Draper House

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 good. At this inspection the rating has remained good.

Good: This meant people were safe and protected from avoidable harm.

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. 

In the 12 months prior to the inspection, there had been a total of 11 serious incidents reported by the service, these included 5 allegations of abuse and 6 incidents involving a call to the police. All incidents were reviewed and closed without further action. 

Staff we spoke with were aware of the process for reporting adverse events or incidents that were to be reported both internally and externally to the service. Staff we spoke with told us that they knew about the duty of candour and what it implied, as well as when it should be applied. We saw evidence in notifications and care records of families being informed of incidents involving their relatives at the service. 

The service issued key learning updates to all staff regularly in a newsletter format. The January 2026 information update included information about the importance of following the observation policy, the updating of the induction pack to include further training on observations, and the importance of boundaries between staff and patients. Staff we spoke with told us that they were kept informed and up to date about learning from other services. 

The service issued a monthly safeguarding update bulletin, taking cases and explaining the rationale behind the case and the appropriate actions, as well as any learning from the incident. 

We saw minutes from regular staff meetings at the service, the minutes showing that staff were able to discuss feedback about incidents and lessons learned. We saw that health and safety were discussed, as well as maintenance of the buildings and the need to report on any aspects of the building that required action or work completion. 

We were informed that a debrief after a serious incident would take place, to support both patients and staff. An incident occurred in April 2026 that required a debrief for staff, this also led to changes in policy. The patient was also debriefed, and agreed changes were made to a care plan to try to ensure a similar incident did not occur again. 

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.

An initial referral could be made through the website for the service; this would be followed up by a more formal assessment. The pre-admission assessment report was a comprehensive assessment document that included required information to formulate a full assessment of a potential patient’s history and current presentation. This included current diagnosis, reason for referral, background history of the patient, personal, family and education history, physical health and forensic history, medication and risk assessment.

Care records that we reviewed showed that pre-admission assessments were completed, and that the information from the assessments were used to populate the care plans and risk assessments of patients at the service. 

We saw evidence of involvement of social care services and relevant healthcare professionals in multi-disciplinary team meeting minutes and discharge planning. The service had a treatment and discharge pathway that outlined 4 phases of treatment from the recovery phase to the discharge phase. This included the input from adult social care services to ensure that the integration back into the community was fully supported. 

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.

Safeguarding training was mandatory at the service. There were 3 types of safeguarding training; safeguarding adults face to face training (89%), safeguarding children (93%), and general safeguarding (95%). The records showed that almost every member of staff was up to date with their training. There were 3 members of staff requiring updated safeguarding adults face-to-face training, we were assured that this was arranged. There was one member of staff requiring general safeguarding updates, and 2 members of staff needed to update their safeguarding children training, again we were assured that this was in hand. 

Staff we spoke with knew how to raise a safeguarding alert and did this appropriately. In the 12 months prior to the inspection the service had submitted 14 safeguarding notifications to the CQC. 

Staff at the service knew how to protect patients from harassment and discrimination. The Equality Diversity and Inclusion policy at the service was clear and comprehensive on ensuring harassment and discrimination were dealt with. Employees who witnessed discrimination, harassment or victimisation were encouraged to report concerns through line management, complaints procedures and whistleblowing procedures. Reports would be handled confidentially and without detriment to the individual raising concerns.

Staff we spoke with knew how to identify adults or children at risk or suffering from significant harm. This was a key aspect of their safeguarding training. Staff were able to identify different types of abuse, including physical, mental or financial abuse. Staff knew that partnership agencies could be informed and utilised to assist in dealing with any such abuse. 

The service had a child visiting and protection policy in place, reviewed and amended in January 2026. The policy followed the guidance of the Mental Health Act Code of Practice. There was a visiting room at the service, and the policy clearly laid out the procedures for ensuring the safety of any child visiting the service. This included level of supervision, length of visit, number of children, it also noted that children must not come into contact with any patient other than the one that they had approval to visit. This also included the names and ages of visiting children, the relationship of the child(ren) to the patient, the date, time and duration of the visit, whether the visit would be at the service or outside the service, the name of the responsible adult, and if applicable the nominated adult. The contact details of the local authority Children’s Services were also required.

The service had a policy that included restraint guidance, the Incident Management Positive Personal Interventions Policy. This document gave instances where restraint could or should be considered and outlined different types of restraint, including how it should be practiced, recording of such incidents, and de-escalation tactics to reduce the necessity of physical restraint. The service also had a blanket restriction policy and a restrictive interventions policy. Patient records clearly indicated when and where restrictions were put in place and the rationale behind the decision.   

Mental Capacity Act

Staff received training in the Mental Capacity Act, it was joint training with Deprivation of Liberty Safeguarding (DOLs) training, and at the time of the inspection 100% of staff had completed the training. Staff we spoke with knew the five statutory principles of assessment of capacity and how to apply them. The service had a Mental Capacity Act and Best Interests policy in place; staff knew how to access this. There was a DOLs policy in place, this outlined the circumstances under which a DOLs application should be considered. The policy outlined actions to be taken and external agencies who needed to be considered and kept informed. 

Care records showed that patients at the service were encouraged and involved in making decisions about their care and what was in their best interest. Consent was clearly indicated within care records. Should a patient be deemed to have limited capacity the service had access to independent mental health advocates who could attend the service and act on the behalf of the patient. 

The Mental Health Act (MHA) administrator at the service compiled a monthly audit about MHA documentation and consent recorded with regard to capacity assessments. This was also reviewed by the pharmacy service that maintained the medication management at the service. 

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. The ward staff participated in the provider’s restrictive interventions reduction programme. 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 6 sets of care records and their accompanying risk assessments. There had been 2 incidents of physical intervention at the service in the 4 months prior to the inspection. There was no seclusion room at the service, nor any long-term segregation. There had been no incidents of rapid tranquilisation at the service in the 3 months prior to the inspection, the service did have a Rapid Tranquilisation of Acutely Disturbed Patients policy in place. The policy was in date and had been prepared with input from the pharmacy service who provided medication management at the service. The rapid tranquilisation policy clearly outlined the circumstances of the use and monitoring of this intervention should it be required. 

Care plans showed that patients were involved in their care plans and were created to show this involvement. We observed a multi-disciplinary team meeting and saw that the patient’s opinions and thoughts on treatment were fully considered and, where appropriate, applied. Copies of care plans had been offered to each patient, and where refused this was recorded.

We observed staff interact with patients, and the communication was clearly understood by patients. The multi-disciplinary meeting we attended showed that patients were fully and clearly briefed on their medications, care and treatment, and journey forward at the service. We were told that should a patient have a particular communication requirement, this would be identified in pre-assessment and, if possible, all efforts made to ensure clear communication would be implemented.

We saw minutes of community meetings where patients were able to feedback thoughts and opinions on the service. The minutes did not have a set agenda; we noted that information that was deemed relevant to the patients was included and could be discussed. There were ‘ground rules’ about expected behaviour in the meetings, and actions were taken from each community meeting and put together in a further bulletin for patients to see that the actions from the weekly community meetings had been completed as they had requested. 

A patient survey was conducted at the service prior to the inspection. The survey for January 2026 had 15 questions about the service with the option to grade between strongly agree to strongly disagree, with a ‘prefer not to say’ option at the end of each question. The majority of the patients at the service took part in the survey, and most of those patients strongly agreed or agreed that the service was meeting their needs and was a good service. 

Care records clearly indicated that advocates were active at the service, should a patient require or ask for assistance.

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.

The service audited and checked the care environment, a report titled “Health and Safety Audit Checklist, Action Plan and Report” was compiled. This report covered all aspects of risk, including required notices and documentation, staff requirements both personal and for the service, fire and electrical safety, first aid, food hygiene, and the general environment. In all, some 12 general headings broken down into 69 relevant aspects of each criteria. The report was detailed and up to date. The service also completed an annual Environmental Risk Assessment. 

The service had two wards, one on each floor. The service used CCTV and hand-held radios that effectively allowed for observation of all parts of the ward. CCTV did not intrude on any privacy for patients. 

The service was anti-ligature in design. There was a ligature-risk assessment and a ligature point audit. As the service was a rehabilitation unit, the levels of anti-ligature safeguards were comparable with the service provided. We reviewed the audit for 31 March 2026. The audit gave a complete breakdown of all aspects of each room at the service, including all fixtures and fittings, and gave a rating for each room as to the risk involved. Any potential ligature point risks had been mitigated adequately.

Alarms were located in all areas, with staff having access. Patients could use call buttons to alert staff if necessary. There was no seclusion room at the service. 

Clinic rooms had equipment relevant to the service. Emergency drugs suitable to the service were available and audited. Nursing offices on each ward had emergency bags and oxygen cylinders, all were checked and found to be in date. Defibrillators were fully charged and operational. 

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.

Staffing at the service as of 17 May 2026 showed 1 lead nurse, 5 Registered Mental Health Nurses (RMNs), 1 bank RMN, one independent ARMN (similar to a bank RMN), 2 RMNs from a sister service to help with night time cover, 2 senior support workers, 3 part time support workers and 15 full time support workers. There were also 6 bank support workers and 1 targeted support worker. There was a responsible clinician, occupational therapist staffing and psychological staffing, as well as other ancillary staff. There was 1 RMN vacancy at the service. 

The service operated on 2 RMNs and 6 support workers during the day, with 1 RMN and 5 support workers during the night. Extra staff would be brought in if required due to incidents or high levels of observations. 

In April 2026, there had been 12.25 hours lost to nurse sickness, and 73.5 hours due to support worker sickness. The staff turnover rate from April 2025 to April 2026 was 24% of some 58 staff, however the vacancies were filled.  Shifts were covered by bank and agency staff.

In April 2026, the service used bank support workers for 53.5 hours and agency support workers for 14 hours. RMN bank support was used for 5 hours and agency bank RMN support was for 4 hours. Bank and agency were used to support and maintain safe staffing levels, and all staff had received an induction and were familiar with the service. 

During the inspection, we observed qualified nursing staff in and around the communal ward areas. Care records showed that one-to-one time with patients was regularly taking place. Staff and patients told us that they only had leave postponed due to high levels of observations or incidents, patients would have their leave rearranged within a matter of hours. Ward activities would only be cancelled in the event of a serious incident at the service, but staff and patients could not name an occasion when this happened. Ward activities were available seven days a week. 

There were enough staff to carry out physical interventions if necessary, and all staff had been trained in restraint and how to conduct observations correctly. 

The service had a monthly audit report on compliance with mandatory and role specific training. The report for April 2026 showed that all training was being completed, the lowest training figures being 89% for both safety interventions and safeguarding. Those staff who were behind in training were to be given extra time to complete the training during working hours. The training included mandatory learning disability training, the training audit for April 2026 showed that Oliver McGowan training stood at 100%.

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.

The service audited infection control using a report format. The report for 10 May 2026 was reviewed. The audit was comprehensive, including a breakdown of all areas of the service. The audit included an action plan section to ensure that any problems noted could be followed up in the next audit. The audit mentioned patient involvement by keeping their rooms tidy. 

Any equipment that required maintenance, calibration or cleaning was noted to be stickered and in date. We did a tour of the service and noted that all furniture was appropriate to the service and was in good condition. 

We reviewed cleaning records; these were up to date. The ward areas were noted to have been kept clean, and we saw cleaning staff working during the inspection. We noted staff washing their hands after and before supporting patients. 

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.

The service had a Medications Management and Administration Policy; this was in date and due for review in 2027. The policy had been reviewed by the external pharmacy who provided medication for the service. The policy was comprehensive and followed national guidance. This guidance was stated in the document. The coverage included transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, and the use of covert medication. An appendix to the policy fully outlined the use of the guidance. 

The service had a Controlled Drugs Policy that was in date. This outlined the procedures and the responsibilities of the Accountable Officer at the service. There was also a Rapid Tranquilisation Policy in place that detailed the actions in the event of this being administered. There had been no episodes of the use of rapid tranquilisation in the 3 months prior to the inspection. The service also had a policy for the self-administration of medication. We were told there were 2 patients self-medicating at the service at the time of the inspection, and records showed no indication of any ongoing issues.

Care records we reviewed on both wards showed that the effects of medication were considered for each patient, and this was explored in the multi-disciplinary meetings (MDT) held at the service. We attended an MDT at the service in which we observed that the patient was involved in discussions about medication, whether the patient felt it was effective, and discussed other alternative medications.

We reviewed high dose anti-psychotic medication monitoring. The pharmacy service conducted audits of the service regularly, and we saw from the audit results that there were no indications of adverse reactions to patients requiring high-dose antipsychotic medication.