The Priory Hospital Chelmsford

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 remained as good. This meant people were safe and protected from avoidable harm.

All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were systems in place for the recording of incidents and immediate actions taken to address these. Staff reported serious incidents clearly and in line with provider policy. Staff recorded incidents on an electronic incident reporting system. The service had effective processes in place for learning from incidents and complaints which were shared with staff. Staff told us they had received feedback following safety incidents and where actions had been taken. Managers analysed and reviewed incidents for themes and trends and took action to mitigate any risks. They reviewed incidents at clinical governance meetings for oversight and scrutiny.

Managers promoted a culture of continuous learning by sharing lessons from incidents through various channels, including safety huddles, team incident reviews, mortality case record reviews, desktop reviews and thematic reviews. Additionally, the service held daily flash meetings where actions taken in response to incidents were discussed and agreed upon.

Patient safety leads were in post at the service and worked with the patient safety team to share key learning messages across the service. A weekly healthcare cascade was used to share learning and good practice and a monthly triangulated learning forum brought together learning from various disciplines across Priory Healthcare.

All staff spoken with demonstrated a clear understanding of the importance of learning from incidents and were able to provide relevant examples. For example, staff referred to a medication error that had been reported as an incident. In response, managers addressed the issue during the daily flash meeting, conducted supervision sessions with the staff involved, and circulated a ‘lessons learned’ document throughout the hospital. This approach promoted wider learning and helped prevent recurrence of similar errors.

Between January and September 2025, a total of 17 serious incidents were reported across Chelmer, Danbury, and Springfield wards. These incidents spanned a variety of themes, including patients requiring acute hospital treatment due to deterioration in physical health, detained patients under the Mental Health Act failing to return from authorised leave, allegations of abuse, service disruptions, and instances of attempted or alleged overdose.

Staff understood the duty of candour. The service had a duty of candour policy which gave additional information on Priory’s standards and expectations in relation to the duty of candour.

Managers ensured action was taken to address incidents and complaints and were open and honest with patients and carers when sharing this information with them when things go wrong.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved 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 safely be met.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

The service had a policy for admission, transitions and discharges from and to the service. Managers demonstrated a clear admission and exclusion criteria that they used prior to accepting admissions to the wards. Managers followed a process when receiving referrals and when admitting and discharging patients to ensure a smooth transition in/out, and between services.

Ward teams had effective working relationships with external teams and organisations

Our review of records from Multi-Disciplinary Team (MDT) meetings indicated involvement of family members, key stakeholders, and care teams in discussing patient progress, future care planning transitions and discharges.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had systems in place to protect people from harm, supported by safeguarding policies for both children and adults. Safeguarding training was included in staff induction and formed part of ongoing mandatory training. All staff had completed this training and those we spoke with demonstrated an understanding of how to identify and report safeguarding concerns. All staff completed mandatory safeguarding training, and at the time of inspection, compliance was at 90.5% for Safeguarding Adults Level 1 & 2 and 96.7% for Safeguarding Combined Level 3.

The service had a safeguarding lead who worked with staff to improve their understanding of safeguarding. We saw that information about how to contact them was displayed around the hospital and was also attached to visitor passes.

During the inspection we viewed the safeguarding log for June – August 2025. Records were up to date, included details about safeguarding incidents and if they were being investigated internally or by the local authority.

Safeguarding learning was shared in various forums including staff meetings, reflective sessions and supervision.

We spoke with 5 family members of people at the service. All told us that they felt their loved one had been safe at the service and they knew how to raise concerns if they needed to. We spoke to 6 patients at the service. All patients said they felt safe except for 1 patient on Danbury ward.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff followed clear procedures to keep children visiting the ward safe. Children were not permitted to visit patients on the wards. Visits from children took place in other areas at the hospital. At the time of inspection, 90.5% of staff had completed training in Safeguarding Children.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service provided patients with a leaflet outlining the expectations around taking leave from the ward, applicable to both detained and informal patients. This ensured that all patients were informed about what to expect before, during, and after their leave, to ensure consistency, safety, and clarity in the process.

Staff involved patients in care planning and risk assessments. We reviewed 6 people’s records which showed holistic care plans covering a variety of needs which were regularly updated after incidents. Most patients said they were involved in care planning and received a copy of their care plans. Risk plans covered historical, current and formulations of risks. Risk assessments were completed or reviewed weekly in multi-disciplinary team meetings as well as prior to taking leave in the community and after an incident.

Staff completed care plans for physical health needs that were individualised, detailed and routinely reviewed. For example, we saw care plans for the management of diabetes and nutritional and dietician support. Staff completed formulations of care to understand the development and maintenance of patients’ presenting difficulties. This helped staff gain a deeper understanding of patients’ needs and informed how best to support them.

Staff completed personal emergency evacuation plans for patients requiring support to evacuate the building in the event of a fire or an emergency.

Staff ensured they placed people on appropriate observations upon admission if they posed any risks to themselves. For example, during the inspection we saw people with eating disorders on Springfield ward being supported at mealtimes.

Staff we spoke with showed a good understanding of the management of risk and reducing restrictive interventions. Staff spoke about using restraint and seclusion as a last resort and gave several examples of interventions they would use to manage and de-escalate situations such as verbal de-escalation, utilising a low stimulus environment or distraction.

Wards had informal patient signs displayed to ensure they knew their rights and that they could leave the ward if they wished to do so. We observed ‘You said, we did’ boards where feedback from patients was shown and actions the hospital had taken to address their feedback was displayed. This included feedback on having access to the internet in the lounge on Chelmer ward and obtaining an umbrella which had been provided.

Levels of restrictive interventions were low and there were no incidents or events that required restraint or rapid tranquilisation between May and September 2025 on Chelmer or Springfield ward. However, Danbury ward had 11 incidents of restraint and 9 incidents where rapid traquilisation was used between May and July 2025. Managers completed a monthly report of restraints that detailed each incident of restraint and rapid traquilisation, the restraint position, restraint holds and interventions used by staff which they monitored.

The service had a blanket restriction policy. Managers completed a blanket restriction register which included the restriction, the rationale and date of review. This was last updated in August 2025 where examples of restrictions included no mobile phone usage during therapy, limited access to the laundry room and personal toiletries, with restricted items to be locked away.

Staff completed a monthly restrictive practice self-assessment audit tool on each ward, which captured key information including the specific restriction in place, the rationale for its use, an action plan to reduce or remove the restriction, and the date it would be reviewed. This process supported a reflective and proactive approach to minimising restrictive practices.

Staff ensured that patients could access advocacy. The service had access to an advocate and Independent Mental Health Advocacy (IMHA) for qualifying patients detained under the Mental Health Act in line with their statutory rights.

We scored the service as 3.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

During the inspection visit, we undertook a tour of Chelmer, Danbury and Springfield Wards which admitted people requiring treatment for mental health needs and eating disorders. We observed the wards were well-decorated, comfortably furnished, clean and well-maintained.

Staff completed regular risk assessments of the care environment. This included environmental risk assessments, medical equipment checks and audits of the clinic room.

The service conducted daily cleaning checks of each ward to ensure the cleanliness of the ward. Staff completed environmental and security checks to ensure the environment was safe. The nurse in charge completed daily safety checks to ensure the safety and security of the ward was checked and maintained.

Managers conducted environmental walkarounds of the hospital to ensure the safety and quality of the environment. Staff completed fire risk assessments, regular audits to ensure fire safety and monitored the evacuation process on the wards.

Ward layouts did not allow staff to observe all parts of ward, as not all areas were easily visible. Danbury ward was split across two floors: the first floor accommodated more acutely unwell patients, while the second floor housed lower-risk patients. Patients could move between floors via the stairs to access the lower ground. Springfield ward was located upstairs which had recently been refurbished, with patients able to access the lower ground floors using either stairs or a lift. Chelmer ward was situated on the ground floor. To address visibility challenges and blind spots, particularly on the upper floor of Danbury ward, the service installed mirrors and allocated staff to remain in less visible areas to manage environmental risks. Additionally, staff employed enhanced observations to support patients identified as having higher levels of risk.

Managers conducted regular blind spot audits to identify, review, and update all areas with limited visibility. In addition, they completed ligature risk assessments, which involved identifying ligature anchor points, rating the associated risks, and outlining the mitigations and actions implemented to reduce these risks. The wards displayed ligature heat maps identifying low, medium, and high-risk areas. These maps also indicated the locations of ligature cutters to ensure staff could quickly locate them in an emergency.

The ward complied with guidance on eliminating mixed-sex accommodation. Danbury ward was a female only ward and Chelmer ward and Springfield ward were mixed sex wards. However, male and female patients’ bedrooms were placed in separate corridors and all wards had ensuite bathrooms and female lounges.

Staff had easy access to alarms and patients had easy access to nurse call systems

The service did not have a seclusion room. However, the service did not admit patients who were at risk of needing seclusion. If a patient’s risks changed, they could be supported with a move to a more appropriate setting.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The service conducted daily cleaning checks of each ward to ensure the cleanliness of the ward. Staff completed environmental checks to ensure the environment was safe and maintained well.

Bedrooms had nurse call alarms in every room which managers ensured were checked on a monthly basis. Each patient had their own bedroom, which they could personalise. Bedrooms were clean and spacious with ensuite facilities.

Staff used a full range of rooms and equipment to support treatment and care. Wards had a clinic room, rooms that could be used for 1-1 meetings, group work and occupational therapy and activities.

Staff reported any repairs to maintenance staff. All repairs were actioned within reasonable timeframes.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the time of the inspection Chelmer, Danbury and Springfield ward had a staffing establishment of 25.7 full time equivalent (FTE) registered nurses and 48.8 FTE healthcare assistants. The services vacancies for healthcare assistants were 12.2 and 5.75 for registered nurses. The service had a ward manager vacancy on Danbury ward and a recent vacancy for an onsite dietician for Springfield ward and a family therapist. However, managers were advertising to fill these positions.

Managers had calculated the number and grade of nurses and healthcare assistants required. The number of nurses and healthcare assistants matched this number on all shifts.

The ward manager could adjust staffing levels daily to take account of case mix. Additional staff were sought if observation levels were changed to manage risk and support patients.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

The number of shifts covered by agency staff was reducing. Data from June to August 2025, showed a reduction in agency hours and there was an increase in permanent staff to meet the needs of patients.

Staffing levels allowed patients to have regular one-to-one time with their named nurse, access to leave in the community and access to activities.

There were enough staff to carry out physical interventions such as observations and restraint safely.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. The service had a rota system where medical staff would cover the service and were available 24 hours a day.

Staff were up to date with mandatory training, with compliance levels not falling below 75% across any area. Overall, the service had an 81.3% compliance rate across all mandatory training courses. Training provided was appropriate to the needs of the patient group and ensured staff had the necessary skills and knowledge to deliver safe and effective care.

In line with new national requirements, the service had made autism training mandatory, and 96% of staff had completed Part 1 of the Oliver McGowan Training, with Part 2 currently in progress.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

All ward areas were clean, had good furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff ensured monthly cleaning audits took place to monitor environmental cleanliness and ensure compliance with health and safety standards, including COSHH regulations and appropriate use of personal protective equipment (PPE).

Staff adhered to infection prevention and control (IPC) principles, including effective hand hygiene practices. Handwashing facilities, signage, and alcohol-based hand gel were readily available throughout the wards. The service conducted regular hand hygiene audits, with the most recent audits showing 100% compliance, demonstrating that staff were consistently following correct handwashing procedures.

The service completed audits of mattresses to ensure they remained in good condition and to prevent healthcare associated infections.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management including, storage, dispensing and administration and did this in line with national guidance.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication. Patients were involved in discussions about medication and care planning.

Doctors undertook medicines reconciliation for patients admitted to the service. Staff reviewed patient’s medicines regularly as part of the multidisciplinary meetings (MDT). Specific advice was provided to patients about their medicines. Side effects were regularly discussed.