Draper House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

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

Good: This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

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

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices, and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

We reviewed care records that showed individualised and comprehensive care plans that showed patient involvement. Patients we spoke with told us they were involved in their care and treatment. We attended an MDT at the service which indicated that patient involvement was at the centre of the meeting. 

The service had some 10 different care plans for patients that were tailored to the needs and treatment of patients at the service. An audit of care plans for April 2026 showed that each patient had been given the opportunity to put advanced statements in place, and each patient had done so. Our review of the care plans showed that, like risk assessments, they had been updated whenever an incident occurred or within the timeframe for checking and updating. 

Patients and staff had joint had community meetings that took place regularly at the service, we reviewed the minutes of each meeting for the 3 months prior to the inspection. They followed an agenda and allowed for input from both staff and patients about items including the ward environment, blanket restrictions, campaigns (such as bowel cancer awareness month), trips or days out, and patient representative feedback. Patients were allowed to raise any points they wanted to about their care or treatment if they wished. 

The service had positivity meetings, patients were also provided with a pre-MDT meeting form to encourage patients to write down any points they wanted to make and discuss their feelings or treatment. The patient representative also attended governance meetings to feed into the service development.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The service supported patients who wanted to be involved in education or work opportunities. A patient had been enrolled in a nutrition and health course the week of the inspection. 7 patients had taken part in a basic life support course, and there was also safeguarding training available for patients. 

The service had a family and friends information booklet, this included information about the service, who would be involved in patient care, outlined the MDT, and how carer involvement and carer support was important, and the family and friend’s forum and events. Patients were encouraged to maintain contact with family, unless there were reasons why this was not conducive to the patient’s wellbeing. 

The service had a multi-faith room that had several religious texts and floor coverings should prayer be a consideration. Should a patient require or request access to a community place of worship, the service would try to accommodate this, or at the least arrange for a pastoral visit.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service made statutory notifications when required to the CQC. We also saw evidence of notifications of referrals to safeguarding teams and other external bodies. 

The service had a general data protection confidentiality disclosure policy in place, issued by the provider. This ensured that the service had to follow the law with regard to confidentiality of data of all patients at the service. The policy related to electronic and written records and took into account consent in all its forms. The service had general data protection regulation and data protection mandatory training, this training was at 100% compliance. 

The service complied with the Accessible Information Standard. There was a communication care plan that covered the 5 key steps of the Standard. We saw a communication care plan for a patient that showed that key questions were asked. 

There was information about treatments, local services, patient rights and how to complain on notice boards across the service. The information was clear and easy to understand. If a patient did not have English as a first language, information could be obtained in a suitable language or given by the use of interpreters. 

Family and carer surveys were carried out, ensuring they were kept informed about their relative, and they were invited to MDT meetings if the patient was in agreement. We contacted a commissioner who informed us that they were kept up to date with any changes in a patient's presentation and/or treatment. The commissioner told us patients were actively involved in their MDT meetings, and the commissioners were invited to all reviews, with documentation provided both before and after meetings.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

The service had a complaints and compliments policy that was up to date. The policy outlined what was deemed to be a complaint, how they can be made and by who, and the process that would be used to investigate and disseminate findings from any such investigation. The service had a poster that informed patients how to make a complaint, who to make the complaint to, and also included the contact details of the CQC should a patient want an external complaint to be made. 

In the 3 months prior to the inspection there were 8 complaints made, all of which had been dealt with within the 28-day handling period. None of the complaints had been sent to the Ombudsman over the same period. The complaint details were fully laid out in the service dashboard.

Learning from complaints was shared in a number of ways, including one-to-one sessions with staff, electronic mail, and team meetings. The service also used a “ShoutOuts” poster to show compliments and praise for both staff and patients each month. The service hospital governance agenda included complaints and compliments for discussion: in the April meeting it described one complaint that was not upheld, but that some positive actions came from the complaint.

Staff we spoke with knew how to handle complaints and knew the policy. There was mandatory training in complaint documentation and reporting, the completion rate was 100%.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The service was compliant with necessary adaptations for disabled patients. This included access to a lift, wide doors, a ramp to enter the building, evacuation sleds and adapted bathrooms for disabled patients. If a patient required a walking aid or a shower chair, the service would ensure one was provided.

Patients had open access to their bedrooms during the day. Mobile telephones could be accessed by patients if they were risk assessed as able to use them without risk, and there was a ward phone that could be used if a patient needed to make a private telephone call. There was internet access, access to outdoor space, and patients were able to personalise their bedrooms. Inspection team members were invited to look at bedrooms that had been personalised by patients who were proud of their environment. 

There was adequate nursing staff cover both day and night, and the local general hospital was in close proximity for both AE and general treatment. The service had a full-time consultant psychiatrist, psychologist input, and occupational therapist input. The service had a full time psychology assistant working 40 hours a week, and a psychologist who gave 1.5 days a week to the service. The occupational therapist worked a 32 hour week, with an occupational therapist assistant who worked 40 hours a week.

The service considered post-discharge care in both its discharge care plans and in MDT meetings. Referral on to social workers, community mental health support or crisis services were all considered prior to discharge. There was good liaison with care coordinators and commissioners, and discharge was only delayed due to non-clinical reasons. 

Draper House had a discharge checklist that comprehensively noted all relevant aspects to be considered for a safe discharge of a patient. The checklist noted 21 points that needed to be considered, including medication to take home, a discharge risk assessment, ensuring all relevant authorities were informed as required, and the GP for the patient informed of the discharge. 

The service did not work to a specified expected length of stay due to the complexity of the patients admitted to the service. A commissioner we contacted stated that the main cohort of patients admitted to Draper House had needs that were often more complex and required longer periods of treatment and support. 

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The culture at the service was open, both patients and staff we spoke with told us that they felt that they could give their views on the service without fear of any reprisal or consequence.

The service had an equality, diversity and inclusion policy that was within date of review. The policy clearly stated that equality impacts would be considered when introducing new policies or services. This would protect people deemed vulnerable or with protected characteristics from being put at any disadvantage.

The service included equality and diversity training in their mandatory training programme. At the time of the inspection the training compliance figure was 100%. The equality policy was created using the Human Rights Act as guidance. 

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Care records that we reviewed at the service showed evidence of staff involving and ensuring patients could make important life decisions. Patients we spoke with told us that they were fully involved in the decision making about their treatment and the choices that were made. 

Care plans reflected patient needs, this was also reflected in the MDT notes. We attended an MDT and saw that the patients were involved and that their requests and feelings were considered. Care plans were personalised and comprehensive.

The MDT showed that the relevant healthcare professionals for each patient were involved in the care and treatment of that patient, and efforts were made to include external authorities, such as care coordinators and social workers.