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

All wards were 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. The service had effective systems to monitor safety through a structured audit programme, with high levels of compliance overall and timely action taken to address isolated shortfalls.

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 and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events thoroughly. Lessons were learned to continually identify and embed good practice.

There were systems in place for recording and reporting incidents. We reviewed incident data from January 2025 to December 2025. During this period there were 60 incidents within this service. Though the incident rate in Lower court was low the data showed that incidents were recorded against different category types. Staff had access to an electronic reporting incident system. When things went wrong, staff apologised and gave patients honest information and suitable support.

Staff told us lessons were shared at handovers. We attended handover on Lower court ward and saw that learning from incidents and patient support and interactions were shared with staff.

Staff were debriefed and received support after incidents.

The service had systems to identify areas requiring improvement, including training compliance and supervision gaps.

The evidence showed a good standard. The service worked with people and their partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. They made sure there was continuity of care, including when people moved between different services, and involved all the necessary healthcare and social care services. Staff planned patients’ discharge and worked with community services and GP practices to make sure this went well.

The service had operational procedures in place to support safe systems, transitions and pathways for treatment and recovery. Staff worked within a multidisciplinary team, made up of nursing staff, healthcare assistants, medical staff, occupational therapists, psychologists, pharmacists and social workers. The team worked well together to look at the patient pathway and delivery of care.

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. There was a clear admission criteria, robust risk and physical health monitoring and escalation process, effective multidisciplinary delivery of evidence-based care pathway from admission through to discharge.

Staff work across the wider provider network to ensure patients’ needs were met within pathways.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect and they made sure to share concerns quickly and appropriately.

The service's processes promoted people living free from abuse, neglect, and avoidable harm. We saw evidence that there were systems, policies, and practices in place to make sure people were protected from abuse and neglect. The service had a comprehensive safeguarding procedure and a range of policies to protect adults and children.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and were aware of the safeguarding leads within the service. However, not all staff were able to clearly articulate safeguarding concerns or provide patient specific examples relevant to the ward. Leaders were aware of this and described ongoing safeguarding training oversight and staff support to strengthen staff confidence and consistency. Leaders had taken action to strengthen safeguarding practice. This included introducing monthly safeguarding workshops, supported by senior clinical leads and implementing competency assessments for all relevant staff (target completion 31 March 2026. Safeguarding will also be embedded into monthly quality walkarounds to test staff understanding and support ongoing oversight.

Staff were kept up to date with mandatory training for safeguarding adults and children. Staff were kept up to date with both training on the Mental Capacity Act, Mental Health Act and the Oliver McGowan Mandatory Training on Learning Disability and Autism. At the time of the assessment, safeguarding adults and children training compliance rate was 100%. We reviewed the service safeguarding log from January 2025 to December 2025. For this period 4 safeguarding concerns were formally reported. Each report recorded the safeguarding concerns raised, immediate action taken and outcomes. We saw collaborative working in partnership with other agencies.

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.

During the assessment, we reviewed 4 risk assessments and saw that patients had a risk assessment in place on admission, and these were thorough and regularly updated. There were management plans in place for identified risks and needs of individuals.

Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff knew about any risks to each patient and acted to prevent or reduce risks. Staff shared key information to keep patients safe when handing over their care to others. Shift changes, handovers and multidisciplinary meetings included all the necessary key information to keep patients safe. The ward staff participated in the provider’s restrictive interventions reduction programme. The service had a reducing restrictive practice policy in place. It aimed to support the reduction of restrictive practices to ensure that least restrictive principles and practices were supported.

There was evidence of appropriate restrictions to manage individual risks that had been care planned. We observed ward rounds where patients and members of the multidisciplinary team discussed individual needs and associated risks. Discussions included agreed risk‑mitigation strategies and how patients and staff would work together to support safe care, including actions to take if a patient became more unwell or attempted to leave the ward. Where appropriate, these plans involved family members and external support services.

The service provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were clear procedures for supportive observations and engagement, staff we spoke with knew these. Observation records were complete and accurately maintained. Staff demonstrated a clear understanding of observation levels and carried out intermittent observations at random intervals in line with provider policy.

The service detected and controlled potential risks in the care environment and made sure equipment, facilities and technology supported the delivery of safe care.

The ward environment was clean, tidy, well-furnished and well maintained throughout. Staff monitored the wards each day to identify any risks or repairs that were needed. 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. Staff did regular risk assessments of the environment. They completed and regularly updated ligature risk assessments for all internal and external areas.

Staff we spoke with knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Staff assessed risks to patients and took action to reduce risks where possible. Staff had easy access to alarms and patients had easy access to nurse call systems.

The wards complied with guidance on eliminating mixed-sex accommodation. All bedrooms were single person occupancy with en-suite facilities.

Fire safety arrangements were robust. Fire Risk Assessments were up to date, regular fire drills were undertaken, and weekly fire alarm testing was completed.

Patients had access to lounges and quiet areas, including a female only area. Therapy and activity rooms were located off the ward. A well maintained outdoor space with seating and recreational facilities were accessible.

The service made sure there were enough appropriately mental health trained, qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Lower Court operated with a fully established nursing workforce, with no current vacancies for RMNs (7.3 WTE) or Health Care Assistants/support workers (9.6 WTE). Staffing levels were planned and delivered in line with a clearly defined staffing ladder, which adjusted staffing numbers according to patient acuity and average daily census. This ensured staffing ratios always adapted to patient dependency.

There was adequate medical cover day and night and at weekends.

The service demonstrated a reduction in reliance on agency staff, with agency usage decreasing steadily from July 2025 and reaching zero agency usage by November and December 2025. Where required, bank staff were used appropriately to maintain safe staffing. This reduction supports continuity of care and reduces risks associated with unfamiliar staff.

Staff turnover throughout 2025 remained low and stable, with monthly turnover generally between 0–2%, and occasional peaks in February and July. Lower Court experienced minimal unplanned staff movement, with no leavers recorded in several months. Four staff left in January 2026 due to planned redundancies, indicating workforce changes were managed and not reflective of instability.

Staffing levels allowed patients to have regular 1:1 time. There were enough staff to carry out physical interventions such as observations. Staff received the necessary training and induction to do this effectively. Staffing levels were appropriate to patient acuity, agency usage had significantly reduced, and patient feedback was consistently positive.

Most staff had received and were up to date with all mandatory training courses. The training was appropriate for the patient group using the service, with an overall compliance rate of 83.6% at the time of the assessment, and systems in place to monitor training due to expire. High compliance 100% was seen in safeguarding adults and children, complaints management, diversity and inclusion, medicines management, and health and safety. But Basic Life Support compliance rate at the time of the inspection was 66.7%. Managers had booked staff on upcoming training sessions.

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. Cleaning records were up to date, and 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 patient and non-patient areas, hand hygiene, mattress audit and an annual compliance audit. At the time of our assessment, Infection Prevention Control compliance rate was 87.5%.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had systems and processes in place to safely administer and record the use of medicines. Staff followed clear systems for prescribing, storing and administering medicines. Medicines, including controlled drugs, were stored safely and securely. Staff had access to emergency medicines if needed.

Care and treatment were person‑centred. Prescribing regimens were individualised and followed recognised national protocols. People were involved in decisions about their treatment, and their preferences were considered as part of care planning. Staff used both medical and therapeutic approaches to support recovery. Doses were titrated in response to clinical need. Staff monitored for side effects and recorded these in the care record. PRN (when required) medicines were used appropriately. The care records showed reasons for use, associated risk assessments and relevant physical health checks. Most PRN use was for short‑term symptom relief such as sleep or anxiety, and was reviewed regularly. At the time of our assessment, Safe Handling of Medicines compliance rate was 100%.