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.

Our overall rating of safe at The Priory Hospital Hayes Grove eating disorder unit is 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 service had a proactive culture around incident reporting and learning to continually identify an embed good practice. The service reported 35 incidents in the last 12 months, which were discussed at team and clinical governance meetings. Each morning staff attended a meeting where all incidents from the previous 24 hours were discussed. Staff we spoke with could describe how and when to report an incident. Staff reported serious incidents as required, following the provider’s policy. Incidents were logged on an electronic reporting database.

Staff demonstrated a strong understanding of duty of candour by maintaining an open and transparent culture. They provided patients and families with comprehensive explanations and apologised when incidents occurred.

Staff said they were involved in discussions about incidents. Staff were aware of recent incidents, such as a patient leaving the toaster on for too long and the fire alarm being set off. Lessons learned were reviewed and management looks at ways to prevent this from happening again in the future, to prevent risk of fire on the ward.

The service had clear admission process is and pathways in which safety was managed and monitored. The service had established strong relationships with stakeholders and external organisations to ensure the continuity of care, including when people moved between different services.

The hospital received referrals and admissions from NHS Trusts and was currently taking part in a pilot with an NHS Trust about focused admissions. The hospitals referral and admission processes ensured that all essential information about the patient was received to determine if the patient's needs could be safely met. A carer shared with us, that prior to their child being admitted to the hospital, they were welcomed to have a tour of the ward and hospital site which they felt was very good practice.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the hospital and post-discharge. We observed evidence of this during meetings and discussions held between the hospital and community teams from external services. Staff used clinical meetings and detailed handovers to communicate any identified risks and ensure a safe transition into the service.

Staff worked to ensure patients weren’t in hospital any longer than needed. The hospital operated a three-phrase treatment plan: acute phrase, the patient is supported with physical stabilisation, and a patient can be discharged at this stage if they are physically stabilised. The progression phase is where patients start to mobilise more and become more involved in their own care by cooking and completing other tasks for themselves. The transition phase involves patients doing what they would do at home, shopping cooking etc and practising a safe environment and continuing to improve their relationship with food.

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 knew who the safeguarding lead within the service was and how to contact them.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff received training in level 1 and 2 safeguarding training for adults and children and demonstrated that they knew how to identify adults at risk of or suffering from harm and worked with other agencies to ensure their protection. We observed that 85.3% of staff had completed their level 1 and 2 safeguarding adults and 88.2% of staff had completed their level 1 and 2 in safeguarding children and 86.7% of required staff had completed Safeguarding Combined: Adults and Children & Young People ‐ Level 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.

We looked at 6 risk assessments and risk management plans during the assessment. Risk assessments included physical and mental health, risks around patients eating disorder, collaboration with services, risk of absconding, self-harm, safeguarding and capacity.

90.3% of staff had completed reducing restrictive intervention breakaway training.

Staff involved patients in care planning and risk assessment, evidenced in care plans and participation in multidisciplinary team reviews. All patients care plans were signed and most patients shared that they had access to a copy of their care plan.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff enabled patients to give feedback on the service they received through regular community meetings; we reviewed minutes from these meetings. The provider was proactive in addressing concerns or queries that were raised by patients.

Staff ensured that patients could access advocacy services. Advocates are employed externally to the service and provide support for individuals to express their views, understand their rights and participate in decisions affecting their care and lives.

At the last inspection, we found not all patients with physical health diagnosis had risk assessment and management plans in place, and staff did not always update records about risks. During this inspection, we found this had been improved and there was no longer a breach of regulation.

The ward environment was clean, tidy, and well maintained throughout, including bedrooms, communal areas, bathrooms, kitchens, and outdoor spaces. Décor was therapeutic, with artwork displayed, and furniture was in good condition.

The ward layout enabled effective observation of patients. Although some areas were out of direct sight of the nursing station and office, risks were appropriately mitigated through CCTV and mirrors. CCTV signage was clearly displayed and visible across the ward. No ligature risks were identified outside the ward risk assessment, and ligature cutters were readily available in a clearly identifiable red pouch within the nursing office. Staff did regular risk assessments of the care environment. Staff had access to this assessment and a map in the staffing office indicating high risk areas.

Patients had unsupervised access only to bedrooms and lounges. Clinical rooms and secure areas were always locked. There was sufficient space to safely manage patient numbers, including for restraint if required.

Fire safety arrangements were robust. Fire Risk Assessments were up to date, regular fire drills were undertaken, and weekly fire alarm testing was completed. No patients currently required a Personal Emergency Evacuation Plan (PEEP), following an initial assessment at admission to the ward. Posters alerting staff to the risk of tailgating were displayed on the ward.

The ward layout promoted comfort, dignity, and privacy. All patients had single bedrooms with en-suite bathroom facilities. We saw that bedrooms were personalised. Patients had access to their bedrooms during the day, except during supervised sessions.

Patients had access to multiple lounges and quiet areas. Lounges were well equipped with TV, DVDs, newspapers, magazines, board games, games consols, crafts and activities, supporting meaningful occupation. Therapy and activity rooms were located off the ward. A well-maintained outdoor space with seating and recreational facilities was accessible.

The service had a designated visitors’ room, which was located off the ward and children were allowed to visit if risk accessed as safe.

The ward operated clear stages of care (acute, progression and transition). Patients in the transition stage accessed the downstairs restaurant for meals, supporting recovery and reintegration. Drinks and snacks were available 24/7, managed through a timetabled approach in line with eating disorder risk management.

Patients had access to information on complaints processes and ward leadership. Independent advocacy attended the ward regularly. Information was available in easy-read formats, with additional languages provided on request. Inclusive information was displayed to support patients with protected characteristics.

A discharge tree was displayed on the ward, where former patients left messages and expressions of gratitude, promoting hope and recovery. Clear information boards were observed, including a named nurse board, and a board displaying all ward staff names and photographs, supporting transparency and patient engagement.

Staff were visible and engaged in communal areas, interacted positively with patients and demonstrated familiarity. The ward atmosphere was calm, supportive and therapeutic.

Staff completed daily and weekly ward checks, including daily environmental and weekly equipment checks. Patient observation records were fully completed with no gaps identified. At the time of the visit, one patient was on 1:1 observation. Staff had a clear understanding of the different levels of engagement and observations to manage patient risk. Staff could clearly describe how to carry out intermittent observations at random intervals, so that there was no predictable period of time that a patient was not being observed. Observation records showed staff carried out intermittent observations at random intervals, in line with provider policy.

Robust risk management processes were evident. The 5-point risk assessment folder and leave risk assessment forms were available and completed, with clear documentation of patient risks and required observations prior to leave. Inspectors observed appropriate preparation and staff oversight prior to supervised sessions and Nasogastric feeding, demonstrating structured and safe practice.

Staff had easy access to alarms and patients had easy access to nurse call alarms wall alarms were fitted in communal areas and in each patient bedroom.

The hospital did not have a seclusion room. The hospital did not accept referrals of patients where there was an indication that the patient may need to be cared for in a seclusion room.

Managers had calculated the number and grade of nurses and health care assistants required to safely support the care and treatment of patients. Managers adjusted staffing levels according to the needs of the hospital, for example, when a patient was nursed on enhanced observations or there was high acuity on the ward.

Staff told us there were enough staff on shift to meet the needs of patients. This included facilitating leave and activities on and off the ward, regular patient engagement, enhanced observations and ensuring staff got appropriate breaks.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff received an appropriate induction to the ward and refresher training where needed. Staff were required to complete mandatory training. The training was appropriate for the patient group using the hospital, staff are required to complete 4-day face to face eating disorder course 77.6% of staff have completed this training. We observed that 81% staff had completed basic life support or immediate life support training. All staff had completed training on Autism and learning disabilities.

Staff received monthly clinical and managerial supervision, where they could discuss safeguarding, audits, required learning and discuss patients they supported. Staff wellbeing, sickness figures and annual leave allowance would also be discussed during their supervision.

Staff had a varied completion rate for their monthly supervisions, with an average of 82.33% over the last 6 months. Management shared that the ward acuity can have an impact on supervision completion percentage. The annual appraisal rate for 2025 was 95.8%, with 2026 annual appraisals marked as ‘in review’ or ‘assigned’.

Staff and management reported that staff morale was low at the moment, due to redundancies being made across the hospital, due to the closure of a ward.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. All areas were clean, had good furnishings and were well-maintained. The service was decorated to a high standard and had a homely feel. Patient artwork was displayed throughout the building.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing. Staff understood how to store and label food in the kitchen.

The service had systems and processes in place to safely administer and record medicines use. Staff followed clear systems for prescribing, storing and administering medicines.

Care and treatment was person‑centred. Prescribing was individualised and supported a therapy‑led model. Medicines were reviewed weekly by the multi‑disciplinary team (MDT), and treatment was discussed with patients. People were prepared for ward rounds and took part in decisions about their medicines. Psychotropic medicines were titrated as needed in line with national guidance. Staff reduced or stopped medicines as people progressed through treatment phases.

Physical health risks were monitored well. Staff completed ECGs, blood tests and regular physical health observations. There was good awareness of re‑feeding syndrome and how to manage it. Supervised administration reduced risks of refusal, hoarding and diversion. The ward used structured, non-medicine based de‑escalation before using PRN (when required) medicines. When oral medicines were not accepted, NG (nasogastric) administration was available, and staff sought pharmacist and dietetic input.

Medicines governance was embedded throughout the service. Staff were supported with daily and weekly checks for the safe and secure handling of medicines by a digital system which recorded when checks were due and completed. Stock and TTO (to take out medicines) cupboards were organised, and short‑dated items were tracked. Pharmacy support was available from an external pharmacy supplier in person or remotely. There was a process for medicines reconciliation (the gathering of accurate information about a person’s current medicines), clear discharge information and timely follow‑up. When risks were identified, the service worked with community mental health and GP liaison teams to support people once they left the ward.

Staff completed post-dose monitoring for patients who received rapid tranquilisation (RT – where a medicine is administered intramuscularly to help calm a person who is extremely distressed and/or agitated). This is required to ensure people are kept safe when medicines are given this way.

There were some small areas for improvement, PRN governance and documentation were not consistently robust, including recording of rationale, alternatives tried and effectiveness, and adherence to dose limits. This can help inform decision making around the use of these medicines. Naso-gastric (NG) administration instructions were not consistently defined on prescriptions, and a ward‑level medicines care plan for preparation and flush volumes was not in place.