The Priory Hospital Hayes Grove

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 requires improvement. At this inspection, the rating has changed to Good.

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.

The provider had established policies and procedures for staff to report incidents, near misses, and safety events. Staff we spoke with knew what incidents to report and how to report them. Examples included medication errors and information governance. Medication errors included incorrect medication being dispensed, medication not being administered, and controlled drug records not being completed appropriately. Leaders ensured that nurses had received up to date competencies surrounding medication. 

The service had established several systems to share learning and best practice. This included daily and monthly meetings, with handovers occurring regularly. Some staff mentioned joint sessions with the ward team to share risks and changes in presentation.

Staff reported that they were debriefed and received appropriate support following incidents. 

There had been 11 serious incidents on the ward in the last 12 months. 

The service worked with people and their partners to establish and maintain safe systems and continuity of care, including when people moved between different services.

At our last inspection the service did not have clearly defined admission criteria within the policies reviewed. During our recent inspection leaders were able to explain the admission criteria. Admission criteria included the presence of a substance misuse need, being medically fit for admission, willingness to engage in treatment, motivation to make positive changes and the ability to provide consent.

Referrals were reviewed and discussed by the clinical and therapy teams. Once they had determined the patients’ needs and if these could be safely met by the service, they were then booked in for an assessment with addiction therapist. A comprehensive assessment was undertaken which included looking at a patient’s history, social circumstances and consent. Staff discussed treatment options with patients.  Following this, contact was made with the patient's GP to obtain relevant health records.  

During our assessment we reviewed 4 records, there was evidence of good physical health assessment and regular use of clinical monitoring tools such as CIWA and NEWS2. Care plans in several cases were responsive and updated regularly, and consent to share information was documented. Care plans were comprehensive and covered 4 areas. These were keeping well, keeping healthy, keeping connected and safe. These were personalised, included individual goals, and clearly reflected patients' wishes. Monitoring for alcohol and opiate withdrawal was recorded in clients’ records.

The service had operational procedures in place to support safe systems, transitions and pathways for treatment and recovery. Staff worked within multidisciplinary teams including, nursing staff, occupational therapists and psychologists, who contributed to discussions and decision making. 

Appropriate safety policies were in place, including safeguarding and infection prevention and control policies. 

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Since our last inspection the provider had made changes to address areas of concern identified. We saw that the provider now ensured that sufficient numbers of staff with the appropriate qualifications, competence, skills and experience were available to safely meet the needs of people using the service.

The last time we inspected, only 52% of staff had completed mandatory medically assisted withdrawal (MAW) training. At this inspection 92% of staff had completed this training. At our last inspection, staff we spoke with demonstrated gaps in key substance misuse competencies, including recognising the signs and symptoms of withdrawal. At this inspection all staff we spoke with were able to describe opioid withdrawal symptoms and had received training in the use of naloxone. Naloxone is a life‑saving medicine used to rapidly reverse the effects of an opioid overdose. Staff we spoke with were able to identify the signs of opioid overdose, were clear how to administer naloxone and could confirm its location within the clinical area. The service had introduced a section in daily team meetings where staff were asked to describe signs of withdrawal, in order to assess their knowledge. There was an information poster on the wall in the clinic room outlining withdrawal symptoms.  

During this assessment, information we looked at indicated staff were able to recognise and respond appropriately to clinical deterioration. Leaders also ensured all staff had completed competency assessments in this area. At our last inspection initial assessment processes did not fully identify or address substance related risks. There was no documented alcohol withdrawal screening or breathalyser test on admission, and although a HoNOS assessment was completed, this focused on routine outcome measures rather than immediate clinical risk. During this assessment we saw evidence of withdrawal screening and breathalysing taking place and being recorded in patient notes. We also saw alcohol and/or substance use, and associated risks were assessed and reflected in the client’s keeping safe plan.

Staff had received and were up to date with all other mandatory training courses. The training was appropriate for the patient group using the service, with an overall compliance rate of 92.3% at the time of the assessment, and systems in place to monitor training due to expire.

High compliance of 100% was seen in safeguarding adults and children, complaints management, crisis management, diversity and inclusion, medicines management, and learning disability training. 

Systems were in place to provide both clinical and managerial supervision, and records showed that staff were receiving supervision. All staff we spoke with stated that they had received regular supervision. Staff stated they used supervision to discuss their role and professional development. Observations of physical healthcare practices were also undertaken.

Safe recruitment processes were in place, with appropriate Disclosure and Barring Service (DBS) checks undertaken. 

The multidisciplinary team was well resourced and included doctors, nurses, occupational therapists, clinical psychologists, providing a range of specialist roles that met the needs of the client group. There was medical cover at all times, with a doctor able to attend quickly in an emergency and a visible clinical presence during the inspection.

Staff participated in appraisal processes. 

Staffing levels enabled clients to access regular one to one time, and there were enough staff to complete required physical interventions such as observations. There were 2 registered mental health nurses on shift during the day and 1 at night. There were 2 healthcare assistants on shift during the day and 2 at night. There was a qualified nurse present in communal areas of the ward at all times. The service also demonstrated strong workforce stability. Staff turnover throughout 2025 remained low, generally between 0–2% per month, with minimal unplanned movement. Four staff left in January 2026 due to planned redundancies, indicating managed organisational change rather than instability. The service had significantly reduced its reliance on agency staff, with usage steadily decreasing from July 2025 and reaching zero in November and December 2025. Bank staff were used appropriately to maintain safe staffing levels, supporting continuity of care and reducing risks associated with unfamiliar staff. 

The service assessed and managed the risk of infection. They prevented and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. We observed all ward areas were clean, tidy and kept well maintained.

The service carries out regular Infection, Prevention and Control audits. These included cleanliness for all areas both client and non-client areas, hand hygiene, mattress audit and an annual compliance audit. At the time of our assessment, Infection Prevention Control compliance rate was 81.8%.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.