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. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. 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. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvement

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 and staff shared the providers visions and values. Staff told us how since the current senior management team had been in post there had been a focus on improving staff morale. Staff told us that the senior management team were visible with an open-door policy so that all staff were involved in looking at ideas and solutions not just leaders.

Staff understood the vision and values of the organisation and believed the hospital was delivering care in line with these values. Leaders incorporated the values into yearly appraisals giving staff the opportunity to show how they worked within the 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 had the skills, knowledge and experience to perform their roles. Managers understood the needs of the patient group and worked towards patients achieving the best outcomes for them. Staff told us if there had been an incident on the ward senior leaders were always quick to respond and would come on to the ward to support staff and patients.

Staff told us senior leaders from the provider were also visible and regularly came to the hospital. Leaders told us how they could always contact the regional team and be fully supported if there were questions or issues they had not come across before.

Both patients and staff told us that managers were visible and approachable, and that management had an open-door policy. We saw this in practice on the wards with ward managers offices being open to staff who were able to ask for advice or support throughout the day. Managers also made themselves available for patients if they wanted to speak to them. The ward manager ensured that staff took regular breaks and opened their office on the ward as a quiet space for staff to spend time.

Managers had been promoted internally and encouraged to develop professionally with support from the provider. Staff were encouraged to develop their skills and training opportunities were available for all staff.

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.

The hospital had a Freedom to Speak Up Guardian. Contact details were displayed in staff areas. Staff received email reminders about freedom to speak up meetings and managers were able to facilitate staff leaving the ward to attend these meetings. All the staff on the ward we spoke to felt confident their voice was listened to and felt they could approach managers directly if they needed to raise a concern. However, therapy staff raised that without clear management structure in place for their roles they did not always feel listened to. They told us they would benefit from someone from their discipline being their direct manager who could understand their specific issues.

Managers told us how they were approached directly if people had concerns. The ward manager said staff had been nominated by colleagues for an internal award for being approachable. We were told that senior leaders were also visible on the ward and staff could approach them directly if they had concerns.

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.

There were equality and diversity champions within the organisation and staff networks such as Women, BME, LGBTQ+ and parents. The number of networks to support staff had increased from 6 in 2022 to 10 in 2025. The provider undertook equality monitoring of staff to ensure it is diverse in its make-up and representative of the patient group and produced a Workforce Race Equality Standards Report and Actions Update. The report outlined the continuing steps they were taking to ensure that equality and diversity was embedded across the organisation.

The hospital promoted equality and diversity on the ward. Managers put reasonable adjustments in place for staff members to help them carry out their role. This included opportunities to change hours or ways of working due to personal circumstances such as caring responsibilities and health issues. Staff told us they appreciated the flexibility that the service offered them which is why they had worked there for a number of years.

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.

Systems were in place to review incidents, performance issues and planning. There were clear frameworks for discussion at a ward, and directorate level to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Staff had implemented recommendations from reviews of incidents such as staff training around observations and absconsion risk assessments.

Staff made notifications to external bodies as needed. The service submitted notifications to the Care Quality Commission in accordance with the requirements of their registration. The service also submitted safeguarding referrals to the local authority. They also provided updates and relevant information to support patients to the regional commissioners.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Leaders were aware of the need for consistency of qualified staff on Oak ward and had made improvements to ensure that there had been a reduction in the need for external staff being required on the ward. Patients did however raise concerns that they had seen an increase in staff coming from other wards since a recent ward closure.

Audit processes gave staff oversight of the service and where improvements were required. The leadership team was committed to developing the service ensuring improvements were being continually made. Leaders were able to share where improvements had been made around care planning and where they had identified areas for continued improvement. Such as in the vocabulary used and patient awareness of care plans.

Managers had access to a risk register for the service which included 14 recorded risks across the whole hospital. The risk register included a score for the severity of each risk when it was initially recorded, currently and the intended risk level. The register included actions being taken to address the risk and a review date.

The ward manager had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Information was in an accessible format, and was timely, accurate and identified areas for improvement. Staff had access to the equipment and information technology needed to do their work. Information governance systems included confidentiality of patient records.

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. They share information and learning with partners and collaborate for improvement.

Managers and staff shared information with regional commissioners for eating disorder services who were routinely involved in reviewing patient’s care and progress. The commissioners were positive about their engagement with the service and praised how the service fully engaged with the process with consistent support and no barriers to admissions.

Managers and staff worked with other services, both within the Priory and broader community, to share information and learning. This included working with other healthcare services, and patient support groups such as advocacy.

The providers senior leadership team were available should patients or staff wish to meet with them to give feedback.

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.

The ward received the Quality Network for Eating Disorders (QED) accreditation from the Royal College of Psychiatrists. Leaders focussed on continuous learning and improvement across the organisation. The service had processes in place to implement improvement and learning from incidents and the leaders we spoke to were able to give us examples of where lessons had been learnt after incidents.

Staff participated in audits across the organisation including around medicine management and learned from suggested improvements. Staff were looking at ways to improve the environment for patients including making use of the weighing room to develop a sensory space for patients.

Staff told us that leadership welcomed their views on improvements that could be made on the ward or hospital. The ward manager on Oak was looking at creating a sensory room and had the autonomy to make decisions about other ways in which the ward area or the delivery of care could be improved.

The ward manager was looking at ways to improve patient care and was writing a proposal to consider day service provision to support patients living in the community. They had also written a standard operating procedure for health care assistants to be trained to be able to support qualified staff to administer NG feeds. This would not only upskill health care assistants but also free up nursing staff to support other patients.