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

The Priory Hospital Altrincham

Overall: Requires improvement read more about inspection ratings

Rappax Road, Hale, Altrincham, WA15 0NU (0161) 904 0050

Provided and run by:
Priory Healthcare Limited

All Inspections

During an assessment of Acute wards for adults of working age and psychiatric intensive care units

We rated the acute wards for adults of working age and psychiatric intensive care unit as Requires Improvement due to several concerns regarding the delivery of safe and person-centred care on Tatton and Dunham wards. Physical health observations were not consistently completed in accordance with patient care plans or the provider's Standard Operating Procedure. Care plans sometimes failed to reflect individual needs, particularly for patients with physical health conditions, neurodiverse diagnoses, or specific accessibility requirements, and did not consistently include the patient voice or evidence of their involvement in the planning process.

On both wards, the arrangements for medicine dispensing did not protect patient confidentiality. In addition, staff were not consistently adhering to key hospital policies, including those relating to dress code, smoking, and cleaning audits, and managers did not ensure these policies were fully implemented. Induction records for agency staff working on both wards were also incomplete, limiting assurance around the preparedness and safety of temporary staff.

We saw some positive and respectful interactions between staff and patients on both Tatton and Dunham Wards. Staff were supportive and responded to patients in a kind and sensitive manner.

The service provided a good range of activities, and had pleasant, accessible grounds that benefited patients and families visiting the hospital.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

  • 96% of staff on Dunham ward had received training in the Mental Health Act.
    87%of staff on Tatton ward had received training in the Mental Health Act.
  • Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.
  • Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were, and staff told us that the administrator made regular contact via email with updates and any Mental Health Act actions required.
  • The provider had relevant policies and procedures that reflected the most recent guidance. However, not all polices were updated in accordance with policy review due dates. For example, Section 2 Admissions - Receipt & Scrutiny of Detention Papers, Section 3 Admissions - Receipt & Scrutiny of Detention Papers, Section 4 Emergency Admissions - Receipt & Scrutiny of Detention Papers, had review dates of 4 November 2024; Section 5(2) Registered Medical Practitioner or Approved Clinician Holding Power - Receipt & Scrutiny of Detention Papers, had a review date of 27 October 2024; Nurse's Holding Power Section 5(4), had a review date of 28 October 2024; and Explanation of Rights under Sections 132 and 130D, had a review date of 12 January 2025.
  • Patients had easy access to information about independent mental health advocacy, and we saw advocates visiting the wards.
  • Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done so.
  • Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted.
  • Staff requested an opinion from a Second Opinion Appointed Doctor when necessary.
  • Staff did regular Mental Health Act legislation audits, and these were reported as a standing item in the Clinical Governance Committee meetings.

Mental Capacity Act

  • 96% of staff on Dunham ward had training in the Mental Capacity Act.
    83% of staff on Tatton ward had received training in the Mental Capacity Act.
  • The provider had a policy on the Mental Capacity Act. Staff were aware of the policy and had access to it.
  • Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.
  • Staff knew where to get advice from within the provider regarding the Mental Capacity Act.
  • Staff took all practical steps to enable patients to make their own decisions.
  • For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. Examples included assistance with personal care and the need for antibiotics.
  • When patients lacked capacity, staff made decisions in their best interests. Staff told us about best interest decisions made in relation to vulnerable patients' access to social media and use of mobile phones on the ward.

During an assessment of Child and adolescent mental health wards

We rated the ward for children and adolescents as requires improvement because parents, young people and stakeholders told us that there was a lack of psychological interventions on the ward and there was no psychologist in the team, and there had been significant staff turnover with consultant psychiatrists, the ward manager and hospital managers leaving. There was a lack of consistency with staffing, with bank, agency and staff from other wards working on the ward which meant young people did not have consistency of support and found it difficult to follow their agreed plans with staff they were not familiar with.

Agency staff were not always supported on the ward, they did not always have an induction into the ward or given clear guidance on how best to support the young people.

Care records did not always reflect the needs of the young people. Handovers did not always include an accurate summary of events. Handover and daily allocation records were not always completed fully.

Staff were not following the dress code policy and managers did not ensure this was fully implemented.

However, staff received regular supervision and training.

We saw examples of staff communicating positively and compassionately with young people.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

  • 94% of staff had received training in the Mental Health Act.
  • Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.
  • Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.
  • The provider had relevant policies and procedures that reflected the most recent guidance. However, there were several Mental Health Act policies and procedures that were not updated in accordance with policy review dates.
  • Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.
  • Patients had easy access to information about independent mental health advocacy. We saw information on display on the ward, including details of the advocates and a “you said, we did” display.
  • Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.
  • Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.
  • Staff requested an opinion from a second opinion appointed doctor when necessary.

Mental Capacity Act

  • 94% of staff had had training in the 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. Staff were aware of the policy and had access to it.
  • Staff knew where to get advice from within the provider regarding the Mental Capacity Act.
  • Staff took all practical steps to enable patients to make their own decisions.
  • The provider had a Gillick competency policy for consent in healthcare settings (a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment without the need for parental consent or knowledge).

During an assessment of the hospital overall

  • We assessed Priory Hospital Altrincham from 20 to 22 May 2025.
  • We assessed the service due to the length of time since it was last inspected and following concerns being raised about the service.
  • The Priory Hospital Altrincham 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. However the service did not have a Registered Manager in place, the previous Registered Manager had left the role, and the current Hospital Director was leaving their role at the end of May 2025.
  • We visited the following wards as part of the assessment:
  • Rivendell Ward, a 15 bed ward for young people, of all genders with an eating disorder. There were 5 people on the ward at the time of the on-site assessment.
  • Tatton ward, a 19 bed acute admission ward for adults of all genders. There were 19 people on the ward at the time of the on-site assessment.
  • Dunham ward, a self - funded 24 bed acute admission ward for adults of all genders with mental health needs or substance misuse needs. There were 23 people on the ward at the time of the on-site assessment.
  • At this assessment we identified breaches of regulations 9 Person Centred Care, 12 Safe Care and Treatment, 17 Good Governance and 18 Staffing.
  • 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 Child and adolescent mental health wards where we assessed 33 quality statements.

    • Requires Improvement

    We rated the service as Requires Improvement. In the acute wards for adults of working age and psychiatric intensive care units, we found 4 breaches of regulations in relation to: reasonable adjustments for patients with protected characteristics, physical health monitoring, assessment and mitigation of environmental risks, oversight and implementation of policies and procedures and ensuring staff receive an induction into the ward they are working on.

    In the child and adolescent mental health ward we found 3 breaches of the regulations in relation to lack of psychology and individual formulation and reasonable adjustments for young people, inconsistencies in handovers and record keeping, oversight and implementation of policies and procedures and ensuring staff receive an induction into the ward they are working on.

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

    14th March 2019

    During an inspection looking at part of the service

    • The inspection of The Priory Altrincham was unannounced and was prompted by notification of an incident following which people using the service sustained serious injuries. This inspection was conducted to ensure that at the time of this inspection, patients were receiving safe care and were protected from avoidable harm. This inspection looked at the key questions relating to safe and well led and did not focus on the specific incident as this is subject to a separate additional investigation. We did not look at the key questions of caring, effective and responsive at this inspection. This inspection was not rated.

    • The hospital followed national guidelines on cleaning standards and monitoring procedures to provide and maintain a clean and appropriate environment to prevent and control healthcare associated infection. Ongoing refurbishment plans had seen improvements to the ward environments. Regular environmental quality checks were conducted and patients could discuss and resolve environmental issues in community meetings.

    • The ward environments were subject to constraints in observation. These were managed and risks mitigated with the use of observation and individual risk management planning.

    • Accessible emergency equipment was available to staff and was maintained appropriately. Medicines were dispensed and stored securely and audits were undertaken to ensure safe practice.

    • Staffing levels were determined using a staffing ladder model. Staffing was reviewed regularly to ensure there was enough staff with the relevant skills to deliver safe patient care. Patients were supported by a skilled multidisciplinary team of staff which included nursing, psychiatric, psychological, occupational and dietetic support. Staff were supported to deliver effective care and treatment they told us that they received meaningful and timely supervision and were supported to maintain their professional skills and experience.

    • Safeguarding processes were in place which reflected national guidance, and understood by all staff. There was a clear structure of reporting and responsibility for safeguarding adults and children. Any concerns relating to adult and child protection were communicated to the relevant protection agencies.

    • There was an established governance structure with a defined hierarchy of reporting and decision making within the service. There were clear systems of accountability and senior managers were actively involved in the operational delivery of the service. There was a clear statement of visions and values, staff knew and understood the vision, values and strategic goals of the service. Processes and systems of accountability and governance were in place and performance management and quality reporting was clearly set out. Risks were identified and monitored. Performance issues were escalated and discussed at relevant governance forums and action taken to resolve concerns.

    • All staff we spoke with were positive about their roles and staff felt able to raise concerns without fear of victimisation and spoke positively about the organisation. They told us that they felt valued, had input into the service and were consulted and involved in service quality developments.

    • The service was committed to improving the services on offer and continually improving the quality of care provided to patients.

    12th and 13th November 2018

    During a routine inspection

    We rated The Priory Altrincham as good because:

    Patients using the service told us that they were treated with dignity and respect and described the staff as caring and helpful. We observed that staff took time to communicate with patients in a respectful and compassionate manner and patients were empowered to become active participants in their care.

    All patients underwent an assessment of need, care plans were holistic and recovery oriented and included physical health assessments, these were completed in collaboration with the patients, progress was regularly reviewed.

    Regular multidisciplinary meetings were held and attendance by outside agencies was encouraged. Families and carers were involved in this process where appropriate. Advocacy services were accessible and available to support patients.

    The hospital followed national guidelines on cleaning standards and monitoring procedures to provide and maintain a clean and appropriate environment to prevent and control healthcare associated infection. There was an established cleaning regime, wards were generally clean although refurbishment work was causing some disruption to the cleaning regime. Clinic rooms were fully equipped. Emergency equipment was accessible to all and was maintained appropriately. Medicines were dispensed and stored securely and audits undertaken to ensure safe practice.

    The ward environments were effectively managed and risks mitigated with the use of observation and individual risk management planning. Regular environmental quality checks were conducted and patients could discuss and resolve environmental issues in community meetings.

    Patients were supported by a skilled multidisciplinary team of staff which included nursing, psychiatric, psychological, occupational and dietetic support. Treatment practices were based on nationally recognised guidance.

    Safeguarding processes were in place which reflected national guidance, and understood by all staff we spoke with. There was a clear structure of reporting and responsibility for safeguarding adults and children. Any concerns relating to adult and child protection were communicated to the relevant protection agencies.

    Restrictive practices were reviewed regularly and patients were involved in the process. Regular patient surveys and community meetings informed improvements in patient care across the hospital.

    Staff were trained in and had a good understanding of the Mental Health Act and Mental Capacity Act. Staff followed local procedures and support was available from a mental health act administrator. Patients were given information and support to ensure appropriate representation and aid understanding of their rights.

    There was an established governance structure with a defined hierarchy of reporting and decision making within the service. There were clear systems of accountability and senior managers were actively involved in the operational delivery of the service. There was a clear statement of visions and values, staff knew and understood the vision, values and strategic goals of the service.

    Staff we spoke with were positive about their roles and were positive about service development. Staff felt able to raise concerns without fear of victimisation and spoke positively about the organisation. They told us that they felt valued, had input into the service and were consulted and involved in service quality developments.

    11 and 12 January 2016

    During a routine inspection

    We rated The Priory Hospital Altrincham as good because:

    • wards were safe for patients and staff did risk assessments to identify and mitigate any risks the environment posed. There were robust procedures to ensure safe administration and control of medication. Adequate staffing levels were maintained and occasionally exceeded
    • care plans were holistic, recovery-orientated and included patients’ views. A comprehensive therapy programme was part of the treatment provided. Patients’ physical healthcare was monitored throughout their stay. Staff started to plan for discharge on admission. Where patients were detained under the Mental Health Act 1983, their rights were protected and staff complied with the code of practice
    • staff monitored incidents and lessons learned from incidents were shared with staff regularly. There were regular comprehensive audits of the requirements of the Mental Health Act and the Mental Capacity Act. Staff audited the quality of care regularly and took action to improve services based on the findings
    • staff were polite, friendly, caring and respectful. Patients told us staff had a lot of time for them. Staff had a good understanding of patients’ needs and involved relatives in patients’ care. Patients had the opportunity to give feedback about their care and treatment
    • there was a clear governance structure that supported the safe delivery of services. There were good lines of communication between ward staff and senior managers. Staff knew how to use the whistleblowing process and felt able to raise concerns. Staff did quality walk arounds to ensure good quality services were maintained.

    However:

    • staff were not following the hospital policy for children visiting the wards
    • there were no cleaning schedules on Rivendell ward. This meant ward staff had no record of the ward areas cleaned
    • staff told us that before December 2015, clinical supervision did not take place regularly.

    15 November 2013

    During a routine inspection

    The Priory Altrincham provided care for patients who needed support with their mental health, specialising in the management and treatment of a wide range of mental health conditions and addictions. These include obsessive compulsive states, eating disorders, addiction treatments and all major acute psychiatric illnesses.

    We found that care was provided in a clean, organised but relaxed environment.Treatment was provided in 48 single rooms on three units within the hospital. Individual bedrooms and public areas had fixtures and fittings that been appropriately risk assessed for ligature points.

    Patients we observed were treated with dignity and respect and were able to share their views and comments with the staff.

    Staff had access to detailed policy guidance in relation to both child protection and safeguarding vulnerable adults.

    We found The Priory Altrincham had systems in place to ensure staff were safely and effectively recruited and employed.

    We found robust systems in place to monitor the quality of the service provided. All policies and guidance were currently up to date and were reviewed on an annual basis.

    We spoke to two patients who told us they were fully consulted on their care and were happy with the way they were being cared for.

    We spoke with four members of staff who told us they felt supported and enjoyed their job within the hospital.

    Patients told us; "I enjoy the group sessions it works for me". "I get the support I need and know I can always chat to someone at any time of the day or night which is a comfort".

    20 September 2012

    During a routine inspection

    The Priory had consent policies and procedures in place which reflected current guidance on informal and formal consent. This enabled patients, their relatives or representatives, to give appropriate consent to care and treatment.

    Care plans were comprehensive and demonstrated clear assessment of the needs of individual patients. On admission a 72 hour initial care plan was implemented to allow a full assessment of need to be carried out, once the patient had the opportunity to adjust and settle into the ward.

    We found that care was provided in a clean, organised but relaxed environment. Risks assessments had been undertaken for all aspects of health and safety. Individual bedrooms and public areas had fixtures and fittings that been appropriately risk assessed for ligature points. Patients had access to large gardens and external designated smoking areas.

    Patients told us : 'I feel safe and secure here, the staff are really trying to help me', 'Everything is explained, you don't have to feel stupid, they make sure that you know what is happening and why'.

    Mental Health Act Commissioner reports

    Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

    Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.