The Priory Hospital Altrincham

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Good.At this assessment the rating has changed to Requires Improvement.

Requires improvement:This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

At this assessment, the service was in breach of legal regulations in relation to safe care and treatment (Regulation 12) and staffing (Regulation 18).

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.

We do not always have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

• Staff did not always understand the Duty of Candour. Duty of Candour action was not recorded in the Datix listing report for incidents. This meant the service did not know which incidents required action under the Duty of Candour regulation and were unable to accurately audit and report Duty of Candour data.
• There were 7 incidents each recorded for Tatton and Dunham wards. None of these incidents were entered in the Datix entries record log and therefore had no rating for harm or impact. We identified that for one patient Datix entries were recorded in daily care records however these were not logged in the Datix listing report. This meant that incidents may not have been reviewed through the provider’s formal governance processes, limiting opportunities for shared learning and reducing the effectiveness of patient safety monitoring and improvement.
• Lessons were learned from recorded incidents. Learning was shared with staff via monthly Lesson Learned bulletins. This showed both site and Priory-wide learnings. The April 2025 bulletin showed actions in relation to data breaches, use of restraint, and formal complaints.
• Care records did not consistently include action taken or decision-making processes, following incidents and their review by the multidisciplinary team.
• The provider had a Healthcare Patient Safety Summary of Learning and Actions publication which was shared with staff monthly. The May 2025 publication included sharing learning about potential ligature anchor points.
• Staff we spoke with knew what incidents to report, how these related to risk, and how to report them.
• Lessons learned was a standard agenda item for the ward governance meetings. The multidisciplinary team attended these meetings.
• Ward management and ward physician meetings were held fortnightly and discussed areas such as clinical governance and patient safety. However, these were informal meetings with no formal minutes recorded.
• Incident escalation and debrief were discussed at ward meetings. Staff told us they were debriefed and received support after a serious incident.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

• The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could be safely met.
• Planned discharges were monitored in the daily hospital senior leadership meeting for each ward.
• Stakeholders and commissioners reported that the service was responsive and effective.
• Discharge arrangements and continuity of care were not always effective, with some examples of poor communication with patients and other providers during transfers and discharges. For example, 1 patient reported that they had not been provided with information by the provider when they transferred to another service.
• Patient feedback about discharge arrangements was mixed. Some reported having structured treatment plans to support discharge, while others felt uninformed or uninvolved in the process.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

• Staff demonstrated knowledge of the provider’s safeguarding procedures, and we saw evidence of appropriate actions being taken to safeguard patients.
• Safeguarding was a standing agenda item at Clinical Governance Committee meetings. Minutes showed discussions included safeguarding reports, training compliance, and communication with the police regarding historical abuse reporting procedures.
• Staff were trained in safeguarding. Training compliance for safeguarding adults levels 1 and 2 for Tatton ward was 89%, and for Dunham ward 96%. Training compliance for safeguarding children levels 1 and 2 for Tatton ward was 89%, and for Dunham ward 96%. Safeguarding combined: adults and children level 3 at 100% for Dunham ward and 96% for Tatton ward. Staff knew how to make a safeguarding alert and did that when appropriate.
• Staff could describe safeguarding concerns they had identified, and the actions taken. They demonstrated an understanding of patient vulnerabilities, including the use of mental capacity assessments and best interests decision-making processes.
• Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.
• There were no designated visitor rooms on the wards. However, staff followed safe procedures for children visiting the service, and arrangements could be made for a room in the main building to be used if required.
• Blanket restrictions records were kept for each ward and were a standing item agenda on the monthly Clinical Governance Meeting agenda. We saw that restrictions were reviewed at each meeting and changes were made during the previous 6 months
• Staff received accredited training in physical intervention. Restraint, restrictive practice and blanket restrictions were recorded and reviewed.
• There were no dedicated ward visiting facilities, with visits needing to take place in communal areas or bedrooms, limiting privacy and dignity. When children were not allowed on the ward, families could use a room in the main hospital building, however this was not purpose-designed or child-friendly.

We do not always work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

• On Tatton Ward, we identified gaps in monitoring following the administration of rapid tranquillisation medicines. Physical health observations were not consistently carried out in line with the provider's Standard Operating Procedure: Post Rapid Tranquillisation/PRN Monitoring, or in accordance with relevant National Institute for Health and Clinical Excellence guidance (Quality Standard QS154). Physical health observations were inconsistently carried out for patients on Level 3 enhanced observations, where National Early Warning Score (NEWS2) recordings should have been completed four times per day. Where patients had refused to permit full NEWS2 observations, minimum recordings, such as respiratory rate or level of consciousness, were not consistently documented. In the last 3 months from December 2024 to April 2025, there had been 19 uses of rapid tranquilisation on Tatton ward. We reviewed audits of rapid tranquilisation and identified that physical observations for 8 of 19 incidents had not been completed as per the provider policy.
• On Dunham Ward, physical health monitoring for patients with significant or enduring health conditions was not consistently undertaken or noted in care records. For example, we identified instances where test results fell outside normal parameters over several days and there were gaps in the daily monitoring of these. We also identified an instance where NEWS2 scores of 6 or below were recorded without any clearly documented nursing follow-up or clinical actions, which would have been expected in line with national guidance and the provider's policy.
• Observations for patients receiving enhanced levels of observation were not always completed as required. We identified gaps in care records on Tatton ward where Level 3 observations were not subject to daily review, as required by the provider's Supportive Observation and Engagement Policy.
• We reviewed 6 care records, including risk assessments and management plans. All assessments were in place and generally of good quality. However, we found one instance where a patient's neurodivergent needs were not reflected in the risk assessment. This meant that the patient's individual needs were not fully considered in their care planning, which could increase the risk of inappropriate or unsafe care and compromise their safety and well-being.
• There were 38 incidents of restraint in the 6 months prior to the assessment, most of which occurred on Tatton Ward. Restraints were used in response to incidents involving self-harm, violence or aggression, absconding, or for care-related reasons.

We do not always detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care. 

• Staff carried out regular risk assessments of the care environment. Ligature risk assessment tools had been completed for Tatton and Dunham wards in July 2024. These were lengthy documents with different documents for different rooms and ward areas, including gardens, this meant new staff would not have the time to read the whole document. It was not clear from the document how staff should manage the risks in the environment as the document states “Locally manage through local procedure” against all identified risks. The ligature risk assessments were incomplete and did not consistently cover all areas of the ward environment or facilities.
• Each ward office displayed a ligature risk heatmap. The heatmap graphics for each ward were not purpose-designed and used small print. This meant they were unclear, and the location of ligature cutters were not clearly indicated.
• On Tatton Ward, we identified several potential ligature anchor points and unsecured items in an unlocked activity room. At the time of inspection, the door lock to this room was broken; however, we were told that repairs were being arranged on the same day and the provider allocated a member of staff to supervise access to this room. Further action was taken on the day of inspection to remove a risk identified in the female lounge.
• Each ward had multiple Blind Spot Audit tools completed for the ward areas, ward gardens, and hospital grounds. However, each entry stated only, ‘Manage identified blind spot through local procedure,’ without providing specific details. The documents did not clearly outline how staff should manage the risks associated with the identified blind spot areas. This meant staff were not consistently mitigating the risk of the blind spots.
• Clinic rooms were well equipped, including emergency drugs that were regularly checked by staff. Resuscitation equipment was located in the Dunham ward clinic and was accessible to both Dunham and Tatton wards. However, there were gaps in the clinic room cleaning audits for both wards, and cleaning records were not retained on Dunham Ward, limiting the ability to audit cleanliness effectively.
• Ward staff had full access to alarms and patients had easy access to nurse call systems. Additional alarms were available for visitors to the ward.
• Technology was used to support privacy, with white noise machines installed above offices and therapy spaces to support privacy and maintain confidentiality during conversations.
• The mandatory 6 monthly fire risk assessment was up to date, and our inspection team was informed on the day of the site assessment about the fire test time and day. Fire safety training compliance was Dunham ward 68% and Tatton ward 70%.

We did not always make sure there were enough qualified, skilled and experienced people, who receive effective support, supervision and development working together effectively to provide safe care that meets people’s individual needs. 

• There were staff vacancies on both wards: Tatton ward had a social worker vacancy, and Dunham had a Cognitive Behavioural Therapist vacancies. Stakeholders told us that there was no psychologist provision on Tatton ward. Staff turnover rates were 4% for Dunham ward, and 5% for Tatton ward. Staff sickness rates were 2% for Dunham ward, and 5% for Tatton ward.
• Managers had calculated the number and grade of nurses and healthcare assistants required. Tatton ward had full establishment, with a calculation for additional staff to be allocated when enhanced observations required this. Dunham ward had full establishment for nurses, and 2.5 FTE health care assistant vacancies.
• Staffing levels were adjusted to take account of patient numbers and case mix. Staff were transferred between wards to cover when required, for example on the day of our assessment Tatton ward had staffing numbers above their requirements and so a nurse was transferred to Dunham ward.
• Managers deployed agency and bank nursing staff to maintain safe staffing levels when necessary. Bank and agency staff usage was low - over the 6 months preceding the inspection, bank usage was 1.5% for Dunham ward, and 2.4% for Tatton ward. Agency staff usage over the 6 months preceding the inspection was 3.4% for Dunham ward, and 4.3% for Tatton ward.
• We reviewed agency induction records for Tatton and Dunham wards. For Tatton ward we reviewed agency induction records for the weeks commencing 21 May 2025 and 13 May 2025. Of 10 records for agency staff working over the timeframe we reviewed, 2 records were fully completed. One agency staff member did not have an induction checklist available to review, and the remaining 7 induction checklists were not completed consistently or in full. For Dunham ward we reviewed agency induction records for 14, 17, 18, and 22 May 2025. Of 5 records for agency staff working over the timeframe we reviewed, 3 records were fully completed, and the remaining 2 induction checklists were not completed consistently. This meant we could not be assured that people had the knowledge or skills to support patients on the ward.
• We were told, and records confirmed, that an insufficient number of registered nurses on night duty had led to delays in administering medicines. In one case, we reviewed medicine charts and saw that a patient did not receive their prescribed medicine on time. This resulted in a significant impact on the patient.
• Staffing levels supported regular one-to-one time between patients and their named nurse. However, 2 patients reported that staff were not always available to assist with their support needs.
• There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely (and staff had been trained to do so). Staffing levels were adjusted in response to increases in patient numbers or higher levels of acuity on the wards. Managers told us requests for additional staff were supported.
• There was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency. However, patients on Dunham Ward expressed a wish for greater access to consultant doctors.
• Staff had received and were up to date with appropriate mandatory training with an overall compliance of 81% for Dunham ward. However, there were several mandatory training areas with less than 75% compliance, these were: Deprivation of Liberty Safeguards (DOLs) 73%; Fire Safety 67%; Infection Prevention Control 59%; IT Security 74%; Mental Capacity Act 68%; Reducing Restrictive Intervention Breakaway Training 63%; Mental Health Act 68%.
  For Tatton ward mandatory training compliance was 81%. However, there were several mandatory training areas with less than 75% compliance, these were: Deprivation of Liberty Safeguards (DOLs) 65%; Fire Safety (eLearning) 70%; Infection Prevention Control 61%; IT Security 74%; Mental Capacity Act 70%; The Mental Health Act 74%.
  All staff on both wards had completed Oliver McGowan autism training level 1. No staff had completed the Level 2 training. However, Level 2 training was being rolled out nationally.
• The provider’s supervision policy stated that nursing and allied healthcare professional staff should have monthly supervision. Dunham ward staff supervision compliance was 100%. Tatton ward supervision compliance was 81%.

We do not always assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

• Staff did not adhere to infection control principles. Staff were not always bare below the elbow, staff had long sleeved clothing on including jumpers and jackets. Staff had watches and jewellery on. Staff were not following the provider’s Standards of Dress, Uniform and Personal Appearance policy in this respect.
• We identified gaps in daily cleaning records for clinic rooms on both wards and for the phlebotomy room on Dunham ward. Some gaps were attributed to housekeeping staff being on leave or unavailable. Records from previous months were not available for audit on Dunham ward, as the records had not been retained.
• Most ward areas were clean, had good furnishings, and were well-maintained.
• Wards had a lead health care assistant with a specific focus on infection prevention and control.

We did not always make sure that medicines and treatments were safe and met people's needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

• Staff did not always follow prescribing instructions when administering medicines, and we found that medicines were not consistently given within the prescribed intervals. We were told, and saw evidence for one patient, that `as needed' physical health medicines were not always administered in a timely manner.
• Staff did not consistently review the effects of medication on patients' physical health in line with NICE Quality Statement 4: Physical Health After Rapid Tranquillisation, particularly for those prescribed high-dose antipsychotic medication. For example, we found gaps in care records relating to physical health monitoring following the administration of rapid tranquillisation, and provider audits also identified that physical observations were not consistently completed. As a result, we could not be assured that this monitoring was carried out reliably.
• Patients who had received rapid tranquilisation had this documented in their notes however, outcomes and National Early Warning Score (NEWS2) observations were not consistently recorded.
• Staff mostly followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and followed national guidance. We saw that controlled drug registers were completed accurately and that controlled drugs were correctly stored and checked.
• Staff told us, and records confirmed, that staff were trained and had been competency assessed to manage medicines. Compliance with Safe Handling and Medicines training was 100% for Dunham ward, and 80% for Tatton ward.
• Medicines were stored securely and in areas that were being temperature monitored.