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

At our last inspection we rated this key question as good. At this inspection the rating has remained as good. This meant people were safe and protected from avoidable harm.

The ward was 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 in which concerns were listened to, patient safety incidents were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

Staff knew what incidents to report and how to report them.

Staff reported serious incidents clearly and in line with provider policy. Staff recorded incidents on an electronic incident reporting system.

The service investigated and reviewed incidents using a number of methods including safety huddles, team incident reviews, mortality case record reviews, desktop reviews and thematic reviews.

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.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. 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.

Staff received feedback from investigation of incidents, both internal and external to the service.

Chelmer ward had a very low number of serious incidents. Staff had reported 2 serious incidents between January and September 2025: a patient was taken to hospital following a deterioration in their physical health and there was an outbreak of diarrhoea and vomiting.

We scored the service as 3. The evidence showed a good standard. The service worked with people and partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The service ensured 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 made sure they shared clear information about patients and any changes in their care, including during handover meetings. Staff held handover meetings at the end of each shift.

Ward teams had effective working relationships with other teams in the organisation.

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 to understand what being safe meant to them as well as partners on the best way to achieve this. The service 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 had a safeguarding policy and clear processes in place for staff to follow. Staff received training on how to recognise and report abuse, appropriate for their role. 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 hospital had a safeguarding lead, and we saw that information about how to contact them was displayed around the hospital and was also attached to visitor passes.

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.

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

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 so that care met their needs in a way that was safe and supportive and enabled them to do the things that matter to them.

Staff completed risk assessments for each patient on admission using a recognised tool, and reviewed this regularly, including after any incident. Risks were reviewed by the multidisciplinary team each day. We looked at 3 patient care records and could see that all risk assessments had been completed on admission, were comprehensive and up to date and had been reviewed and updated after incidents.

Staff involved patients in care planning and risk assessment. Staff told us that care plans were co-produced with patients and were discussed in ward rounds and reviews. Patients told us they had been involved in writing their care plans and had been given copies. Patients had a safety plan that focused on how to keep themselves safe and who they preferred to support them with this.

Prior to admission, staff sought permission from patients to contact their family members in order to gather additional information about how the patient's addiction had affected them. With the patient's consent, staff also asked family and friends to assist with the patient's risk assessment and care planning.

All patients had access to advocacy during their stay at the hospital. Information about how to access the advocate was displayed around the wards and given to patients on admission.

Levels of restrictive interventions were low and there were no incidents or events that required restraint or rapid tranquilisation between May and September 2025.

Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe. Staff we spoke to were able to tell us about the various de-escalation techniques they would use such as verbal de-escalation and utilising a low stimulus environment or distraction.

Staff followed provider policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm.

The ward manager conducted a monthly self-assessment audit of restrictive practice. which audited any blanket restrictions (those that applied to all patients on the ward) and restrictions that applied to specific patients which were individually risk assessed. On Chelmer ward there was an expectation that patients did not use their mobile phones during therapy times and staff were present when patients opened incoming mail as per Priory Healthcare policy.

We scored the service as 3. The evidence showed a good standard. People were cared for in safe environments that were designed to meet their needs. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care.

During the inspection visit, we undertook a tour of Chelmer Ward which admitted people requiring treatment for addictions and substance misuse. We observed the ward was well-decorated, comfortably furnished, clean and well-maintained.

Staff could not observe patients in all parts of the ward and outside space. Staff used relational security and supportive observations to keep people safe. The service did not admit patients who were at high risk of self-harm or a risk to others. If a patient’s risks changed, they could be supported with a move to a more appropriate setting.

The ward complied with guidance on mixed sex accommodation. People had their own bedrooms with ensuite facilities and there was a separate lounge for female patients.

Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe.

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

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

The service did not have a seclusion room. 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.

Each patient had their own bedroom, which they could personalise. Bedrooms were clean and spacious with ensuite facilities.

Patients had a secure place to store personal possessions. Patients had lock boxes under their bed where they could store valuable items.

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

The service displayed the names and photos of all staff on each ward, so that staff and visitors were aware of the staff working on the wards.

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

We looked at the staffing figures for the ward. At the time of the inspection Chelmer Ward had a staffing establishment of 1 ward manager, 7.7 full time equivalent (FTE) registered nurses and 12.8 FTE healthcare assistants. There were vacancies for 2.2 registered nurses and 1.9 vacancies for healthcare assistants.

Additional staff were assigned to the wards when there were high levels of acuity.

The service used bank staff familiar with the service to cover vacancies and periods of sickness and annual leave.

Levels of sickness were low. At the time of inspection, the service had a sickness rate of 3.24%

During our inspection visit we could see the wards were fully staffed, and staff told us there were enough staff on the wards. Patients we spoke with said there were always staff visible on the wards and there was always a staff member available if they needed them.

Staff had completed and kept up to date with their mandatory training. Overall, staff compliance with mandatory training was 87.3%. There was no mandatory training with a compliance rate of less than 85% except for The Oliver McGowan Mandatory Training on Learning Disability and Autism – Tier 2 which had only just been introduced. Compliance for Tier 1 of this training was at 90.9%.

The mandatory training programme was comprehensive and met the needs of patients and staff.

Managers monitored mandatory training and alerted staff when they needed to update their training. Managers received a regular report showing compliance with mandatory training. This report included details of training that was soon to expire.

Managers gave each new member of staff a full induction to the service before they started work.

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

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

All ward areas and clinic areas were clean and well maintained. We saw that the ward environment was clean and tidy when we undertook a tour as part of our inspection visit.

We viewed cleaning records and audits and saw they were up to date and demonstrated that all areas of the hospital were regularly cleaned. Staff completed monthly cleaning audits of the ward which included checking that staff were correctly using personal protective equipment. Staff also completed mattress audits to ensure patient mattresses were not damaged or unclean as damaged mattresses could pose an infection risk.

Staff followed infection control policy, including hand washing. Masks and hand gel were available at the ward entrance and staff followed personal protective equipment guidelines. We saw that posters were displayed at the hospital reminding staff to wash their hands. Compliance levels for mandatory training in infection prevention and control were at 94.4% at the time of inspection.

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 by enabling them to be involved in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely.

Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines. Patients’ medicines were reviewed as part of an overall review of their progress at ward rounds. Staff provided information about possible side-effects. Patients were involved in discussions about medication and care planning.

Staff stored and managed all medicines and prescribing documents safely. All medicines were stored in locked cabinets, or in the medicine fridge in the clinic room. An external pharmacy conducted a weekly audit of medicines.

Staff completed medicines records accurately and kept them up to date.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. No patients were receiving doses of medicine above the level recommended in the British National Formulary (BNF).