Barnt Green

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last assessment we rated this key question requires improvement. The service was in breach of
legal regulation in relation to Regulation 17 Good Governance. The provider has made improvements
and is no longer in breach of regulation. The provider now has governance systems and processes in
place to safely support Jubilee patients to seclusion. At this assessment the rating has changed to
good.
Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood
the provider’s vision and values and how they applied to the work of their team. Staff felt respected,
supported and valued. Performance and risk were generally managed well. Teams had access to the
information they needed to provide safe and effective care. Staff collected and analysed data about
outcomes and performance. They used this to identify improvements.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. We saw service vision and values posters displayed around the service.

The provider’s senior leaders had effectively communicated the provider’s vision and values to frontline staff. The Priory Plan 2026–2030 set out the service’s strategic goals, including supporting the whole care journey, being the provider and employer of choice, strengthening a culture of belonging and leading in digital innovation. The provider introduced refreshed values for 2026–2030, focused on living your life, putting people first, positivity, support, excellence and integrity.

Staff had opportunities to contribute to discussions about the service strategy for Barnt Green hospital. Staff felt listened to, respected, supported and valued. Staff we spoke with were aware of how to raise their views and ideas through line management, team meetings or staff champions.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had a good understanding of the services they managed and could clearly explain how teams worked together to provide good care. The hospital director, ward managers and deputy ward managers demonstrated clear oversight of ward performance, including what was working well and the progress made since the last inspection. This was consistently reflected in staff interviews and ward governance meeting minutes.

Staff told us that leaders were visible within the service and approachable for both staff and patients. Staff were able to name senior leaders, and we observed leaders present on the wards during the assessment. Senior managers had completed a ‘knowing each other’ form, which captured personal or meaningful information to help staff get to know them. These forms were shared with ward staff and stored within the safe wards folder.

Staff we spoke with were positive and complementary about managers. Local leaders said the staff group had developed more confidence in their roles since the last assessment.

Leadership development opportunities were available, including opportunities for staff. These included provider‑led leadership skills training, mentoring and coaching, support for staff stepping into senior or acting roles, and development opportunities through supervision and appraisal. Leaders spoke positively about the Priory management leadership fundamental training programme level 3, and Inspirational leadership level 4.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us local leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns.

The service used a patient satisfaction survey to gather feedback. In January 2026, 13 surveys were issued, 6 were returned and 5 patients declined to participate. Overall, 70% of respondents strongly agreed with the survey questions. The highest scores related to feeling supported to live their lives during admission and on discharge, feeling safe around other patients, and knowing who to speak to if they were unhappy, such as their key worker, advocate or the hospital director.

The last staff survey was completed in April 2025. The provider issued 125 surveys, of which 48 were returned, giving a response rate of 38%. This represents a relatively low level of engagement. The survey identified several areas for improvement, including staff empowerment, overall job satisfaction, and support from line managers. Areas that scored less strongly included communication, regional leadership visibility and diversity and inclusion.

The service had 4 Freedom to Speak Up champions, 1 on each ward and 1 representing reception staff. Posters displaying Freedom to Speak Up contact details were visible throughout the service. Staff were aware of the provider’s whistleblowing policy, and whistleblowing information was accessible across the hospital. Staff told us they felt respected, valued and able to raise concerns without fear of discrimination.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

As part of Priory’s Plan for 2026–2030, a strategic goal is to embed a culture of openness, inclusion and trust, where everyone feels they truly belong. The service is currently launching the Patient and Carer Race Equality Framework (PCREF) learning module. Once the learning module has been completed across the site to support the implementation of PCREF, the service will invite applications for Equality and Diversity Champion roles.

Staff had access to equality, diversity and inclusion networks, including REACH, LGBTQ+, Disability and Difference, Men That Talk, Menopause, Neurodiversity, Parents’ and women’s network.

Some staff told us they were able to work flexibly to support personal circumstances such as caring responsibilities and health issues.

The provider undertakes equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Since the last assessment, the provider had reviewed its seclusion policy across Priory hospitals, including the use of seclusion in non-designated areas. Governance arrangements now require a 24‑hour report and a team incident review for all episodes of seclusion in non-designated areas. Staff told us these changes had increased their confidence in the use of seclusion, particularly when transferring patients from Jubilee ward to Clent ward for seclusion.

There was a clear framework of what must be discussed at monthly patient safety, safeguarding and clinical governance meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Themes identified through meetings, along with agreed actions and changes to practice, were communicated to staff and embedded into ward practice. Monthly patient safety bulletins were displayed across the service. These bulletins were produced in an easy‑read format and included feedback on the number of incidents, emerging themes and the top three key learning points. The bulletins also highlighted learning updates, examples of good practice, divisional learning, policy updates, areas for improvement, compliments received, and learning from complaints and team incident reviews.

Staff undertook or participated in local clinical audits. These included, for example, infection prevention control, care plans, Mental Health Act, ligature points, blind spots, safeguarding and blanket restrictions audits. The audits were sufficient to provide assurance and staff acted on the results when needed.

Staff demonstrated a clear understanding of the arrangements for working collaboratively with other teams, both within the provider organisation and externally, to ensure patients’ needs were met. There were established and effective lines of communication and positive working relationships between the crisis and home treatment teams, local authorities safeguarding teams, NHS providers, and commissioners, which supported coordinated care and continuity of services.

Performance and risk were generally managed effectively, with appropriate oversight and governance processes in place. However, the service faced ongoing challenges related to the high acuity of patients, which required additional staffing on some wards. Leaders were aware of these pressures and took action to mitigate risk to ensure consistent compliance with staffing expectations.

Staff maintained and had access to a ward-level risk register, ensuring risks were identified, recorded and reviewed appropriately. Staff at ward level understood how to escalate concerns when required, and the risks raised by staff aligned with those documented on the risk register, demonstrating consistency and transparency in risk management processes.

The service had an established Business Contingency Plan to ensure continuity during emergencies, such as adverse weather events or loss of internet access.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. The provider was using new information technology for staff recruitment applicant tracking systems; and staff rostering systems with tools for management of safe staffing, including bank and agency staff.

Information governance systems included confidentiality of patient records. All staff received mandatory training in data protection and confidentiality with training compliance at 100%. The service provided patient with welcome leaflets and booklets outlining how personal information is managed securely and how confidentiality is upheld, ensuring patients are informed about the protection of their data.

Leaders and managers had access to information on electronic dashboards to support them with their management role. This included information on the performance of the service, staffing and patient care.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders engaged with external stakeholders such as commissioners, local authorities Healthwatch, and Integrated Care Boards to strengthen oversight and drive improvement. Leaders worked closely with other Priory services sharing best practice.

External healthcare professionals were invited to multidisciplinary meetings to review patients ongoing care and treatment.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. Leaders can attend patient community meetings if requested and were available to meet with patients on request at their convenience. The senior management team conducted weekly walk-rounds on wards, providing patients with regular opportunities to meet the team and share feedback.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service demonstrated a positive learning culture, with staff and leaders using incident themes, feedback and outcome data to inform improvements.

The provider implemented a nine‑month quality improvement project to reduce the use of enhanced patient observations, initially on Clent ward, from January to September 2025. During this period, the number of enhanced observations reduced from 6,094 to 726, representing an approximate 88% reduction. The project has since been extended to Jubilee ward. Through this programme patients benefited from reduced levels of observation, enabling more individualised and patient‑focused care. Trauma‑informed care approach was successfully introduced on the Clent ward. The project strengthened multidisciplinary working and led to positive outcomes for staff wellbeing. Benefits for staff included reduced work‑related injuries and sickness absence. These improvements were supported by regular debriefs and safety huddles, reflective practice, supervision, and access to a trained mental health first aider.

Staff introduced a safe, person-centred approach to managing menstrual care on Clent ward. Menstrual products were provided based on individual patient’s risk assessments, with dedicated menstrual champions on the wards. Staff discussed menstruation as part of patient risk support during our visit.

The service is working towards accreditation by the Royal College of Psychiatrist for Psychiatric Intensive Care Units. Leaders said the initial assessment had been positive.