The Priory Hospital Hayes Grove

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on the best available evidence.

Our rating of effective stayed the same. We rated it as good because:

Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

During the assessment we reviewed 4 care records. Staff completed a comprehensive mental health assessment of patients in a timely manner, or soon after admission.

Staff developed care plans that met patients’ identified needs during assessment. We reviewed 4 care plans that were personalised, holistic and recovery oriented. The care management plans included input from different professionals such as General Practitioners (GPs), Occupational Health, Psychologists and any other relevant professionals to meet individual needs.

There was evidence of patient involvement in care planning. Care records showed a collaborative approach between staff and patients, including empowerment and an individualistic approach to care. Staff offered patients a copy of their care plan.

There was limited evidence of carers’ involvement in care planning from the records. However, carers we spoke with told us they were involved, and not all patients had agreed to carer involvement or had families/carers.

Staff assessed patients' physical health needs in a timely manner after admission. Patients' physical health was regularly monitored and checked. We saw examples of good physical health monitoring and appropriate escalation process in patients' records.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence. Patients had access to psychological interventions, this included individual and group support such as cognitive behavioural therapy (CBT), Dialectical behaviour therapy (DBT) and Eye movement desensitisation and reprocessing (EMDR).

Staff ensured that patients had good access to physical healthcare and supported patients to live healthier lives. Patients took part in meaningful activities to develop everyday living skills and could access groups and services within the local community such as the local swimming pool and gym. Staff used recognised rating scales to assess and record severity and outcomes. They also participated in clinical audit, benchmarking and quality improvement initiatives. The ward used Health of the Nation Outcome Scales (HONOS) to assess and record patient treatment outcomes.

The team included or had access to the full range of specialists required to meet the needs of patients in the service, including doctors and nurses, occupational therapists, clinical psychologists, social workers, pharmacists, dieticians and support workers.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group.

Managers provided new staff with appropriate inductions including students.

Managers provided staff with supervision, and opportunities to update and further develop their skills. Supervision compliance was variable, with strong performance mid-year but a notable decline towards end of 2025, particularly for managerial supervision. In December, clinical supervision compliance was 60% and managerial supervision 18.75%. Most staff said they found supervision with their managers very helpful.

Managers ensured that staff received the necessary specialist training for their roles. For example The Oliver McGowan Mandatory Training on Learning Disability and Autism. The compliance rate for training Tier 1 at the time of the inspection was 100%. The Tier 2 was 41.7% as training was conducted face to face.

Managers identified the learning needs of staff and staff told us there were opportunities for further development. For example, deputy ward manager told us that there are ongoing teaching packs to do with all staff around seizures and training, this will take effect once they know the staffing level.

Managers ensured that staff had access to regular team meetings. Staff said that they discussed activities on the wards, complaints and compliments, learning from incidents and audits, and this was reflecting in meeting minutes.

Staff worked effectively across teams and services to support people, by sharing their assessment of needs when they moved between different services.

Staff held regular and effective multidisciplinary team meetings. We observed a multidisciplinary handover meeting and saw detailed, patient-led discussions. Staff discussed new risks since the previous meeting and shared important information that all attendees should be aware of. Staff shared information and updates on patients, their presentation, and level of risk and support needed. They also shared activity updates for each patient and any external team input and plans.

The teams had effective working relationships, including good handovers and regular team meetings. Staff shared information about patients at effective handover meetings within the team, for example, shift to shift.

Staff had effective working relationships with teams outside the organisation, including for example, local authority social services and GPs.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Ward activities helped promote a healthy lifestyle for patients, for example, walking groups and sports activities.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service responded appropriately to referrals, declining those that were not suitable or where required support could not be safely provided. Over the last 12 months, 46 referrals were declined for appropriateness reasons, indicating appropriate gatekeeping and risk awareness.

Care delivery was responsive to patient acuity through flexible staffing arrangements and structured ward routines.

Family involvement was supported through structured forums and regular communication opportunities.

Care planning and risk assessment audits reviewed the quality, completeness, and individualisation of patient records. Restrictive practice audits examined the use of any blanket restrictions and the management of behaviours that challenge, ensuring that practice remained proportionate, justified, and evidence‑based.

Physical health audits assessed the monitoring and escalation of physical health needs, as well as how effectively physical healthcare was integrated within mental health pathways. Observation and engagement audits evaluated whether patients were being appropriately observed and meaningfully engaged in therapeutic activity to support their recovery and wellbeing.

We saw that audit findings were translated into both local and divisional action plans, demonstrating a clear link between audit outcomes, learning, and ongoing service improvement.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff took all practical steps to enable patients to make their own decisions. There was evidence within care records that staff complied with the Mental Capacity Act 2005. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. At the time of our assessment, Mental Capacity Act compliance rate was 87.5%.

The service maintained a comprehensive Mental Health Act (MHA) and consent oversight system for patients on Lower Court Ward. At the time of review, all patients were admitted informally, and the service did not admit patients detained under the Mental Health Act. There was clear recording of ward allocation, bed numbers and informal status, with structured systems in place to track current and historical MHA‑related information, including alerts, expiry dates and previous Deprivation of Liberty Safeguards (DoLS) activity, although no active DoLS were recorded at the point of review. The service worked closely with the local NHS mental health trust and had clear escalation arrangements in place. Where a patient’s mental health deteriorated and there were concerns that an MHA assessment may be required, staff referred promptly to the local mental health service to ensure patients received appropriate assessment and support in line with statutory requirements.