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. At this assessment and inspection, the rating has changed to good. This meant people were safe and protected from avoidable harm. The ward was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

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.

The provider reported 695 incidents on Oak ward between 1 October 2024 and 30 September 2025. Staff recorded clear actions taken and lessons learned on the incident log. Due to the nature of the eating disorder ward some of these incidents were in relation to staff using holds to administer nasal gastric feeds (A nasal gastric feed (NG feed) is a method of delivering nutrition directly into the stomach through a nasogastric (NG) tube.).

Staff knew what incidents to report and how to report them. The ward followed the provider’s policy on incident reporting. We reviewed patient safety bulletins that provided staff with an overview of the number of incidents in a month, and any themes or issues identified. Leaders analysed common themes and addressed these ensuring clinical practice continued to balance risk management alongside person centred care.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff and managers discussed incidents in staff and governance meetings. Where there had been a serious incident the provider shared an immediate patient safety bulletin with all staff.

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 provider had a contract with regional commissioners where most of the referrals into the service came from. The service also received referrals internally from the Priory group, but this was less frequent. Staff explained that commissioners met weekly to discuss patient referrals and rated patients on a red, amber, green scale based on their current presentation. Staff told us external partners supported patients in the community for as long as possible and admitted them only when they needed additional support and intervention.

Nursing staff contacted the patient to introduce themselves and support their transition to the hospital after admission was agreed. 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.

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 we spoke with had good knowledge of safeguarding and any potential safeguarding concerns were discussed in, handovers, clinical governance and multidisciplinary meetings.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff kept up to date with their safeguarding training with 100% of staff having completed safeguarding adults and children level 1 and 2 training. All staff we spoke to knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff knew how to make safeguarding referrals and who to inform if they had concerns. We saw that staff made appropriate referrals following incidents on the ward.

Staff explained the safeguarding procedures to patients on admission and patients had access to relevant information.

The hospital monitored the use of restraint and restrictive interventions and worked closely with staff to ensure they were appropriately trained and up to date with relevant practice and policy. Staff informed patients about any blanket restrictions and explained why they were in place. They kept these restrictions to a minimum.

Mental Capacity Act

Staff we spoke to had a good understanding of the Mental Capacity Act. The provider reported 95.5% of staff completed Mental Capacity Act training on Oak ward.

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.

For patients who might have impaired mental capacity, staff did not always clearly assess and record capacity to consent with the involvement of the patient or family and carers.

The service did not always assess capacity on a decision-specific basis regarding significant decisions and used assessments that covered a period instead of completing each separate decision. However, there was evidence in some care records that when patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

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 only after attempts at de-escalation had failed. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 5 electronic care records. Staff completed risk assessments on admission, reviewed them during multidisciplinary team meetings (MDT) and updated them after incidents. Staff identified and recorded changing risks to, or posed by, patients in care plans.

Some risk assessments did not clearly show how staff involved patients in assessing risk. However, when asked patients told us they had worked on risk management with staff. Staff had not recorded whether they offered patients a copy of their risk assessments and care plans. Although 1 patient told us they did have a copy of their care plan.

Staff supported patients to consider points they would like to discuss in multidisciplinary meetings. Patients completed a form prior to multidisciplinary team meetings to set out points for discussion during their meeting including issues around risk management.

Staff told us they were committed to reducing restrictive practices. We saw that staff used de-escalation techniques to support patients on the wards. Staff rarely used restraint, but its use increased when a patient needed NG feeding and resisted its administration. One patient told us that when they were restrained it was needed as it was to stop them self-harming and it was done safely. Staff completed restraint reduction training specifically around supporting patients with an eating disorder. Staff told us how they ensured they don’t just administer the feed and then leave the patient. They continued with a gentle touch and supported them through it. Managers were aware of the impact restraint for NG feeding had on patients and the staff administering, so they ensured it was as therapeutic as possible.

Use of restraint was low in the 12 months prior to our assessment, staff recorded 16 incidents of restraint . All but 1 involved the same patient and related to NG feeds, physical health checks, or reducing self-injurious behaviour.

Staff ensured that formal patients could access statutory advocacy. However, information on how to access advocacy was displayed in communal areas but referred to the previous provider, so was removed to be updated during our visit.

Observations were carried out, and levels were regularly reviewed based on risk. A patient told us how they had seen their observations levels reduced as they did not need the higher level at that time.

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.

All communal ward areas were clean, generally well maintained, well-furnished and most items were fit for purpose. However, we noted that some of the furniture in bedrooms such as chairs were fraying and needed to be replaced. We informed ward staff, and they stated they would replace damaged items.

Oak ward was arranged over three floors. The lounge, kitchen and therapy rooms were located on the ground floor, and patient bedrooms were located on the first and second floors. Due to the layout, staff could not easily view all areas of the ward. However, staff used convex mirrors to mitigate blind spots in some patient areas, such as the lounge, art therapy room and staircases. Staff used individually risk assessed patient observations to manage the risk in other areas where staff could not easily view patients.

Patients had access to a garden space with staff supervision and staff implemented additional observations for any patients who were deemed to be at risk of absconding, based on individual risk assessments.

Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Managers completed comprehensive, up to date ligature risk assessments and accurately identified risks. We were told that patients could not access the kitchen, garden and art room without staff supervision. However, we observed that the art room was left open during our visit and patients were accessing this without staff supervision. One patient highlighted that they had access to various items such as a pen with a metal spring which they had used to self-harm previously. We immediately raised these concerns to staff, who secured the room to mitigate potential risks, and asked the ward manager to review the situation.

The ward complied with guidance on mixed sex accommodation. Oak Ward admitted both male and female patients, with each having their own en-suite bedroom. At the time of inspection, there was only one male patient. The manager made sure everyone’s privacy was respected, by including measures to prevent the male patient from passing female bedrooms to access his own. There was a room on the ward that had been designated as a separate female only lounge. However, as noted during our previous inspection, this room served as the disabled access to the ward. Staff and patients told us there wasn’t always enough room for therapy sessions on the ward, so they sometimes used this room.

Staff had easy access to alarms and patients had easy access to nurse call systems. All staff had a personal alarm which linked to all hospital areas. Each patient had access to a call bell in their bedroom.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. We found that all equipment was in place although we could not see a record to evidence calibration of equipment had taken place. When asked, staff said they were not aware of the calibration process. However, leaders provided records after the inspection that showed all equipment was calibrated bi-annually with the last calibration taking place in September.

The physical health observation room on the ward was small with containers of medical equipment stacked at the end of the examination couch due to limited space. Managers were considering how to make the limited spaces they had more accessible for all patients. They were considering turning the room they were currently using for weighing patients to create a dedicated sensory space. This would allow for a more therapeutic space, especially for neurodiverse patients.

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 service reported no current staff vacancies. Staff turnover on Oak ward averaged 7% over the last 12 months, and sickness absence was 3%. The percentage of staff that had an appraisal in the last 12 months was 100% for Oak ward. In the 3-month period of July to September 84% of staff received supervision.

Staff rotas showed that a qualified nurse was always present on the wards. Managers calculated the number and grade of nurses and healthcare assistants required. Our review of staff records showed that the number of nurses and healthcare assistants matched requirements on all shifts. Medical cover was adequate day and night, and an on-call doctor could attend the ward quickly in an emergency.

When necessary, managers deployed bank and agency nursing staff to maintain safe staffing levels. Agency staff accounted for 4% of shifts between July and September 2025, and bank staff for 2%. Patients raised concerns about the use of agency staff who did not have specialist training to support their needs. However, all permanent staff working on the ward had completed and were up to date with specialist training in eating disorders and MANTRA (The Maudsley Model of Anorexia Treatment for Adults).

Patients told us about the high turnover of therapeutic staff at the time of our visit. The dietitian and psychologist had either left or were leaving that week which was causing some concern around continuity of care. Leaders were aware of these issues, and a temporary dietician was working on the ward who was familiar with the staff and patients. The wider psychology team would continue to support the ward as the provider was not currently recruiting for an additional psychologist.

Patients and staff told us about several reported incidents of staff sleeping whilst on observations. Managers explained and showed the steps they had taken to investigate these incidents, including moving staff from night to day shifts and providing additional training. Some patients told us they were unclear about the actions taken and still saw the same staff covering nights, which made them feel unsafe.

Patients and carers told us that last-minute cancellations regarding off-ward activities were due to staff not being available. Staff told us that trips off the ward were cancelled due to unplanned incidents requiring extra staff support.

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.

All ward areas were clean and well-maintained. However, some of the furnishings appeared old and in need of replacement. When pointed out staff noted this and stated they would be replaced.

At the previous inspection, cleaning records were not completed in line with the provider’s policy. However, during this inspection, staff were completing records; but some entries were not signed as required by policy. Patients also raised concerns in community meetings regarding the cleanliness of the wards, such as sticky tables in the dining room and mould in bathrooms. The staff actioned this and it appeared to have been resolved at the time of our visit, although it was a reoccurring theme over a number of months.

Staff completed infection prevention and control checks and audits to ensure required standards were met. Staff had access to an infection prevention and control policy and support from infection prevention and control leads within the hospital and wider provider. Staff completed infection prevention and control training as part of the mandatory training programme.

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 followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance. All clinic rooms were clean, and staff had access to all appropriate equipment. We observed that the fridge used to store medication could be accidentally turned off due to the positioning of the plug, however this was highlighted to staff who planned to consider solutions to mitigate against this.

Staff completed medicines records accurately and kept them up to date. We reviewed all patient’s medication and physical health records on the wards at that time. Staff completed them fully and accurately.

Staff followed national practice to check patients had the correct medicines when they were admitted, or they moved between services.

Staff learned from safety alerts and incidents to improve practice. We saw that medication errors were discussed in daily meetings, within clinical governance and lessons learned cascaded to all staff.