Barnt Green

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

At our last assessment we rated this key question requires improvement. The service was in breach of legal regulation in relation to Regulation 12 Safe care and treatment. The service has made improvements and is no longer in breach of regulation. The provider now has systems and processes in place to ensure staff can safely support patients to seclusion. The ward environments on Jubilee and Clent wards are now clean and well maintained. At this assessment the rating has changed to good.

Wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had made improvements and is no longer in breach of regulations. Staff now assessed and mitigated risks. Care plans now guided safe practice. The provider now had enough staff to ensure people’s safety and meet their needs. People were now supported to have choice and control and were involved in planning their care.

Staff recorded incidents using an electronic incident reporting system. Between May 2025 and January 2026, a total of 687 incidents were reported. The most frequently reported incidents related to the use of restraint and rapid tranquillisation, predominantly on Clent ward.

We reviewed incident data recorded between September 2025 and January 2026. Staff typically recorded 8 to 20 incidents per month. However, on Clent ward there was a significant increase in incidents in January 2026. Manager told us this increase was due to an influx of patients with higher levels of complexity and acuity.

Incidents were a standing agenda item at clinical governance meetings, which were attended by the multidisciplinary team. Clinicians reviewed all reported incidents and confirmed that they were managed effectively and appropriately at ward level by the teams.

Service managers reviewed all incidents. They escalated more serious incidents to a more senior level. Managers investigated incidents through local investigations.

Learning from incidents was routinely discussed during patient safety meetings. For example, in November 2025, staff identified the importance of clear communication, maintaining firm professional boundaries, timely escalation of concerns, and consistent adherence to policy when supporting informal patients on leave. Measures were implemented, including ensuring patients fully understood the consequences of non‑compliance and providing support to promote safer decision‑making. This demonstrated that learning from incidents was reviewed and appropriate actions had been taken.

Staff effectively applied verbal de-escalation and calming communication techniques during periods of crisis. The provider positively recognised staff confidence in using these approaches when managing incidents, helping to maintain patient safety in the least restrictive manner possible.

Staff were offered a debrief following an incident and any lessons learnt were fed back to them.

Staff had set up patient safety lessons learned notice board. The patient safety lead produced monthly patient safety bulletins and included information on lessons learned from incidents.

Staff received additional mandatory training on incident recording and the reporting of near misses, which had resulted in improved accuracy and consistency in incident documentation. Reporting incidents was also incorporated as an objective within staff supervision, revisited during yearly appraisals, and was an agenda item in team meetings to reinforce accountability and good practice.

The service maintained an ongoing site improvement plan, which included actions to enhance patient safety across the site. This incorporated follow-up actions arising from the previous CQC inspection visit.

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.

The service provided acute wards for adults of working age and psychiatric intensive care units. The service had a clear criterion for people to access the service. Managers reviewed referrals to determine if the patient’s needs could be safely met.

Patients told us that they were shown around the ward on arrival and informed of their rights. All wards had welcome leaflets and booklets to give to new patients.

The service worked collaboratively with other services to ensure that patients were supported. For example, the service worked closed with social services, generic outpatient appointments, community mental health teams and NHS providers.

Staff supported patients to plan for future changes, discharges and to seek ongoing support.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrate 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.

The service had policies on safeguarding adults and children. Policies included clear expectations for duty of care, risk assessment, and effective multi‑agency cooperation.

Staff ensured that children’s visits were carried out safely and in accordance with established procedures. Decisions about children visiting the service were made collaboratively and appropriately by the multidisciplinary team.

Between May 2025 and January 2026, the service reported 39 incidents to the local authority. Managers worked closely with local authority safeguarding teams and NHS providers to respond to and manage these incidents appropriately.

Staff had completed mandatory safeguarding training. Training compliance ranged from 95-100%. Staff completed training in safeguarding adults and children at levels 2 and 3. Designated safeguarding leads completed level 4 training. Compliance rates were above the service target (90%).

Staff had completed mandatory, accredited training in physical interventions. The compliance rate for this training was 96%. The service consistently recorded and regularly reviewed the use of restraint, restrictive practices and any blanket restrictions.

The service had an identified safeguarding lead, and monthly safeguarding meetings were held to monitor emerging themes and trends. Following each meeting, a safeguarding bulletin was distributed to all staff to support shared learning and promote safe practice. A Priory safeguarding statement was displayed across the service, which demonstrated the provider’s commitment to keeping patients safe and adhering to safeguarding policies.

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 and seclusion 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.

Staff used standard forms for clinical risk assessments. During this assessment, we reviewed three patients’ clinical risk assessment plans, with a particular focus on how patients were supported both prior to and during periods of seclusion. Since the previous inspection, the provider had reviewed its seclusion policy and related standard operating procedures across Priory Hospitals. Governance arrangements had strengthened, with all episodes of seclusion in non‑designated areas now requiring completion of a 24‑hour report, a team incident review, and a further review through the patient safety and clinical governance processes.

While patients were in seclusion, staff completed all required documentation and reviews to justify the use of seclusion and monitor the patient. Post‑seclusion observations were carried out, alongside ongoing mental state assessments and regular environmental safety checks. Nursing and senior clinical reviews were undertaken within the required timescales.

Staff involved patients in care planning and clinical risk assessment plans. This. Patients could have a copy of their care plan if they wanted.

Staff supported patients to understand their care and treatment. Interpreters were provided if required.

Staff enabled patients to give feedback on the service they received at weekly community meetings. Ward managers attended and chaired these meetings, ensuring senior oversight and a consistent forum for patient engagement. Their presence enabled timely responses to concerns raised and facilitated immediate feedback or resolution where appropriate.

Staff ensured that patients could access advocacy.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

At our last inspection, the communal and laundry areas on Jubilee and Clent wards were visibly unclean. At this visit, both wards were clean, tidy and well maintained. Ward managers now complete monthly cleanliness audits and report the findings through clinical governance processes. Now, a member of the housekeeping staff attends daily safety huddles to support effective communication and agree actions. The housekeeping team deep clean all laundry areas weekly and communicate directly with ward managers to promptly address any concerns about cleanliness.

Staff had easy access to alarms. Patients had easy access to nurse call systems. The service provided alarms for staff and visitors.

Staff carried regular risk assessments of the care environment including ligature audits, blind spot audits and heat maps showing the location of high, medium and low risk ligature points. Staff were assigned to corridor areas. Staff had mitigated the risks caused by blind spots by installing curved mirrors. Closed-circuit television (CCTV) was installed in all communal areas.

The ward complied with guidance on eliminating mixed-sex accommodation. There were separate male and female sleeping areas, designated bathroom facilities, and clear signage. Staffing arrangements were in place to maintain dignity and privacy. Staff conducted routine environmental checks.

Jubilee ward did not have a designated seclusion room. When a patient needed to be secluded, they would be escorted by staff to Clent ward. There were two seclusion rooms on Clent ward. If both seclusion rooms on Clent ward were being used, staff could seclude the patient in a non-designated area, such as the patient’s bedroom. Seclusion in non-designated areas was conducted in accordance with the hospital’s policy for this. At this visit both seclusion rooms were out of order and specialist contractors were on site carrying out repairs. However, we saw the seclusion rooms allowed clear observation and two-way communication and had toilet facilities and a clock, in accordance with the Mental Health Act Code of Practice.

Since our last assessment, leaders had introduced a new seclusion and long-term segregation policy, developed in consultation with staff. Staff received two days of restrictive intervention training. Trainers also provided ongoing on-site support.

Data showed between May 2025 to February 2026 there had been three incidents of seclusion in non-designated areas, all subject to a 24-hour governance review. We reviewed two seclusion records, including one where a patient was cared for in her bedroom (non-designated area) due to seclusion rooms being out of service. Staff managed care safely and documentation was completed appropriately.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff maintained equipment and kept it clean.

The service showed some shortfalls. Staff received effective support, supervision and development. Patient acuity levels were high, and the service remained reliant on bank and agency staff to maintain safe staffing levels. The service ensured there were enough skilled and experienced staff available to provide safe care that met people’s individual needs.

The service had sufficient staffing levels to ensure patient safety. Managers had calculated the required number and skill mix of nurses and healthcare assistants using the Priory Healthcare staffing ladder tool. However, due to the high acuity of patients, additional staff were frequently required on some wards. As a result, the service continued to rely heavily on bank and agency staff.

Beacon ward had a capacity of 10 beds, Jubilee ward 12 beds, and Clent ward 10 beds. When operating at full capacity during the day, Beacon and Jubilee wards were staffed by two nurses and two healthcare assistants, while Clent ward was staffed by two nurses and four healthcare assistants. At night, core staffing levels reduced to one nurse and two healthcare assistants on Beacon and Jubilee wards, and one nurse and three healthcare assistants on Clent ward. However, some staff said staffing levels weren’t always adequate.

Staff recruitment data for February 2026 identified a high number of vacancies across wards and site‑based roles. The highest level of vacancies was recorded on Clent Ward, with six healthcare assistant posts unfilled, followed by Jubilee Ward, which reported four health care assistant vacancies. The lowest level of vacancies was identified on Beacon ward, with one registered nurse (mental health) post vacant. In addition to ward‑based roles, there were also site‑wide vacancies for one receptionist and one chef.

Managers and staff were supported to make ward-level decisions to increase staffing when higher observation levels were required. For example, when patients engaged in more severe and complex self-harm behaviours, staff were able to increase the level of observation based on their own risk assessment at the time, where this was deemed necessary to ensure the patient’s immediate safety. This decision could then be communicated to the nursing team afterward. However, not all staff agreed that this approach was consistently followed in practice.

A quality improvement project had reduced the use of enhanced patient observations on Clent ward by approximately 88% between January and September 2025, supporting a safer and more effective deployment of staff. The project since been extended to Jubilee ward. However, it was unclear how the provider was managing this reduction, as additional agency staff were still required to meet patient’s needs.

Managers adjusted staffing levels daily in response to high acuity. Where staffing shortfalls occurred, Priory bank staff who were familiar with the service were used.

The provider used bank and agency staff across wards to support patient observations and staff sickness. Provider data from May 2025 to February 2026 demonstrated clear variation in reliance on agency staff across the three wards. Clent ward consistently showed a higher reliance on bank staffing throughout the reporting period, with percentages remaining significantly above those seen in Beacon and Jubilee in every month. This indicates ongoing and sustained staffing pressures, which were recognised and subject to continued management oversight. In contrast, Beacon and Jubilee wards demonstrated lower overall reliance on bank staff, with usage fluctuating in response to operational pressures. Both wards show periods of improvement, particularly between November and December 2025, suggesting effective workforce planning and responsiveness to demand.

Clent ward operated with high agency staff usage in excess of 60%, highlighting the need for ensuring patient safety was maintained. Beacon and Jubilee wards maintained average agency staff usage below 30%, indicating generally stable staffing arrangements with episodic workforce pressure. The provider confirmed that increased patient acuity at the beginning of 2026 on Clent ward also contributed to higher staffing demand, with assurance provided that patient safety was maintained throughout.

Staff data for January 2026 showed an overall staff turnover rate of 0.7%, indicating a high level of workforce stability during the period. Turnover varied by staff group. The highest turnover was recorded among administration staff at 8%. In contrast, there was no turnover among doctors, nurses, and health care assistants, indicating strong retention within frontline clinical roles.

Staff sickness data for January 2026 showed low sickness levels with healthcare assistants 4% and administration staff 3%. In contrast, doctors, nurses and therapy staff recorded the lowest sickness levels at 1%. All staff groups were below the Priory Healthcare sickness target rate of 5%.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

In January 2026, staff training compliance ranged from 94% to 100%. All training was appropriate for the patient group. In February 2026, overall compliance at the service fell to 91%. The manager explained this was due to delays in training records being signed off by the trainer, despite staff having attended the training. Staff training data from March 2026 showed mandatory training for reducing restrictive intervention breakaway training was at 96%.

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.

At the previous inspection, the care environment within the Jubilee and Clent communal areas, including the kitchen and laundry facilities, were not adequately cleaned or well maintained. During this inspection, all areas were found to be clean, well maintained, and appropriately presented.

Significant improvements have been made in relation to infection prevention and control (IPC). An infection prevention and control lead is now assigned on every shift, with a checklist completed each shift to ensure standards are consistently met. In addition, an infection prevention and control champion had been appointed across the site to provide oversight and support.

Infection prevention and control leads, including housekeeping staff, now attend daily huddles and flash meetings to review and follow up on any IPC concerns promptly. Infection prevention and control guidance has been incorporated into the staff induction programme to ensure new staff are aware of their responsibilities from the outset.

A structured deep‑clean programme has also been implemented for kitchens, laundry facilities and courtyard areas, further strengthening environmental hygiene and maintenance arrangements.

Staff adhered to infection prevention and control principles, including effective hand hygiene. Regular infection prevention and control audits are now in place, including audits of cleanliness standards and hand washing practice. Hand washing guidance was displayed in clinic rooms. Nurses were advised in supervision and team meetings to wash their hands prior to medication rounds and before the administration of any intramuscular medication. Mandatory infection prevention and control training was completed by all staff, achieving 100% compliance at the time of inspection.

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.

Staff followed good practice in medicines management and adhered to national guidance. We checked Jubilee and Clent clinic rooms were clean, well maintained, and suitable for the safe management of medicines. The service stored and managed all medicines and prescribing documentation safely. Medicines were kept securely in locked cabinets within ward clinic rooms or in designated medicines fridges.

Staff reviewed each patient’s medicines regularly and provided appropriate advice to patients and, where appropriate, their relatives. Nurses we spoke with were able to explain how medicines were safely administered and disposed of. Medicines reviews formed part of multidisciplinary team meetings, ensuring coordinated and person‑centred care. Staff shared information about the purpose of medicines and possible side effects. Patients were actively involved in discussions about their medication and care planning.

An external pharmacist visited weekly. They conducted clinic checks across all three wards. The emergency medicines bags were also checked by the pharmacist and replenished as required. The service maintained an active action log to monitor and address any issues identified during these audits, demonstrating effective oversight and continuous improvement.

The service ensured that people’s behaviour was not controlled through the excessive or inappropriate use of medicines, which supported safe, ethical, and person‑centred care.