Priory Horizon House

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 patients were protected from abuse and avoidable harm. At our last assessment we rated this key question as good. At this assessment the rating remains good. This meant people were safe and protected from avoidable harm.

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.

However, the service did not always detect and control potential risks in the care environment.

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 evidence showed a good standard. 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. Lessons were learnt to continually identify and embed good practice.

Safety was a top priority and involved everyone, including staff and people using the service. Staff understood what incidents they needed to report and how to report them in line with the provider’s policy. The service did not report any serious incidents in the last 12 months.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. Managers debriefed and supported staff after incidents. Managers investigated incidents thoroughly and we saw evidence that changes had been made as a result of feedback.

Staff received feedback from incident investigations, both within the service and from external sources. The service shared this information through a monthly clinical governance newsletter, which highlighted lessons learned and recommendations to improve patient care. Staff also discussed feedback and identified further improvements during regular team meetings.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had effective systems, pathways and processes in place to support the safe care and treatment of people as they moved through services. Staff understood their responsibilities to ensure patients had continuity of care, both within the service and post-discharge.

Staff assessed, monitored and managed patients’ risks in line with national guidance. Staff used recognised clinical tools to identify and escalate deterioration, and risk information was communicated promptly during handovers.

Staff maintained clear admission, transfer and discharge pathways. Records showed that staff completed pre‑admission assessments when appropriate and gathered relevant clinical information to support safe decision‑making. When patients transferred to other services or the community, staff shared essential information promptly, including risk assessments, medicines information, and care plans. For example, we observed a discharge planning meeting where staff involved all the necessary health and social care services, including the local housing officer, to ensure people had continuity of care following discharge. The meeting demonstrated clear coordination, with each professional contributing to the person’s care plan review.

Staff explained that although length of stay could occasionally be slightly longer at this service compared with similar hospitals, this was to ensure people received the full benefit of the dedicated medical input available at the service. Managers highlighted that this approach contributed to a low rate of readmission. Staff advocated strongly for people to remain on the ward when clinically needed, including in circumstances where funding decisions might otherwise create delays.

Managers told us they had never discharged a patient without appropriate housing being available. Staff worked proactively with housing providers, local authorities and social care teams to ensure safe accommodation arrangements were secured before discharge. They emphasised that their role was to ensure people were supported and safe throughout the transition process, and we saw evidence of this commitment in the meeting we observed.

Most of the patients we spoke with told us they understood their care and treatment and the reasons for their admission. Staff were helpful in explaining information to those who did not initially agree with their admission and worked collaboratively with them towards a safe and appropriate discharge.

However, one patient told us they had not been informed about key aspects of their care, including the treatments available to support their physical and mental health needs, their Mental Health Act rights, how to make a complaint, or what local services were available to support them. This indicated that not all patients consistently received the information they needed to understand their care, exercise their rights or access support.

The evidence showed a good standard. 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. The service shared concerns quickly and appropriately.

Staff had the skills and knowledge to keep people safe. They were trained in safeguarding and understood their responsibilities in recognising and responding to concerns. Staff knew how to raise a safeguarding alert and did so when required. They gave clear examples of how they protected people from harassment and discrimination, including people with protected characteristics under the Equality Act.

Staff were able to identify adults and children at risk of, or experiencing, significant harm. They worked effectively in partnership with other agencies, such as local authorities, crisis teams and community services, to manage safeguarding concerns and ensure that risks were addressed.

Staff followed safe procedures for children visiting the service. Staff ensured visits were planned, supervised appropriately, and took place in designated safe areas separate from the ward environment.

Staff monitored restrictive practices and used them only when necessary to maintain safety. Staff used de‑escalation techniques as the first response, and restraint was used as a last resort. When restraint was required, staff recorded incidents clearly, reviewed them promptly, and discussed learning within the team.

Staff had processes to identify, review and reduce any blanket restrictions. Where restrictions were in place, for example, controlled access to items or areas—they were proportionate, clearly justified and regularly reviewed to ensure they remained appropriate. Patients we spoke with understood the reasons for these restrictions and told us staff explained them clearly.

Mental Capacity Act

The provider reported 83.9% of staff had had training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards.

Staff were aware of the policy and had access to it. 78.1% of staff were up to date with their deprivation of liberty safeguards training.

The service had arrangements to monitor adherence to the Mental Capacity Act.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

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. 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 reviewed 6 care records during the inspection to determine whether risk was being assessed and managed appropriately. All records contained an up‑to‑date risk assessment, which covered key areas of potential risk and captured relevant information to support ongoing risk management.

There was clear evidence that staff involved patients in their care planning and risk assessment. Care plans reflected patients’ views, and patients participated in multidisciplinary team (MDT) reviews where their progress, risks and goals were discussed. Patients had access to copies of their care plans and told us they understood the information shared with them.

Staff communicated with patients in ways that supported understanding of their care and treatment, including adapting communication for individuals with communication difficulties. People also had access to appropriate advocacy services to support them in expressing their views and making decisions about their care.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care.

The ward environment did not always support safe care. We saw worn and unkempt areas in the hospital, including the front garden, which needed maintenance. In this area, we found two skips containing items that could pose a risk, as well as gardening tools, including a shovel, which were accessible to patients who had unsupervised access to the area. These items created avoidable safety risks that staff had not identified and addressed.

When we reviewed the environmental ligature risk assessment, we found it did not include the lift, even though patients could use it without staff supervision. This meant the service had not identified or planned for possible ligature risks in that area. We also found blind spots on the ward, including inside the lift, that staff had not recognised or recorded. These blind spots reduced staff visibility and increased the risk of harm, including risks to sexual safety on the mixed gender ward. Because staff had not fully identified or assessed these risks, leaders did not have a complete understanding of the environmental issues and plans to reduce risks were incomplete.

During our review of the clinic room, we also found expired items in the first aid kit, some dated as far back as 2021, indicating that checks of emergency equipment were not consistently effective. We noted a gap in daily oxygen checks in June, meaning staff could not be confident that the equipment was always safe and ready for use.

When we raised our concerns with managers during the inspection, they explained that the hospital was already carrying out a site improvement plan. They acknowledged the issues we found and acted quickly to put appropriate measures in place to reduce the environmental risks.

The evidence showed a good standard. The service made sure there were enough 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.

Managers calculated the number and skill mix of nurses and healthcare assistants needed to provide safe care on the ward. Most staff and patients told us there were enough staff on duty to meet people’s needs.

Our review of staffing information showed there were no vacancies for registered nurses or healthcare assistants at the time of the inspection. The service did have vacancies for an occupational therapist and an assistant occupational therapist, but managers were managing these gaps effectively. Active recruitment was underway, and interim arrangements were in place to ensure patients continued to receive appropriate therapeutic support.

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

Staff had received and were up to date with mandatory and statutory training. At the time of our inspection, the compliance rate for most mandatory and statutory training did not fall below 95%, which met the providers policy requirements. Managers maintained oversight of each staff member’s training requirements, and compliance with mandatory training was consistently monitored. All staff had access to adequate supervision and annual appraisals, with completion rates of 100% for June 2025.

We reviewed a sample of staff files and found that all contained the required checks, including up-to-date Disclosure and Barring Service (DBS) certificates.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

A qualified nurse was always present in communal areas of the ward and staffing levels allowed patients to have regular one-to-one time with their named nurse.

However, some patients told us that their planned leave was sometimes cancelled and they did not always have access to one-to-one sessions with their named nurse. Managers explained that cover was almost always provided and leave would only be cancelled under exceptional circumstances.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During our visit, we found several areas of the hospital that were worn or unkempt, including the garden where we observed litter. Managers told us that approximately 80% of the hospital was carpeted, which poses an IPC risk. They informed us that they had obtained quotes to replace this with vinyl flooring as part of the wider site improvement plan. Training data showed that compliance with mandatory IPC training was 73%, which was below the providers policy.

However, the service had effective systems in place to manage and reduce infection risks, in line with national guidance and best practice. Infection prevention and control (IPC) was a standing agenda item at monthly team meetings, ensuring staff remained up to date with relevant information and expectations. Staff adhered to core IPC principles, including appropriate hand hygiene and a bare-below-the-elbow approach.

Overall, equipment was well maintained, clean, and checked regularly. Cleaning schedules were completed consistently and demonstrated that ward areas were cleaned frequently and to a good standard.

Patients told us that the hospital environment, including toilets, bathrooms, and the kitchen, were kept “very clean”.

The evidence showed a good standard. 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.

Staff followed good practice in medicines management and did it in line with national guidance.

Our review of care records showed that staff regularly monitored the effects of medication on patients’ physical health in line with national guidance, particularly for those prescribed high‑dose antipsychotic medication. We reviewed 4 patient medicines administration charts and found that patients had been given their medicines as prescribed.

However, during our review of the clinic room, we identified expired medicines and found an open insulin box in the medicines fridge with no record of when it had been opened. This meant staff could not be assured it was still safe to use.

When we raised these concerns with the management of the service, they immediately rectified all the issues.