The Priory Hospital Hayes Grove

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• 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 hospital 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 inspection, the rating has remained Good.

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 look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. 

At our last inspection leaders did not consistently demonstrate effective oversight of staffing, skill mix, and clinical risk within the service. Since our last inspection, leaders ensured that all staff received medically assisted withdrawal training. This indicated that leaders’ knowledge of substance misuse practice and associated clinical risks was relevant to the service. This training had also been rolled out across the wider organisation. 

Staff we spoke to stated that leaders were supportive, non-judgmental and created an environment for learning. 

The service promoted an open and positive culture. Staff and people told us they felt able to speak up and believed their views would be listened to and acted upon. This was supported by feedback during the inspection, where staff described feeling safe to raise issues without fear of reprisal.

The provider had policies and processes in place to support freedom to speak up, and staff were aware of these. We saw evidence that learning from incidents and complaints was shared in team meetings, and staff were encouraged to contribute to discussions about service improvements.

This approach demonstrated openness to feedback and a commitment to continuous improvement.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Governance systems were effective in identifying, monitoring and addressing risks relating to staff competence, training and the safe delivery of care. Governance processes were in place, these had ensured that all staff had the knowledge, skills and training required to safely deliver substance misuse treatment, including the management of withdrawal and opioid overdose.

Since our last inspection oversight of workforce competence was embedded. The service had addressed the previous low compliance with mandatory medically assisted withdrawal (MAW) training. They had ensured that all staff received training and had the appropriate competence. Since our last inspection staff’s knowledge relating to the use and access of naloxone had improved. Leaders had ensured that since our inspection the skill mix of staff was appropriate for the patients on the ward.

Staff across roles, including registered nurses and healthcare assistants, were able to identify the signs of opioid overdose or describe the use of Naloxone, which is essential knowledge within this service context. This indicated that training was effective and that they had ensured staff competence.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. 

Audit findings were translated into local and divisional action plans, showing that governance structures were in place to support learning and service improvement. Staff were able to demonstrate how audit outcomes informed planned actions. 

Staff had implemented recommendations from reviews of incidents, complaints and safeguarding alerts at the service level.  

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required.  

The service had plans for emergencies. For example, adverse weather or a flu outbreak.  

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care.  

Information governance systems included confidentiality of patient records. We identified some wording inaccuracies in 1 patient record and highlighted these to senior staff at the time. Senior staff took this on board and outlined how this would be addressed. 

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service demonstrated effective systems to support continuous learning, improvement and innovation across the organisation. Processes were effective in identifying and responding to risks in a timely way.

The service had processes to support learning and improvement. 

Staff told us they were able to contribute ideas for improvement through team meetings, and opportunities for professional development, including specialist training and apprenticeships, were available. There was evidence that demonstrated learning from incidents, audits or feedback was embedded into routine practice or used to deliver sustained, measurable improvements.