Woodbourne Priory Hospital

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 inspection we rated well-led as requires improvement. The service was in breach of legal regulation in relation to good governance (regulation 17). 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 that leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Teams had access to the information they needed to provide safe and effective care.

However, the service did not always have clear responsibilities, roles, systems of accountability or good governance.

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 scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders ensured there was a shared vision and strategy that staff in all areas knew, understood and supported. The provider’s vision was to become the leading European provider of mental health and rehabilitation services. The provider’s values were striving for excellence, being positive, putting people first, acting with integrity and being supportive. We reviewed the provider’s ‘people enabling strategy’, which was underpinned by 7 strategic goals. These included goals to provide evidence based clinical pathways to patients and to embed a culture of openness, inclusion and trust where people feel they belong.

Leaders described how they demonstrated the values in their work, examples included always striving for improvement and being the best, supporting staff through regular supervisions and being positive. Another leader told us the provider’s values reflected the culture of care values. Staff spoken with were able to describe the provider’s vision and values.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders at every level were visible and led by example, modelling inclusive behaviours. We spoke with 20 staff and 19 told us that leaders at the hospital were capable, compassionate and approachable. Staff said that leaders completed regular walk arounds of the wards and would always speak with them and patients. Frontline staff told us that their ward managers were approachable and supportive. Some staff spoke about a previous negative culture at the service and said the current senior management team (SMT) had done a lot to improve this. Staff told us the hospital director encouraged the provider CEO to visit to see how the service promoted living the provider’s values. The CEO has visited 4 or 5 times this year and the regional managing director often visits and will sit and talk to patients and try to resolve any issues. However, we were concerned that therapy staff were not able to access appropriate clinical support. We raised this with the hospital director who advised they were seeking support from therapy leaders within the provider.

Leaders were knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role. The head of facilities told us they had been supported to complete additional training for their role which enabled them to improve their team’s performance. The hospital director told us they met weekly with the directors of the provider’s other locations in the region, this was a good opportunity to share learning and support one another.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns and promoted the value of doing so. All staff spoken to knew how to raise concerns. The provider reported 192 Freedom to speak up (FTSU) champions were in post across the organisation. The hospital had 3 FTSU champions at the time of our visit. The provider reported 83 speaking up concerns were raised via the FTSU process between April 2024 and March 2025. To protect staff, this data was not broken down to specific locations, so we are unable to report on data for the hospital. The hospital director chaired monthly ‘Your say forums’ for staff. We reviewed minutes from these and saw they were attended by a range of staff from different wards and service functions. Staff told us their wards would have a ‘Your say forum’ representative that sought their views and took these to the forum for discussion. We saw evidence of staff being kept updated with the recent contractual changes that were causing some anxiety for staff.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders took action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. We reviewed the provider’s ‘Workforce Race Equality Standards’ report and actions for 2024/25. The provider was embedding and promoting their network of Diversity Champions, Freedom to Speak Up Champions and working in partnership with ‘Your Say Forums’. The provider was rolling out a Black Minority Ethnic (BME) Coaching and Mentoring Programme for aspiring leaders as part of their organisational strategy. Leaders promoted a zero tolerance policy and supporting guidance to raise awareness of the support and avenues of action available to colleagues who experienced any form of discrimination in the workforce. The provider reported 43% of staff were BME. In terms of career progression 72% of BME staff believed the provider offered equal opportunities. Most staff spoken with said the culture at the service was inclusive, however 1 staff member told us BME staff were treated differently.

Leaders took active steps to ensure staff and leaders were representative of the population of people using the service, however there was still improvements to be made in this area. We reviewed the provider’s Patient and Carer Race Equality Framework (PCREF) report for September 2025. Leaders reported that “September showed a mixed picture of alignment. Maple Ward was well aligned between BAME inpatient proportions and staff representation. However, in most wards staff were underrepresented compared with inpatients, raising concerns about whether cultural needs were being fully met.” The report highlighted that “the proportion of detentions involving BAME service users was 75.7%, remaining high across the hospital. This continues to suggest inequity at the point of detention and highlights the need for culturally appropriate early interventions and alternatives to admission.” The report states “Restrictive practices continue to demonstrate disproportionality. Seclusion (100% BAME), restraint (73BAME), and rapid tranquillisation (25% BAME) all require close monitoring. Trauma-informed, anti-racist de-escalation and post-incident reviews co-produced with service users are key priorities.”

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not always operate effective systems and processes to make sure they assessed and monitored their service against required regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended). We were concerned that governance and oversight processes had not identified breaches of regulation 9. Concerns were raised with the provider, over the past 18 months, by CQC MHA reviewers in relation to staff understanding and application of informal patients’ rights, yet this was still identified as a concern during the inspection and assessment.

Leaders implemented relevant or mandatory quality frameworks, recognised standards, best practices or equivalents to improve equity in experience and outcomes for people using services. The SMT established improved governance processes as evidenced by the clinical governance meeting minutes reviewed. These meetings were attended by the hospital director, medical director, ward managers and other staff as required. The hospital director implemented the use of data sets to enable improved monitoring of service performance. Attendees reviewed incidents, staffing levels, patient and carer involvement, IPC, health and safety, medicines and the environment.

There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care. Managers told us how they were able to use the data available for their ward to monitor and improve the care provided to patients. They described how they used dashboards to monitor staff attendance and told us audits ensured actions were implemented to make required improvements, for example, to the quality of care plans. Managers reported an improvement in the information flow from board to ward. They told us leaders provided useful reports, for example, on safeguarding that helped with oversight of their ward and identification of themes and trends.

We reviewed the risk register for the service; leaders identified 14 risks for the acute and PICU service. Leaders rated 12 as medium risk and 2 as low risk. The identified risks reflected those raised by staff and included the risk of only 1 seclusion room on the PICU, occurrence of violence and aggression and anti-barricade doors not functioning as intended. All identified risks included mitigations and any actions required.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. The hospital director told us about working with system partners and reaching out to other regions to promote the service. Leaders told us about inviting system partners to charity events at the service to help promote positive relations. Leaders described adapting to the changes in the health landscape.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff and leaders had a good understanding of how to make improvement happen. Staff spoken with told us the leaders had made significant improvements to the service since our last inspection. Provider quality improvement (QI) leads had visited the service to promote the use of QI on the wards. Staff told us about quality improvement initiatives on their wards including the use of ‘safewards’ and the ‘culture of care’ work on Elm ward. The aim of the ‘safewards’ model is to make psychiatric wards more peaceful through reducing conflict and implementing positive interventions such as soft words and mutual expectations. The ‘culture of care’ programme is part of NHS England’s ‘Quality Transformation Programme’. This programme aims to improve the culture of inpatient mental health, learning disability and autism wards for patients and staff so that they are safe, therapeutic and equitable places to be cared for, and fulfilling places to work. Elm ward staff presented their culture of care work to the provider’s regional awards ceremony and won ‘ward of the year’. Maple ward manager told us there was an ongoing QI project on the ward to make it less clinical and more homely. The head of facilities told us about collaboration between their team and the nursing teams to improve ward environments with input from patients, for example, patient artwork on the walls. The OT team led an innovation called’ Wearhouse’, which involved turning a cupboard into a clothing resource for patients using donated clothing. Two of the consultants told us about a published research paper they completed titled “Aripiprazole-Induced Orofacial Dyskinesia in a Young Male”. This followed work they did with a patient who experienced facial problems as a side effect of the medication they were taking. The consultants stopped the medication for this patient. The hospital published a monthly magazine, ‘The Woodbourne Buzz’, which the provider advised was developed with patients. It included patient stories and contributions, activities and also highlighted positive work completed by staff.