The Care Quality Commission
  • Mental Health
  • Independent mental health service

The Priory Hospital Dewsbury

Overall: Requires improvement read more about inspection ratings

York Road, Earlsheaton, Dewsbury, West Yorkshire, WF12 7AF (01924) 436140

Provided and run by:
Priory Rehabilitation Services Limited

Important: The provider of this service changed. See old profile

All Inspections

6 and 7 October 2021

During a routine inspection

Our rating of this location stayed the same. We rated it as requires improvement because:

  • The service was not well led. Some of the systems in place were not effective to assess, monitor and improve the quality and safety of services provided. There was an unclear framework to ensure managers disseminated information in a structured manner. Managers had limited oversight and assurance on some aspects of the hospital such as sharing lessons learnt, training and appraisal compliance, cleanliness and maintenance, and timely and accurate record keeping.
  • Patients on Hartley ward with a learning disability had not had a positive behaviour support plan created in line with national guidance.
  • The facilities on the wards did not fully support the privacy and comfort of the patients. Staff were unable to discreetly observe patients in their bedrooms during the night without disturbing them.
  • Jubilee ward required further improvements to ensure it was dementia friendly. The garden area did not create an environment to encourage patients to remain active. Plans for improvement were not robust.
  • Ligature risk assessments were not kept on Hartley ward or updated following every admission to the ward.
  • There was limited access to the electronic system for agency staff and the use of the electronic systems was very slow.
  • Staff on Hartley ward did not always regularly review and update care plans when patients' needs changed.
  • The services banned and restricted items list was not service or ward specific and was not reviewed regularly and updated depending on the patient group.

However:

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
  • The ward team included or had access to the full range of specialists required to meet the needs of patients 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.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients.

3 and 4 March 2020

During a routine inspection

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

  • The wards were in need of redecoration and refurbishment and the environment on Hartley Ward was not clean in all areas. Health support workers had to carry out cleaning tasks during the evening and at weekends but they did not always have time to complete these tasks.
  • We could not see whether staff undertook routine physical health monitoring on all occasions following the administration of rapid tranquillisation and ligature risks were not always updated following the admission of new patients on Hartley ward.
  • The design, layout, and furnishings of the ward did not support the needs of patients with dementia and patients did not have access to a bath on Jubilee ward. Patient bedrooms did not have viewing panels which meant staff having to enter patients’ rooms at night which could have disturbed people. On Hartley ward, the design of the showers did not support patients’ privacy and dignity.
  • On Jubilee ward, staff did not use protective equipment with patients at meal times which meant some patients had food spilled on their clothing. At inspection, most patients wore the same type of clothing and many did not have socks on. On Hartley ward, care plans were not always holistic and did not show evidence of patient involvement or discharge planning.
  • Some of the systems in place were not effective to assess, monitor and improve the quality and safety of services provided. For example mechanisms were not in place to ensure that the risks on Hartley ward were managed well or that staff undertook appropriate physical health monitoring following all instances of rapid tranquillisation. Managers did not have oversight of blanket restrictions on the hospital and the restrictions log on Hartley ward did not reflect all the restrictions there were in place. 
  • The hospital used high numbers of agency staff but, at inspection, they did not have access to the electronic patient care record. Not all staff knew how they could be consulted or involved in the changes that were taking place in the hospital.

However:

  • Staff on Jubilee ward managed patient risk well. Staff on both wards minimised the use of restrictive interventions and followed good practice with respect to safeguarding.
  • Staff managed medicines well and patients had access to appropriate physical health monitoring and follow-up when they needed it.
  • Staff on jubilee ward developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients 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 a range of specialist staff. Managers ensured that these staff received training, supervision and appraisal. 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.
  • Staff treated patients with compassion and kindness and dignity. They understood the individual needs of patients and actively involved them and their families and carers in care decisions.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.

13 -14 July 2017

During a routine inspection

We rated The Priory Hospital Dewsbury as good because,

  • The hospital environment was clean and well maintained. Staff undertook environmental risk assessments to mitigate and manage risks. All patients had comprehensive risk assessments and the hospital used a range of recognised tools. The hospital had robust medication management and regular audits to ensure any gaps were being identified and continuously improved. Staff understood their responsibilities under safeguarding and made appropriate notifications to the local safeguarding authority as well as statutory notifications to the Care Quality Commission.
  • All patients had comprehensive, person centred and holistic care plans. There was evidence of collaboration with patients and carers within the documentation. Patients had access to a full range of multi-disciplinary staff including a psychologist, psychiatrist, registered mental health nurses, occupational therapist, health care assistants and a newly appointed registered general nurse. Multi-disciplinary meetings were detailed and covered all aspects of the patients care including, risk, medication and discharge plans. Staff had a good working knowledge of the Mental Health Act. They had support from a Mental Health Act administrator who was also responsible for ensuring all documentation was correct and up to date.
  • We received overwhelmingly positive feedback from carers about the good care received by their family members. They highlighted staff were caring, kind and compassionate when working with patients. We observed staff treating patients with dignity, empathy and kindness. Patients were able to feedback on the service during their weekly community meetings, they could highlight concerns, issues or areas they would like to see improvements.
  • The hospital successfully discharged patients on both Hartley ward and Jubilee ward in the last 12 months. The hospital responded to all complaints in a timely manner, apologised in all instances as well as providing good will gestures as part of the outcome. The hospital provided had a range of facilities which promoted the patients recovery, they included a gym, multi-sensory room and a skills kitchen.
  • Robust governance systems were in place to measure the effectiveness of the service using key performance indicators. Regular governance meetings were held locally at the service and outcomes were communicated at regional and national governance meetings. The senior staff and registered manager were aware of the key risks that affected the hospital and understood what plans were in place to manage it. There were audits in place to identify gaps within systems. The hospital had action plans aligned to all the audits. Staff could submit to the risk register after discussing the risk with the registered manager. Staff morale was positive and they felt as though they could approach senior staff regarding issues or concerns. They did not feel at risk of victimisation and felt the hospital would support them wherever possible.

However,

  • We found staff on Hartley ward had left a sheath on the auricular thermometer after it has been used.
  • Physical health information was not always stored within the physical health template. We found physical health information stored within contemporaneous notes, care plans and risk assessments, This meant physical health information was not always easily found.
  • Care plans were not always future orientated, and did not discuss plans for discharge.
  • Although psychology support was available one to one, the hospital did not have any therapeutic groups to offer patients.
  • The providers central electronic information system did not always accurately reflect compliance figures for supervision. Although staff were receiving regular monthly supervision the providers system identified a compliance rate of only 60%.

13/11/2016 - 14/11/2016

During an inspection looking at part of the service

We found that:

  • Staff managed medicines safely. The hospital had improved medicines management arrangements as robust arrangements were in place. This meant that staff administered medicines as prescribed. The hospital had accurate and up to date records for medicines in stock. Staff regularly checked dates to make sure they were safe to use.
  • The provider had systems in place to monitor the side effects of anti-psychotic medicines. This meant if patients had any adverse effects from anti-psychotic medication, appropriate action was taken including alterations made to the dosage or frequency or alternative medication sought. Where patient’s self- administered medicines the appropriate risk assessments were in place.
  • We observed kind and compassionate interactions between staff and patients. Staff were motivated and had good morale. Patients told us that they were happy with the care they received and thought staff were caring.
  • The provider had systems, processes and audits in place to effectively monitor the running of the service and identify any risks, themes and trends.

At this inspection all the actions we told the provider it should take had been completed as follows:

  • Staff completed ligature audits with the appropriate scoring. This was in line with the provider’s policy. Ligature cutters were easily accessible within the staff office. The service had implemented additional safeguards by conducting ligature training drills so staff would be prepared in the event of patient ligaturing.
  • Staff updated risk assessments after incidents had occurred and they completed care records with patients. These included direct quotes and comments from the patient.
  • The provider had removed some of the locked doors in the patient areas, for example, the quiet lounge. However, we found that locked doors remained on the skills kitchen, laundry room and areas not accessible to patients.
  • The hospital staff communicated to patients of any changes happening to within the hospital including building work. This was facilitated through the patient meetings.