The Priory Hospital Altrincham

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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

Requires improvement: This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

At this assessment, the service was in breach of legal regulation in relation to good governance (Regulation 17).

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.

We do not always have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

• Staff knew and understood the provider’s vision and values and how these were applied within their teams. These were discussed in staff appraisals. The vision, ‘Making a real and lasting difference for everyone we support’, and the values, ‘Striving for Excellence, Being Supportive, Being Positive, Acting with Integrity, and Putting People First’, were routinely shared, including in email footers.
• At the time of our inspection, the hospital director was due to leave the service and an interim director from another Priory Group hospital had been appointed. Staff told us they had received limited information about the leadership transition and reported feeling unsettled and uncertain. They said they would have welcomed greater clarity and communication regarding the changes in senior leadership.
• Staff were not given the opportunity to contribute to discussions about the strategy for their service. For example, the rationale for changes to staffing arrangements, that introduced rotating staff across wards, had not been clearly communicated. Staff told us this led to uncertainty, and that a lack of clarity had resulted in speculation within teams. Some staff felt uncomfortable with the new arrangements where this had led to them working in areas where they had less experience or confidence.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

• Leaders had the skills, knowledge, and experience needed to carry out their roles effectively. Staff gave positive feedback, highlighting recent improvements in the service’s governance and leadership.
• Leaders were described as approachable and visible within the service. For example, staff valued the hospital director’s informal Friday ward visits, which provided regular opportunities for informal conversations and visible leadership. Ward managers told us they felt supported by senior leaders and had good working relationships with them.
• Leaders demonstrated a strong understanding of the services they managed and could clearly explain how teams were working to deliver high-quality care. Ward managers and directors of clinical services had a detailed knowledge of their wards, including what was working well, areas of progress, and where further improvement was needed. Commissioners told us that ward managers had in-depth knowledge of their patients and that the service maintained high standards of care and treatment.
• Leadership development opportunities were available, including opportunities to undertake leadership courses.
• There had been significant changes within senior leadership, with two hospital directors leaving in the 12 months prior to the assessment and the current hospital director was also leaving, with a hospital director from another site arriving to provide interim cover. Staff described disappointment at another change in the hospital director, and managers described some anxiety expressed by staff about a further period of uncertainty.

We do not always create a positive culture where people feel that they can speak up and that their voice will be heard.

• Patients and carers did not always have opportunities to give feedback on the service they received in a manner that reflected their individual needs. There was no carer's survey for this service. Information was not available in other languages for patients whose first language was not English. This meant the service was not seeking feedback from all patients and carers. The Relative Satisfaction Survey Analysis 2022-2024 presented results at hospital level. This meant staff did not know the results for their specific service or ward to support them to make any changes.
• Managers and staff had access to patient feedback through community meeting minutes. However, actions were not consistently documented, and outcomes were not always recorded. This limited the ability to monitor whether changes had been implemented in response to feedback. The Clinical Governance Committee agenda included a standing item on Patient and Carer Experience, where feedback, complaints, compliments, and engagement were reviewed. Related actions were itemised and subject to ongoing monitoring. However, the healthcare patient satisfaction survey analysis was not broken down to ward level. This meant staff did not know the results for their specific service or ward to support them to make any changes.
• A staff feedback report showed responses across 15 domains, highlighting increases or decreases since the previous survey. Results were benchmarked against Priory Group averages, enabling staff to clearly see how their hospital was performing in comparison. The results of the most recent staff survey had lower scores in all sections showing poorer performance against the provider's national average scores. Areas that had reduced since the previous survey included the provider acting on concerns raised, regional senior leaders being visible and displaying the organisations values, teamwork, systems enabling staff to fulfil their role, work life balance and equality diversity and inclusion.
• The provider presented Freedom to Speak Up data for The Priory Group overall, so we were unable to assess reporting at the individual hospital level.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

• The provider had equality and diversity champions in place, and it promoted the 7As of the Authentic Allyship. This is an approach used by the provider to provide a framework for valuing equality, inclusion, diversity and fairness within the service.
• The provider had established `Thriving at Priory' SMART objectives to promote diversity, accompanied by clear messaging on zero tolerance for racism. Mechanisms were in place to support staff in raising concerns, including a dedicated diversity and inclusion email for escalating issues, a 24/7 independent and confidential bullying and harassment helpline, and access to a colleague assistance support line.
• Managers put reasonable adjustments in place for staff members to help them carry out their role.
• The provider was in the process of implementing the Patient and Carer Race Equality Framework (PCREF), there was an implementation document in place and a PCREF taskforce had been launched.

We do not always have clear responsibilities, roles, systems of accountability or good governance. We do not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

• The provider's Local Arrangements for Safeguarding Adults at Risk procedure included key contact details for provider and local authority safeguarding leads. However, the section `Action to take if an allegation of abuse is made to you' does not reference the requirement to report Persons in a Position of Trust (PiPoT) concerns under the Care Act 2014, where applicable. This means the provider had not ensured that staff were aware of, or understood, the circumstances requiring a Persons in a Position of Trust (PiPoT) referral or the relevant procedures. Staff we spoke to did not demonstrate a working knowledge of PiPoT.
• Leaders did not ensure consistent adherence to the provider's policy on smoking and vaping. During the inspection, we observed staff smoking at the hospital entrance, which is a direct breach of the Priory Group's Smoking — Cigarettes & E-Cigs/Vapes policy. Staff also told us that cigarette smoking remained a persistent issue within the hospital grounds. This concern was further reflected in staff and patient meeting notes, which documented repeated discussions about cigarette butt littering around the premises, including near ward entrances—despite the provider's clear prohibition of smoking or tobacco use anywhere on hospital property, including entrances and outdoor areas. On Dunham ward, patients were observed vaping in their bedrooms, which contravenes the Smoke Free Hospitals policy. Staff did not consistently enforce this policy, and local managers failed to ensure its implementation. Additionally, carers complained that their relatives experienced negative impact on their health and wellbeing due to other patients' vaping.
• Leaders did not ensure that staff followed provider policies in relation to dress code on the wards. We saw staff were not bare below the elbow, some with long sleeved clothing, staff had nail varnish on and false nails. Staff had watches and jewellery on. We saw that staff were reminded of the dress policy in team meetings, however staff were not following the organisation's policy, and managers were not ensuring the policy was implemented.
• The provider had Mental Health Act policies and procedures that were not updated in accordance with policy review dates. The following policies were beyond their review dates: 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; Section 5(2) Registered Medical Practitioner or Approved Clinician Holding Power - Receipt & Scrutiny of Detention Papers; Nurse's Holding Power Section 5(4); and Explanation of Rights under Sections 132 and 130D.
• There were gaps in the daily clinic room cleaning records on both wards, covering both housekeeping and clinical care tasks. For example, in the phlebotomy room, only 8 of the 31 days in April 2025 were initialled as cleaned. On Tatton ward, clinical care cleaning tasks were recorded more consistently, but housekeeping tasks were documented on only 8 of the 31 days, with some entries incomplete. In addition, cleaning records were not retained on Dunham ward. This meant the service were not submitting expected audits and reviews, limiting the ability to effectively audit cleanliness, and therefore the provider could not be assured of the quality of care that the service was delivering.
• Clinical Governance Committee meetings took place bi-monthly and there was a standard agenda. However, there was no clear framework outlining the required content for discussion at ward, team, or directorate level meetings to ensure essential information was consistently shared, actioned, and followed through. For example, while the Clinical Governance Committee meetings included a standing agenda item for Patient and Carer Experience, patient feedback was not consistently reviewed. Similarly, ward community meetings and staff meetings did not always document actions in response to patient feedback or the outcomes of those actions. As a result, there was insufficient assurance at directorate level that issues raised by patients were resolved, that agreed actions had been completed, or that there was learning from incidents and complaints. However, minutes recorded that ward managers were to be invited to Clinical Governance Committee meetings in future to show actions taken to address patient concerns from May 2025.
• There was no review of governance and performance at ward level. Discussions took place at the hospital wide Clinical Governance Committee meetings. This meant it was difficult for ward leaders to have the oversight of governance and clinical effectiveness.
• Management of risk, issues, and performance was a standing agenda item at Clinical Governance Committee meetings. However, the risk register was not consistently always presented and discussed, and actions or updates were not consistently recorded. As a result, there was no reliable record of how risks were being monitored or managed
• Information governance systems included confidentiality of patient records.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

• The provider collaborated with local Alcoholics Anonymous (AA) groups and facilitated regular meetings on the hospital site. This enabled patients undertaking the Alcohol Treatment Programme to access peer support in a familiar and accessible environment, promoting continuity of care and supporting long-term recovery.
• Leaders demonstrated active engagement with external stakeholders, including commissioners and advocacy services. Stakeholders described managers as approachable, responsive, and accessible. They reported that communication was timely, with emails consistently acknowledged and queries addressed in a proactive manner. Advocacy representatives also noted that they were encouraged to participate in ward-based patient meetings, reflecting a collaborative and inclusive approach to patient support and external partnership working.
• The Clinical Governance Committee meetings included a standing agenda item for stakeholder feedback, incorporating updates from quality reports. However, the meeting minutes provided only limited detail or a summary of engagement with external bodies, making it difficult to assess the scope, content, or effectiveness of partnerships.

We do not always focus on continuous learning, innovation and improvement across our organisation and the local system. We do not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. We do not always actively contribute to safe, effective practice and research.

• The Clinical Governance Committee agenda included a standing item for Evidence-Based Practice, intended to capture relevant or new national guidance, such as NICE guidelines. However, in the 6 months prior to the assessment, this section did not include any documented implementation plans or associated actions.
• Staff were not involved in research.
• Innovations were not taking place in the service.
• Staff did not participate in national audits relevant to the service. Minutes reviewed did not show involvement in any national audits.
• Clinical Governance meetings presented and reviewed compliments and complaints at each meeting. Complaints were monitored and outcomes reported. In these meetings A Lessons Learned Framework was used to identify the top 3 lessons learned from the meeting to report upwards to the provider’s regional Clinical Governance Committee.
• Wards did not participate in accreditation schemes relevant to the service, for example Quality Network for Inpatient Working Age Mental Health Services (QNWA).
• The service facilitated student placements including psychology and nursing.