Draper House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this inspection the rating has remained good.

Good: This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We looked at 6 sets of care records during the inspection. The care records were seen to be comprehensive and inclusive. Patient involvement was evident in all aspects of treatment.

The service conducted a pre-admission assessment of all patients considered for admission. This comprehensive assessment included a full background history of the patient, reason for referral, and personal history that looked at employment and family history. It also included forensic history, physical health history and medication history. The service had a 40-point admission checklist that ensured that all relevant notes were complete with regard to the patient. 

The admission checklist covered physical health checks, as well as ensuring that a “My Physical Health” book was completed with input from the patient, to ensure that nothing was missed that the patient may not have discussed during the admission process.

The care plans of the patient showed that they were fully involved in the care planning process. They were personalised, holistic and recovery-oriented, following the treatment plan that was agreed. We saw that care plans had been updated. The service had a number of care plans for each patient, including My Discharge care plan, My Legal care plan, My Medication care plan, My Physical Health care plan and My Occupational and Functional care plan. 

Care plans were audited monthly. We reviewed the care plan audits for the 3 months prior to the inspection, this was done in a spreadsheet, and we saw that there was full monitoring of care plan updates. The spreadsheet also showed when patients had declined specific care plans, for their own reasons. 

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

The service had a patient information booklet that was given to all patients prior to admission. The 32-page booklet fully outlined the service and included the treatment pathway and treatment and discharge plans, how they worked and the personal role of the patient in making it work. This included the part therapy would play, both from occupational therapist and psychologist input. The booklet was easy to read and very informative.

The treatment and discharge pathway displayed all the ways that therapy input would help and outlined the opportunities for training and work/vocational opportunities within the community. The treatments and therapies used at the service were all supported by national guidance. The multi-disciplinary team was compiled of the full range of specialists that would be required for a rehabilitation service. 

Care records showed physical healthcare was considered and implemented at the service. The service had weekly visits by a GP and by an advanced nurse practitioner to monitor and deal with physical healthcare issues. Should emergency physical healthcare be required, patients could attend either an urgent care centre or the accident and emergency department at the local general hospital. 

The pre-admission assessment allowed for consideration of food and drink requirements for patients admitted to the service, and this was considered throughout the admission. The service provided fluids and snacks as well as a comprehensive menu, and patients who required specific supplemental nutrition would receive it. Patients were able, if risk assessed, to prepare meals for themselves. 

Clinical audit took place at the service. The service maintained an extensive master audit spreadsheet, this showed the audits carried out at the service, their frequency and who was delegated to complete the audit. This included infection prevention and control audits, cleaning rosters and health and safety checks. Care plan audits, physical healthcare audits and other clinical audits were clearly being monitored. We saw evidence of the audits having been carried out regularly. 

A quality dashboard was used to indicate and deal with any issues raised as quality concerns. The dashboard showed the method of assessment, as well as the details, any updates and any outcomes. 

The multi-disciplinary team was staffed by relevant specialists for a rehabilitation service, including a consultant psychiatrist, occupational therapist, psychology input if the patient was receiving psychological therapies, a targeted support worker, nursing staff, and external care coordinators and the inclusion of family or carers, where the patient would allow input. Staff were skilled and experienced in their fields for the patient group.

The service had a training and induction essentials policy that was in date, for review in 2027. This outlined the aims of induction, and what was expected of employees at all levels within the service. There was an induction pack, this broke down the induction process and ensured that all aspects of training were covered with a sign-off by a mentor or trained staff. There was a probation sign-off pack to show that probation had been successfully completed. An audit was carried out on inductions; we reviewed the audit for February 2026 and saw that the staff were being checked as to their progress. 

Staff we spoke with told us that supervision and appraisals regularly took place. The service had a tracker spreadsheet that was up to date at the time of the inspection, this showed that both appraisals and supervision were taking place. The tracker showed that appraisals stood at 100%, All staff were within time allowed for appraisals, only staff still on induction were not included as they were receiving frequent supervision. Supervision was seen to be happening frequently for all staff on a one-to-one basis. 

We reviewed staff meeting minutes for the 3 months prior to the inspection. The meetings followed an agenda that included previous actions completed, patient care, environmental issues, and issues that staff wished to raise. 

Staff we spoke with told us that there was specialist training available. The registered manager for the service spoke about leadership training for different staff at different levels, as well as other apprenticeships. There was also training in health and nutrition. 

We spoke with the registered manager about staff performance issues and were told that these would be dealt with promptly and effectively. 

Mental Health Act

Mental Health Act (MHA) training was mandatory at the service. The service also had a MHA and a Mental Capacity Act (MCA) policy that was up to date. 98% of the staff at the service had completed the training, scheduling was in place for total completion of the training.

Staff we spoke with understood and were able to discuss the subject knowledgeably. The knew where to access a copy of the MHA Code of Practice at the service. There was a MHA administrator for the service, the administrator prepared a monthly audit of how the MHA was being implemented. The audit included consent to treatment checks, any mental health tribunal cases, section 132 of the MHA (patient rights and the requirement to inform detained patients of those rights), and any Ministry of Justice reports that were required. Staff we spoke with knew who the MHA administrator was and could approach the administrator for advice if needed. Patient rights were explained in a way that was easy to understand.

Patients we spoke with told us they had access to independent advocacy. We were told that the advocate would visit the ward to talk with patients, and they could ask to speak to an advocate at any time. A new advocacy service took over the advocacy provision on 11 May 2026, shortly before the inspection. We were provided with a breakdown of the attendance of the advocates for the 3 months prior to the inspection. This showed attendance at MDTs and individual support for patients at the service. 

Patients who had Section 17 leave (permission to leave the hospital for agreed periods of time) were able to do so. At the time of the inspection there were no informal patients at the service, so there was no notice informing informal patients of their right to leave the service as and when requested. Staff stored copies of Section 17 leave forms on the electronic records system, ensuring that the information was freely available to all relevant staff. 

The service had discharge care plans in place that included Section 117 aftercare information for patients who had been detained under Section 3 of the MHA. This allowed powers authorising admission to hospital for treatment, if applicable.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Care records we reviewed showed that MDT meetings were regularly taking place. We attended an MDT meeting during the inspection. The meeting was comprehensive and inclusive, with all relevant parties present. The patients were able to put forward their views, and these views were clearly taken into consideration.

Handovers took place at the start of each shift, and the nursing team prepared a handover document that contained relevant information about patients and their presentation during the shift, plus any other required information to ensure patient and staff safety. We reviewed a handover document; this showed a high level of detail in the information passed over.

We saw evidence that care coordinators and other relevant teams were actively taking part in looking after patients at the service, and we were told that the relationship with these teams were effective. The service had an ongoing service level agreement with a local GP practice; we saw that this had been in place for a number of years. The service kept a running log of the contacts with the service, and whether the GP or advanced nurse practitioner had attended the service, who they had seen and what action taken. 

Quality Statement Score:

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service had information about healthy eating and habits at the service. There was a large poster showing the Healthy Habits intervention at the service, explaining how they wanted to “promote patient well-being through education and skill building in areas such as nutrition, physical activity and daily routine.”.

Each patient at the service had a “My physical health and wellbeing” care plan. This included identified specific needs for that patient, a history of physical health needs, allergies, baseline observations, challenges, and health promotion directions. 

The service also had introduced menus that were based on the “healthy plate” approach to diet and nutrition. The service also offered physical health activities to patients, including weight and dumbbell sessions, aquarobics, walking groups, circuit training, other low-level impact exercises. There was also a Level 1 nutrition and health course for patients to learn about healthy eating. 

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service used the Health of the Nation Outcome Scales (HoNOS) to assess and record severity and outcomes. Each patient at the service had a care programme approach pack which had a specific section dedicated to outcomes using the HoNOS rating scale. We reviewed one such pack and saw that the ratings were updated on a regular basis. The outcomes of the care programme approach were audited monthly, summarizing any problems or successes with the service approach to patient care. Commissioners were kept informed of any results or recommendations.

Patients at the service could access computers if risk assessed, and staff used hand-held devices to update the electronic patient record system, or to carry out observations. 

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff took all practical steps to enable patients to make their own informed decisions. The service had a Mental Capacity Act (MCA) and best interest policy that was in date at the time of the inspection. The policy fully outlined the rationale for the MCA and how it should be applied. There was also an appendix that included examples of the capacity assessment tool, the optimizing capacity assessment tool, the best interest checklist and a flow chart for assessing capacity. 

Care records showed that capacity was considered during patient admission. Staff received mandatory training in the MCA, and the training records showed that over 95% of staff had up to date training, and other staff were scheduled to complete training. 

Patients had access to advocates who were able to speak for patients who might otherwise be unable to show capacity to make certain decisions. Consent and capacity were audited at the service; we reviewed audits for the 3 months prior to inspection. The audits were completed by the MHA administrator. They included consent to treatment checks, both by the service and the pharmacy who supplied and monitored medication at the service. Where the audit identified any problems, these were acted upon and monitored to ensure that lessons were learned. It was noted during the inspection that the service had signage outlining the capacity statutory principles, they were even evident in general bathrooms at the service. 

6 sets of care records were reviewed during the inspection, and all had relevant capacity and consent documentation present.