix to make sure patients received consistently safe, good quality care that met their needs. Wards were staffed as planned on the days we visited. We noted there were enough staff on shift trained in the use of restraint and basic and intermediate life support. We asked 9 patients if there were enough staff to ensure they received care and support when they needed. Five patients responded positively. All 4 patients spoken with on Maple ward said yes and 1 of 2 patients spoke with on Acer ward said yes. Both patients spoken with on Aspen ward and 1 on Acer ward said there were not enough staff and their leave was often cancelled. A patient on Elm ward told us there were not enough staff and it could be hard to get out to the garden as patients could only access the garden with a staff member. We spoke with 10 staff members about staffing levels on their wards, 5 voiced concerns that there were not always enough staff to meet patient needs, for example, escorting patients on their section 17 leave. Managers told us staffing had improved across the wards as patient numbers reduced. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. However, we spoke to a carer who told us staffing was inconsistent and they felt information about their relative was not shared effectively across shifts.

Staff received training that was appropriate and relevant to their role. The provider reported a compliance rate of 98% for staff mandatory training. Staff were able to access additional specialist training including suicide awareness, autism awareness, trauma informed care and managing behaviour that communicates distress.

Although staff told us they received the support they needed to deliver safe care, we found managers were not always ensuring staff received regular supervision. The provider reported a compliance rate of 75% for staff supervision between 1 October 2024 and 30 September 2025, the data provided was not broken down into clinical and management supervision as requested. Three of the 4 wards reported a compliance rate under 75%: Aspen at 65%, Acer at 71%, Elm at 74%. Maple ward reported the highest at 88%. We noted an increase in supervision compliance in the latter months of the reporting period. The provider reported all staff were up to date with their appraisals. Staff told us they were able to attend monthly staff meetings, with an option to attend virtually if not on shift.

Staff at all levels had opportunities to learn, and poor performance was managed appropriately. Staff told us they were able to attend conferences and seminars, examples included a seminar on the culture of care. Medical staff told us the provider supported them with their continuing professional development. Managers described managing poor performance. This included addressing an increase in incidents of staff sleeping whilst on shift. Leaders told us some staff were dismissed and for others they took a wellbeing approach. This included a wellbeing campaign, advising staff to ask for a break if they were feeling tired, especially when allocated to observe patients. Leaders also supported some staff with reasonable adjustments.

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.

Patients were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic. We asked 9 patients across the 4 wards if their ward was clean, all replied yes. We observed ward areas to be clean and well maintained with good furnishings.

There were clear roles and responsibilities around infection prevention and control. The head of facilities completed bi-monthly infection, prevention and control (IPC) audits on each ward. They allocated identified actions to relate staff to complete. Leaders assigned a staff member as IPC champion on each ward. Staff spoken to were able to describe IPC processes they followed, for example, hand washing regimes, use of personal protective equipment and management of sharps and spillages.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Most patients were appropriately involved in decisions about their medicines. We spoke with 9 patients about the medicines they were taking. All said that staff discussed their medicines with them, including in ward round, and they received their medicines at the right time. Eight patients knew what medicines they were taking, 1 patient on Aspen did not. Another patient on Aspen said although staff discussed their medicines with them, they did not listen when they said another medicine would work better.

Patient’s medicines were not always appropriately supplied and administered in line with the relevant legislation, current national guidance or best available evidence. We reviewed the care record for a patient on Aspen ward. We reviewed an entry where staff recorded the patient as repeatedly requesting PRN (as required) medication, this was refused due to the medication being out of stock. Staff did not offer an alternative. We reviewed prescription charts for 3 patients on Aspen ward. Staff were not always able to administer prescribed medicines as they were out of stock. This included ‘fortisips’ not administered on 12 occasions across 4 days for 2 patients, antibiotics not administered on 6 occasions across 2 days, and vitamin D not administered on 2 days for 1 patient. There was no evidence of patient harm due to this. We found large quantities of stock medicines in Aspen and Maple clinic rooms. The fridge and medicines cupboard on Maple ward were overflowing with ‘fortisips’ and there was no stock list available. On Elm ward we found staff were encouraged to use medicines already on site which could be from other wards. This meant medicines were not in the original boxes. This was not in line with the provider’s medicines policy which stated, “Medicines must be kept in original containers”. We reviewed prescription charts for 2 patients on Elm ward. We found a lack of clear direction for staff in relation to the use of different PRN medicines. We discussed this with the medical director who advised they would investigate.

There were appropriate arrangements for the safe management, use and oversight of controlled drugs. Patient’s behaviour was not inappropriately controlled by medicines.