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 regulation in relation to Regulation 18 Staffing.

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 did 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.

• Rivendell ward had had 4 incidents of moderate harm in the last 12 months.
• The provider had a Healthcare Patient Safety Summary of Learning and Actionspublication which was shared with staff monthly. The May 2025 publication included sharing learning about potential ligature anchor points.
• The hospital produced monthly ‘lessons learned’ bulletins which included site wide and provider wide learning.
• All staff knew what incidents to report and how to report them.
• Staff did not always understand the Duty of Candour. When asked for a summary of the duty of candour incidents, the provider shared 4 incidents that were rated as moderate harm, they were not always appropriately rated. This meant the service did not know which incidents required action under the Duty of Candour regulation. There had been an incident where a young person was on 1:1 arms length observations, they were female and were being observed by a male member of staff. They went into the toilet area, the staff member was not arms length, and the young person tied a ligature. The provider did not follow the Duty of Candour requirements following this incident. The provider had an action of reviewing staff’s knowledge and understanding of Duty of Candour as part of an action plan following a complaint to the service. This meant the service could not be assured that all staff understood the requirements of the Duty of Candour.
• Staff did not always receive feedback from investigation of incidents, both internal and external to the service. We reviewed team meeting minutes for the last 6 months and only the minutes for the week prior to the on site assessment provided feedback to staff following complaints and incidents.
• Minutes showed there had been meetings with the staff team to update on the increased oversight from commissioners.
• Staff were debriefed and received support after a serious incident. There was a planned reflective practice session for the team.

We did not always work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We do not always ensure continuity of care, including when people move between different services.

• The service’s referral and admission process was that referrals were made by commissioners. The quality of the service was reviewed by the Greater Manchester provider collaborative for child and adolescent mental health services (an NHS-Led Provider Collaborative is a group of providers of specialised mental health, learning disability and autism services who have agreed to work together to improve the care pathway for their local population - they will do this by taking responsibility for the budget and pathway for their given population). The provider collaborative met with the provider regularly as there had been concerns raised about the quality of care being provided.
• Staff did not always involve all the necessary healthcare and social care services to ensure young people had continuity of safe care, both within the service and post-discharge. Families and stakeholders told us that the service could not meet the needs of all the young people they were supporting, were not always responsive to young people’s needs and did not always have the staff with the skills and knowledge to meet their needs.

We did not always 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 do not always 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 were trained in safeguarding, with safeguarding adults levels 1 and 2 compliance at 95%. Safeguarding children levels 1 and 2 compliance was at 91% and safeguarding adults and children level 3 compliance was at 94%. Staff knew how to make a safeguarding alert, and did that when appropriate.
• Staff did not always ensure patients who were supported at arms length observations were supported by staff of the same gender to promote their privacy and dignity. This caused unnecessary negative psychological impact on patients and their families.
• Staff did not always share and record changes in risk, for example a patient had turned 18 during their admission and this was not recorded in a timely way in the handover records, and it was not clear to staff in care records what potential risks they needed to be vigilant of and the frequency of review.
• There was not a visitor’s room available on the ward, however there was a room in another building that could be booked if required, usually visiting took place in patients’ bedrooms.

We did 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.

• We reviewed 5 risk assessments and risk management plans during the assessment. They had recently been updated to include the 5 P’s; presenting risk, predisposing factors, precipitating factors, perpetuating factors and protective factors.
• There were 325 incidents of restraint in the 6 months prior to the assessment. These were mainly used to facilitate nasogastric feeds (239), to encourage a patient to rest and reduce their exercise levels, especially post feed (51), to stop patients self-harming (28), to stop patients from absconding (4) and in response to a patient displaying violence and aggression to others (3). There were 3 occasions of rapid tranquillisation in the last 3 months.
• Staff did not always involve young people in care planning and risk assessment. We spoke with 2 young people, 1 young person told us they had been included in the process, the other told us they were not involved in the creation of their care plan and risk assessment, however they had seen a copy and had an opportunity to discuss it with their named nurse. Records showed young people were mostly involved in the creation of their care plans and they were mostly individualised and included goals.
• Staff communicated with young people so that they understood their care and treatment, including finding effective ways to communicate with young people with communication difficulties. We saw ‘about me’ resources in use.
• There was a ‘you said, we did’ board on the ward, capturing changes made following the community meetings.
• Staff ensured that young people could access advocacy. Details of the advocacy service were displayed on the ward.

We did 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. The ligature risk assessment was completed in July 2024. This was a lengthy document with a different document for each room on the ward, 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 said, “Locally manage through local procedure”.
• The ward layout did not allow staff to observe all parts of ward. There was a seating area of the lounge which had a blind spot, although there was CCTV in there, this was not a live feed used to observe the environment. This meant staff would not have a clear line of sight of the ward.
• Staff had easy access to alarms and young people had easy access to nurse call systems, there were call buttons in their bedrooms. However, the alarm we tested to summon assistance was not working effectively.
• Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

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

• There were vacancies for a family therapist (0.8WTE) that was being covered by an agency member of staff, Responsible Clinician (0.6WTE) however when we were on site, a consultant from another site attended and they were taking over the role on a temporary basis. There was no psychologist (1WTE) on the ward and there was an agency psychologist due to start on 19 May 2025, however this had been delayed.
• Young people, families and stakeholders we received feedback from told us that the turnover in staff had an unhelpful impact on the young people’s recovery. The turnover rate was 9% for the ward for the last 12 months. The sickness absence for the service was 12% for the last 12 months.
• Managers had calculated the number and grade of nurses and healthcare assistants required. The allocation was 3 registered nurses and 5 support workers for day shifts and one registered nurse and 3 support workers at night. However, there were more staff on the evening handover we observed due to enhanced observations.
• Figures provided by the service showed that there had been 6% bank staff usage and 3% agency staff usage in the 6 months prior to the assessment.
• On the day of the assessment there was one agency registered nurse and 3 agency support workers, with 2 permanent registered nurses and 3 permanent support workers.
• When agency and bank nursing staff were used, those staff did not always receive an induction and were not always familiar with the ward. On the day of the assessment 1 of the 4 agency staff had not worked on the ward before and had not had an induction to the ward. Staff told us this and it was confirmed by the records we reviewed. We observed the staff member not knowing where to go to seek support, and not knowing who the other staff were or how best to support patients. They had been allocated to conduct observations following a meal, which can be the most difficult time of the day for patients with an eating disorder diagnosis. An incident occurred and there were no staff available in the area to support. This meant staff were not always provided with the information needed to fulfil their role and support patients effectively.
• We also reviewed agency inductions for week commencing 5 May 2025. Of 11 agency staff working over the timeframe we reviewed, 2 did not have an induction checklist in place and 3 were not completed in full, this means 5 out of 11 induction checklists either weren’t in place or were not completed in full. This meant we could not be assured that people had the knowledge or skills to support the young people on the ward.
• We conducted a Short Observation Framework for Inspection 2 (SOFI2) observation in the service, which is a structured observation which captures people’s experience of care during the on site assessment. This showed staff were not present in communal areas of the ward at all times. There were times post-meal when patients were in the lounge area without any staff present. This meant patients were not being supervised and staff were not available if they required any assistance.
• Patients told us that staffing levels did not always allow them to have regular one-to-one time with their named nurse and also said they did not have access to skilled, knowledgeable staff when they needed assistance and were having a bad day. We also observed this, when a patient was distressed following meal support, there was not a staff member present in the area to respond.
• Patients told us that staff shortages meant there were times when they were unable to go off the ward when they wanted to.
• There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely (and staff had been trained to do so).
• There was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency.
• Staff had received and were up to date with appropriate mandatory training with 89% compliance overall. However, the courses with less than 75% compliance included safe handling of medicines with 33% compliance and Oliver McGowan autism training level 2, which no one had completed. However, this was being rolled out nationally.

We did 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 maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.
• Most ward areas were clean, had good furnishings and were well-maintained. There was a vacant bedroom which had graffiti on the wall, there was a hole in the wall and staining on the wall in the therapy/activity room.
• Staff did not adhere to infection prevention and 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 Standards of Dress, Uniform and Personal Appearance policy dated 03/08/2023 which states “ 6.2 Appearance - With regard to personal appearance the following applies: Fingernails must be kept short at all times to protect from any scratching and any infection. Nail varnish is not permitted for any colleagues who have direct contact with service users. 6.3 Clothing - Arms must be bare below the elbow to allow appropriate hand hygiene. This is defined in the Department of Health’s “Bare Below the Elbows” guidance and IPC03 Hand Hygiene:6.5 Finger rings - One plain metal band may be worn. No rings with stones are to be worn when dealing directly with service users’ care as scratches and abrasions to the skin could occur.” Also the local procedure “Workplace Uniform/Dress Code Procedure for all staff, PH Alt 06 dated November 2024 which states that “we will strongly advise use of “bare wrists” while on duty – no watches/jewellery etc.”

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

• Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and complied with relevant national guidance.
• Medicines were stored safely in all areas where people were being cared for.
• People were supported with goal-orientated care plans.
• Systems were in place to ensure regular medicines were given safely and at the right time. On people’s medicines records, allergies were recorded accurately. Physical health monitoring was carried out regularly. When it was necessary to give rapid tranquilisation, the reason for this was clearly documented and national guidelines were followed regarding monitoring and observation of the person.