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 Regulation 17 Good Governance.

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 did 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 they were applied in the work of their team. They were shared in email footers. The vision was “Making a real and lasting difference for everyone we support.” The values were “Striving for Excellence, Being Supportive, Being Positive, Acting with Integrity and Putting People First.”
• Staff did not have the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff felt like there was constant scrutiny of the service and did not feel like there was an opportunity to be listened to by senior leaders.
• Agency staff were not informed of changes and did not feel as included as they were in other services where they worked.
• Minutes showed that staff and leaders were aware of the external concerns about the service and discussed action plans that the team were working on. Minutes showed challenges with staffing levels, and ability to support and train agency members of staff. Although the staff rotation had positives, minutes showed, and staff told us that this generated gaps in young people’s care where staff unfamiliar on the ward were being asked to support young people with meals and snacks and did not understand the importance of structure, routine and consistency. There were times when young people had not received their nutrition as prescribed or planned as a result of this.

We did not always 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 did not always have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

• There had been significant changes within senior leadership, with 2 hospital directors in the 12 months prior to the assessment and the current hospital director was leaving, with a hospital director from another site arriving to provide interim cover. There had been 4 ward managers in the 12 months prior to the assessment. This had caused young people, families and staff to feel unsettled and that there was a lack of consistency and clear aims for their recovery.
• The ward manager had been in post since March 2025, they were focused on learning about the ward, and had a good understanding of areas for improvement. Minutes showed they had arranged a recent team meeting which was more thorough than previous meetings at which they had updated staff on the actions they were working on.
• We saw and staff told us that leaders were visible in the service and approachable for young people and staff. Staff spoke positively about the outgoing hospital director, their presence on the ward and approachability.
• The ward manager was working through the training available, they planned to complete training in complaints management.

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

• Young people 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 a family questionnaire that was given following review meetings and also a weekly questionnaire. However, families told us that they did not see any changes happen following the completion of the questionnaires and their questions were not answered so they were disillusioned with completing future questionnaires. This meant the service was not always responding to feedback.
• There was a parents and carers group held monthly via Teams which was facilitated by the family ambassadors who did not work for the service but worked for the provider collaborative which commissioned the service.
• Managers and staff had access to the feedback from young people, via the community meeting minutes. However the healthcare patient satisfaction survey analysis was hospital wide, this meant staff did not know the results for their service or ward to support them to make any changes.
• The results of the most recent staff survey were lower in all sections than the provider’s average. Areas that had reduced since the previous survey included the provider acting on concerns raised, regional senior leaders being visible and displaying the organisation’s values, teamwork, systems enabling staff to fulfil their role, work life balance and equality, diversity and inclusion.
• Young people and carers were not always involved in decision-making about changes to the service. However young people were involved in the interview for the ward manager, which was a positive example of patient engagement.
• Young people and staff could meet with members of the provider’s senior leadership team, we saw in community meeting minutes that the hospital director and other senior leaders attempted to join a meeting however there were no young people available to attend this meeting.
• We reviewed the minutes from the community meetings and found that actions were not completed in a timely manner, for example young people had been asking for a radio or music in the rooms where they had their nasogastric feeds and had to wait for over a month for this to be resolved.

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.

• There were equality and diversity champions within the provider e.g. LGBTQ+ with a document explaining the role of a champion. There were posters about being an ally and contact details for the diversity networks.
• The provider had SMART (Specific, Measurable, Achievable, Realistic and Timebound) objectives in place for promotion of diversity awareness. The CEO had written an article about zero tolerance of racism and where colleagues could go for support, including the colleague assistance helpline.
• Staff were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. We spoke with staff where these had been put in place.
• 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 did not have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We do not always act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

• There was no clear framework of what must be discussed at a ward level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. We reviewed team meeting minutes and all except one were updates from the enhanced monitoring from commissioners and were very brief notes. The most recent team meeting that took place just before the assessment was more detailed and did include themes from complaints and actions the service were working on. However, there was no learning shared from other parts of the organisation.
• Clinical governance meetings took place bi-monthly and there was a standard agenda. We reviewed the minutes and found there was no patient and carer feedback for this service, Rivendell ward. Also, there were no clinic room audits completed for the February 2025 meeting and no report on clinical effectiveness. This meant the service were not submitting expected audits and reviews and the provider could not be assured of the quality of care that the service was delivering.
• Governance meeting minutes showed that the service was not fully compliant with the completion of outcome measures with the young people.
• The service had a ward improvement plan and 2 action plans from complaints that they were working through. Staff told us they were in the process of combining the action plans as it was difficult to have oversight of 3 action plans.
• Staff did not always undertake or participate in local clinical audits. Minutes showed there were delayed audits in relation to Adolescent Risk Management Plans and Incident, Datix and Care plans.
• Staff did not always understand the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Stakeholders told us that the service did not always complete the agreed actions and at times the nursing team's view was different than the multidisciplinary team's view and the teams did not seem to be aligned, which had a negative impact on young people's recovery. Concerns about the lack of a model of care were expressed by stakeholders, which impacted on care delivery and outcomes for young people.
• Management of risk, issues and performance was not always discussed at the governance meetings, we reviewed the minutes for the last 6 months, which was 2 meetings, and found in 1 of the meetings the risk register was discussed with additional risks noted to be included. At the following meeting there was no update in relation to this, and the risk register was not included as an item for discussion.
• Senior leaders maintained and had access to the risk register, the staff at ward level were not aware of the risks included in the risk register that related to the ward.
• Staff concerns matched those on the risk register. This included lack of psychology input and increased monitoring from commissioners.
• The service used systems to collect data from wards and directorates that were over-burdensome for frontline staff. The service was expected to complete audits, review manually the training and supervision compliance and have oversight of 3 different action plans. There was no overview of the service created, for example a dashboard where managers could access the information easily and monitor trends and progress. There was no review of governance and performance at ward level, discussions took place at the hospital-wide clinical governance meeting, which meant it was difficult for ward leaders to have oversight of governance and clinical effectiveness.
• Staff did not always have access to the equipment and information technology needed to do their work. Staff, stakeholders and families told us that the information technology infrastructure did not support efficient remote access to meetings which meant participants could not fully access and contribute to the meetings.
• Information governance systems included confidentiality of patient records.
• Leaders did not ensure that staff followed provider policies in relation to dress code on the wards. We saw staff who were not bare below the elbow, some with long sleeved clothing, staff had nail varnish on and false nails. Staff also had watches and jewellery on. 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.
• Handovers were not completed in full, with dates not always recorded and were sometimes completed in pencil. When risks changed, they were not recorded promptly on the handover. Daily allocation records we reviewed were sometimes completed in pencil without the allocation of duties completed or dates included. We observed a handover, and the description shared with staff of an incident we had observed was not an accurate reflection of what we saw. This meant staff were not receiving all the necessary information to support young people effectively. Systems and processes were not in place to ensure staff recorded all required information.

We did not always understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We do not always share information and learning with partners and collaborate for improvement.

• Leaders engaged with external stakeholders, such as commissioners and advocacy services. Stakeholders told us there was a lack of structure to admissions, and difficulty in determining an agreed multidisciplinary formulation and care aims in a timely manner during the admission. Also, a lack of cohesiveness amongst multidisciplinary working. The team did not have a shared view on a young person’s care and treatment. This meant it was difficult for young people to progress in their recovery and for families’ engagement with the service.
• Turnover in staff was shared as an area that has had a detrimental impact on young people’s recovery and external relationships. However, stakeholders told us the newly appointed ward manager had made a positive impact on the service, improving documentation and addressing concerns.
• Stakeholders told us that the service was not always responsive to requests, they did not always receive requested information, and the service was not always proactive with their engagement with community teams. Minutes and actions following meetings were not always shared in a timely manner and reviews for young people were disjointed and made it difficult to understand the young person’s progress.
• There were no formal processes for young people, carers and staff to meet with members of the provider’s senior leadership team. The monthly parent and carers group was facilitated by the family ambassadors who were external to the service. The main feedback from staff was via the freedom to speak up route. This meant there was limited partnership working in place.

We did 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 actively contribute to safe, effective practice and research.

• Staff were not given the time and support to consider opportunities for improvements and innovation. The service did not have any quality improvement initiatives in place, although clinical governance meetings for the last 6 months did note the site improvement plan which was in place.
• 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.
• The ward is accredited with the Royal College of Psychiatry’s Quality Network for inpatient Child and Adolescent services (QNIC) until October 2025. However, staff told us they are not applying for full reaccreditation, noting the service challenges and have applied for peer review at this time.
• The service had in the past had a variety of student placements including psychology and nursing. There was a nursing student at the time of the assessment.