Woodbourne Priory Hospital

Updated 13 January 2026

We assessed Woodbourne Priory Hospital from 28 October 2025- 11 November 2025. This assessment included an on site inspection visit, including an evening visit.

We assessed the location to review the progress made against the requirement notices that were served on the provider following the inspection in January 2023. We found that the service had made improvements and had met most of the actions of the requirement notices.

Woodbourne Priory Hospital was registered with CQC in November 2010 to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of disease, disorder or injury. The service had a controlled drugs accountable officer and a Registered Manager.

We visited the following wards as part of the assessment:

Acer ward, adult acute ward for men and women with 9 beds (6 patients at the time)

Maple ward, adult acute ward for men and women with 16 beds (6 patients at the time)

Elm ward, adult acute ward for men and women with 14 beds (7 patients at the time)

Aspen ward, adult psychiatric intensive care unit for men with 9 beds (3 patients at the time)

Oak ward, a specialist eating disorder ward with 9 beds (7 patients at the time)

At this assessment we identified breaches of regulation 9, person centred care.

At this assessment we assessed 2 assessment service groups; Acute wards for adults of working age and psychiatric intensive care units where we assessed 33 quality statements and Specialist Eating Disorder Services where we assessed 33 quality statements.

We have assessed the location against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. Staff completed appropriate training to enable them to support people with a learning disability and autistic people. The provider reported 100% of staff completed ‘Introduction to Learning Disabilities Training’. Staff completed training in ‘Autism & Communication’, ‘Autism & Sensory Experience’, ‘Autism & Supporting Families’ and ‘Autism, Stress & Anxiety’. The provider recently introduced an autism lead role for the location. We saw that care and treatment reviews took place for patients with a learning disability or autistic patients.

We rated the location as good. However, in the acute wards for adults of working age and psychiatric intensive care units, we found breaches of regulation 9 in relation to: Staff not upholding informal patients’ rights and not ensuring patients had access to meaningful activities to promote their independence. Staff not always involving patients in planning their care and managing their risks. In the specialist eating disorder ward we found breaches of regulation 9 in relation to: Staff not upholding informal patients’ rights and not ensuring patients had access to meaningful activities to promote their independence.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 3 October 2025

We assessed the acute wards for adults of working age and intensive care units at Woodbourne Priory Hospital from 28 October 2025- 11 November 2025. This assessment included an on site inspection visit, including an evening visit.

We assessed this service to review the progress made against the requirement notices that were served on the provider following the inspection in January 2023. We found that the service had made improvements and had met most of the actions of the requirement notices.

Woodbourne Priory Hospital was registered with CQC in November 2010 to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of disease, disorder or injury. The service had a controlled drugs accountable officer and a Registered Manager.

We visited the following wards as part of the assessment:

Acer ward, adult acute ward for men and women with 9 beds (6 patients at the time)

Maple ward, adult acute ward for men and women with 16 beds (6 patients at the time)

Elm ward, adult acute ward for men and women with 14 beds (7 patients at the time)

Aspen ward, adult psychiatric intensive care unit for men with 9 beds (3 patients at the time)

We rated the service as good. The service had made improvements and is no longer in breach of regulations 10, 12, 15 and 17. The service demonstrated a positive learning culture and staff knew how to safeguard patients from abuse. Environments were safe and clean and staffing was safe and effective. Staff and teams worked well together and were able to evidence how they monitored and improved patient outcomes. The service ensured information was up to date and accessible. The service promoted equity in experience and outcomes. Leaders were capable and compassionate and encouraged staff to speak up. Leaders were committed to improving workforce equity, diversity and inclusion and promoted learning, improvement and innovation.

However, the service did not always treat patients as individuals and staff did not always treat patients with kindness and compassion. The service did not always ensure informal patients’ rights were upheld and that patients had access to meaningful activities to promote their independence. Staff did not always involve patients in planning their care and managing their risks. The provider had not ensured premises were fully accessible. Governance systems had not identified and acted on breaches of regulation and concerns found during this inspection and assessment.

The service was in breach of regulation 9, person centred care.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

Staff were trained in the Mental Health Act, the Code of Practice and the guiding principles. The provider had relevant policies and procedures that reflected the most recent guidance that staff had easy access to. Patients had easy access to information about independent mental health advocacy. Staff explained to patients their rights under the Mental Health Act in a way that they could understand. Staff requested an opinion from a second opinion appointed doctor when necessary. Staff stored copies of patients' detention papers and associated records correctly. However, the service had not displayed a notice to tell informal patients that they could leave the ward freely.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff took all practical steps to enable patients to make their own decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. The service had arrangements to monitor adherence to the Mental Capacity Act.

Updated 3 October 2025

We inspected Oak Ward at Woodbourne Priory on October 29 and 30. Oak ward is a nine bedded eating disorder ward run by a multi-disciplinary team (MDT). Their aim is to provide an effective treatment package for both males and females aged 18 years and over, who require an inpatient stay to monitor, stabilise and treat their eating disorder.

At the previous inspection the eating disorder service was rated requires improvement in safe and well-led. It was rated good in all other areas. At this assessment we found improvements and our rating of this service improved. We rated it as good.

The environment was clean and well maintained. The ward manager ensured all permanent staff completed specialist training, and use of external staff was kept to a minimum. Patients told us staff involved them in producing their care plans and their risk assessments and included them in Multi-Disciplinary Team (MDT) reviews.

However, we saw some informal patients were not always able to freely leave the ward. Information displayed around rights did not clearly explain informal patients right to leave the ward. Staff completed mental capacity assessments for patients lacking capacity, but they were not always decision and time specific in line with legislation.

The service was in breach of regulation 9, person centred care.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

Staff were trained in and understood the Mental Health Act, the Code of Practice, and the guiding principles.

Staff had access to administrative support and legal advice on the implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were, and relevant policies and procedures were in place.

Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice. Patients had access to independent mental health advocacy.

However, it was not always clear that informal patients were made aware of their right to leave the ward at any time. Information on informal patient rights to leave the ward was not clearly displayed. We also saw that informal patient’s wishes to leave the ward were not always followed with concerns around risk being noted as the reasoning.

Mental Capacity Act

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. Staff understood the Mental Capacity Act, particularly the five statutory principles, but this was not always reflected in the recording of capacity assessments.

Staff completed capacity assessments for patients as part of the assessment upon admission. In one care record, we saw that staff did not always detail the patients’ voice or involvement, and assessments were not time and decision specific. However, we saw in some areas, such as care plans, that staff made decisions in patients’ best interests, recognising the importance of the person’s wishes, feelings, culture and history.

Updated 28 June 2023

Our rating of this service improved. We rated it as requires improvement because:

• Staff did not always manage risk well. Staff did not always follow the provider’s policy and procedures on the use of enhanced support when observing children and young people assessed as being at higher risk harm to themselves or others. Levels of restrictive interventions on Mulberry ward were varaible.
• The treatment room was not clean and the fridge used to store specimens was dirty. Clinic rooms were not checked for out of date items regularly.
• Not all children and young people’s care plans were personalised, holistic and recovery-orientated. Not all staff had access to training to meet the needs of children and young people they were supporting.
• Not all children and young people felt safe on the ward.
• Staff did not always treat children and young people with compassion and kindness, respect their privacy, or understand the individual needs of children and young people. They did not always actively involve children and young people or their families and carers in care decisions.
• The governance processes on the ward did not always operate effectively or provide the right assurances at a team level. Agency induction checklists were not always complete. Staff did not always score children and young people’s paediatric early warning score (PEWS) records correctly. Managers did not have sufficient and effective systems and processes to ensure that medical equipment and devices stored in the clinic room were kept in date, calibrated, or cleaned regularly.

However:

• The wards had enough nurses and doctors. They managed medicines safely and followed good practice with respect to safeguarding. Staff provided a range of treatments suitable to the needs of children and young people and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of children and young people on the ward. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
• Staff managed discharge well and liaised well with services that could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• Leaders had a good understanding of the needs of the children and young people and how to address these as well as a comprehensive understanding of the service they managed.

Updated 22 September 2022

Long stay or rehabilitation mental health wards for working age adults

• The Manor is a private adult mental health and addiction therapy ward and has nine beds. The Manor also offers an aftercare programme for patients who have completed the inpatient service.

Updated 28 June 2023

Our rating of this service stayed the same. We rated it as good because:

• The service provided safe care. The clinical premises where clients were seen were safe and clean. The service had enough staff. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the clients and in line with national guidance about best practice.
• The teams included or had access to the full range of specialists required to meet the needs of clients under their care. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team.
• Staff treated clients with compassion and kindness and understood the individual needs of clients. They actively involved clients in decisions and care planning.
• The service was easy to access. Staff planned and managed discharge well and had alternative pathways for people whose needs it could not meet.
• The service was well led, and the governance processes ensured that its procedures ran smoothly.

However:

• Staff did not always complete observations of physical health, during clients’ withdrawal from alcohol, at the frequency specified by the client’s consultant.