The Priory Hospital Preston

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.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. Risk assessments did not always contain all known information about patients’ risks and care plans did not always contain all the information required to provide safe care for patients. Environmental checks were not being completed consistently across wards and environments contained risks that had not always been identified. Medicines were not always being administered in line with requirements.

However,

There were sufficient skilled staff who had received appropriate training to meet patient’s needs. Levels of seclusion were very low and staff attempted de-escalation prior to carrying out restraint.

The service was in breach of Regulation 12 for people’s safe care and treatment

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.

We scored the service as 3. 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.

The service had had 2177 incidents in the 12 months prior to our inspection, of these, 69 had been recorded as upwards reporting incidents which required further investigation, as per the providers policy and 2 were recorded as serious incidents.

There had been several absent without official leave (AWOL) incidents over the last 12 months. One of the incidents resulted in significant injury to the patient. A full review was carried out and managers identified learning points including information not being shared at multidisciplinary team meetings, inaccuracies in documentation and previous risks not always being transferred to new risk assessments. Following this incident, the service undertook a review of the multidisciplinary team processes and restructured these to improve the quality and effectiveness of the team. Managers also provided staff with training to support staff to improve their understanding of the new systems.

All staff knew what incidents to report and how to report them and staff reported all incidents that they should report. Staff understood the duty of candour. They were open, transparent and gave patients and families a full explanation if and when things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service and met to discuss that feedback. Incidents were discussed at the daily flash meetings.

Although incidents were also discussed in some of the team meetings, the team meeting agendas were different across wards, and some wards did not have prompts to review incidents. However, staff told us there was a folder in the office containing learning from incidents and managers produced 7-minute briefings to share key messages.

For example, managers shared a 7-minute briefing relating to how to reduce medicines errors and omissions following a spike in medicines not being given due to them being out of stock. They also shared a briefing providing staff with guidance about completing the 5-point risk assessment prior to a patient going on leave, following incidents of patients going absent without official leave (AWOL).

Staff were debriefed and received support after a serious incident.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

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. The provider had an up to date admissions, transfer and discharge policy in place. Nurses at the provider’s bed hub screened referrals and then reviewed these with managers. Staff at the service then reviewed a patient’s history and background prior to taking a decision to admit them into the service.

Staff told us that information provided prior to admission was sometimes considerable and that this meant it was sometimes difficult for them to effectively review all the information within the relevant timescales, in order to make decisions about patient risks and needs. The service had identified this was as an area for improvement and were taking action to improve the process with its partners.

Staff did not always involve all the necessary healthcare and social care services to ensure patients had continuity of safe care. For example, staff arranged professional’s meetings to review ongoing care for patients post discharge. However, relevant professionals were not always invited to discharge meetings.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Staff had received safeguarding training and knew how to make a safeguarding alert. 99% of staff had completed the safeguarding combined adults and young people course.

Staff mostly knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff had submitted 36 safeguarding referrals in the last 12 months where there had concerns that people were at risk. However, staff had not always submitted a safeguarding referral when required. During our inspection, we identified 1 concern relating to patient care where staff had not submitted a safeguarding referral. This was completed following our inspection.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff followed safe procedures for children visiting the service.

The hospital had a register of blanket restrictions which are restrictions that apply to all patients on the ward. There was evidence these had been reviewed and removed when they were no longer relevant.

Mental Capacity Act

95% of staff had received 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 Mental Capacity Act policy, including deprivation of liberty safeguards which was up to date and relevant. Staff were aware of the policy and had access to it.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They mostly did this on a decision-specific basis with regard to significant decisions. However, we reviewed 1 record where a capacity assessment was not decision based.

The service did not have arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Health Act and there was limited consideration of capacity within these audits.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe and supportive.

All patients had risk assessments and accompanying care plans which were reviewed regularly; however, these did not always contain all the patients’ identified risks. We reviewed 8 risk assessments. Of these, 3 did not refer to known risks, including those identified during the patient’s assessment, those shared with the service by other professionals, or risks identified following incidents. This meant that significant information about patient risk, including risk to staff, others and health risks, were not always present in risk assessments or in patients’ care plans.

Whilst we were on site, we observed an incident where staff were required to make a decision about a patient’s leave but did not have the required information to make the decision safely. The information was not present in the patient’s care plan or risk assessment, although it was recorded elsewhere in the patient’s file. This meant it was not easily accessible for staff members having to make day to day decisions about patient care and the staff members making the decision were not aware of the information. We raised our concerns with the provider at the time of the inspection, and the documents were updated to ensure relevant information was readily accessible to staff making decisions about a patients care.

Staff had not always recorded patient’s physical health needs in their care plans which meant staff were not always aware of patient’s physical health problems. For example, we identified 1 patient who had a significant physical health problem disease. This was not present in their care plan which meant that staff had no guidance as to how to support the patient with this issue. We raised this during our inspection, and the care plan was updated to include care and treatment for this following our inspection.

There were 113 incidences of restraint in the service over the last 3 months. Of these Elswick ward had had the highest number with 59 restraints being carried out in the last 3 months. Staff had not used prone restraint in the last 3 months. Managers reviewed all restraint incidents and there was evidence of debriefs taking place with staff and patients and lessons learnt being identified following restraint. There were 19 instances of rapid tranquilisation in the last 3 months.16 of these occurred on Elswick ward, 3 on Rosemary ward and 0 occurred on Cottam ward.

Seclusion numbers were very low. There were 0 seclusions across all wards in the past 3 months and 1 seclusion in the past 18 months.

Staff did not always involve patients in care planning and risk assessment. Care plan templates were person centred and provided frequent opportunities for staff to record patient’s opinions regarding their care and treatment, although these were not always completed. However, staff supported patients to share their views on risk within multi-disciplinary team meetings and patients told us they felt included in decisions about their care.

Staff communicated with patients so that they understood their care and treatment. Patients and carers told us staff communicated well with them and said staff always made time to explain things to them.

Staff enabled patients to give feedback on the service they received including via surveys and community meetings. Staff also ensured that patients could access advocacy.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular risk assessments of the care environment. However, security check documentation for Rosemary ward was not always fully completed. Wards used different systems for completing security checks. The paper systems used on Rosemary ward were detailed, whereas the electronic system used on Cottam ward did not contain the same level of detail. This meant it was difficult to identify if checks on Rosemary ward had also been carried out on Cottam ward because this was not clearly recorded.

Staff had completed ligature risk assessments for each area of the hospital. These were up to date and there was a ligature heat map displayed in staff offices which showed areas of high risk. Staff had mostly mitigated the risks adequately. However, we identified a loose ceiling tile that presented a potential ligature risk. We highlighted this to the provider during our inspection and this was fixed immediately.

Fire risk assessments had been carried out by an external agency and staff reviewed these on a 6 monthly basis to ensure they were up to date.

Ward layouts did not always allow staff to observe all parts of ward. However, the provider had mostly installed mirrors to support staff to check blind spots. We found one blind spot where mitigations were not in place. Following our inspection the provider installed mirrors to mitigate this.

We found some environmental issues on Rosemary ward including peeling paint in the garden areas, a dip in the floor outside the bedroom corridor which was a trip hazard and some staining to the wall in the lounge. There was also limited space in some areas on Rosemary ward which was identified on the risk register. Plans were in place to address this and to improve the environment on this ward.

We observed several patients vaping in communal areas on the wards, even though this was meant to be limited to patient bedrooms. The provider was taking action to address this, such as discussing this issue in the weekly patient forum.

All wards were single sex accommodation and therefore complied with guidance on same-sex accommodation.

Staff had easy access to alarms and patients had easy access to nurse call systems.

There was one seclusion room which was located on Elswick ward. This allowed for clear observation and two-way communication with patients, it had toilet facilities, was well ventilated and patients could see a clock. The room had been used once in the last 18 months.

Clinic rooms were clean, secure and equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. However, the clinic room on Rosemary ward had 1 sharps bin that was not labelled, did not have medium size gloves available and the oxygen cylinders were not stored in line with guidance.

The service had a fridge to keep blood samples in, which was located in the main reception area. The reception area had a glass roof and could be very warm during the summer months. We reviewed the checks for the fridge and found the temperature to be regularly above those recommended. This had not been escalated, and no action had been taken to address this issue. We raised this with managers during our inspection, and they introduced a new procedure for monitoring the fridge temperatures and ordered a new fridge because it was not working properly.

We scored the service as 2. The evidence showed some shortfalls. The service mostly made sure there were enough qualified, skilled and experienced staff. They did not always make sure agency staff received effective inductions onto the ward although staff received support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had 17.8 whole time equivalent (WTE) vacancies at the time of our inspection. A number of these vacancies were due to over recruitment in order to support enhanced observations and some had already been recruited to, and managers were carrying out pre-employment checks. Managers were over recruiting registered mental nurses (RMNs) and health care assistants (HCAs) to help meet the needs of the service.

The average staff turnover per month for the 12 months prior to the inspection was 2.2% across the whole hospital and the average sickness absence over the previous 12 months was 4.2%. In the 3 months prior to our inspection, managers had used 175 registered mental health nurse agency shifts and 1007 health care assistant agency shifts. In addition, they used 48 registered mental health nurse bank shifts and 190 health care assistant bank shifts. Agency use was broadly the similar on Cottam and Elswick ward and lower on Rosemary ward.

Managers had calculated the number and grade of nurses and healthcare assistants required. The number of nurses and healthcare assistants matched this number on most shifts. The ward manager could adjust staffing levels daily to take account of case mix and managers moved staff between wards when needed.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. These tended to be higher on weekends and night shifts.

When agency staff were used, it was not always clear whether those staff received an induction and were familiar with the ward. We attended an evening handover. There did not appear to be a process for identifying staff who were new to the ward. Following the handover, a staff member identified themselves as new to the ward and staff provided him with an induction.

Staffing levels allowed patients to have regular one-to-one time with their named nurse.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. No cancelled leave had been recorded in the last 12 months and patients told us staff facilitated their leave.

There were enough staff to carry out physical interventions, observations and restraint safely and staff had been trained to do so.

There was adequate medical cover day and night. A doctor was present on site at all times, and a consultant was on call to provide extra guidance. Staff liaised with the acute hospital in case of physical health emergencies.

Staff had received and were mostly up to date with appropriate mandatory training. The training was appropriate for the patient group using the service and included safeguarding combined, basic life support with defibrillator, immediate life support, the Mental Health Act and the Oliver McGowan mandatory training on learning disability and autism. Although 95% of staff had completed tier 1 of the Oliver McGowan training only 51% had completed tier 2 because not all staff had not completed their initial assignment for this course.

3. We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff mostly maintained equipment well and kept it clean. Most ward areas were clean, had good furnishings and were well-maintained, with the exception of some staining in one of the lounge areas.

However, we found one patient bathroom that had a dirty sink and shower and one of the kitchen pantries which was dirty and contained some damaged and dirty cabinets. The service had plans to replace these and this was completed following our inspection.

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

Staff adhered to infection control principles, including handwashing. Handwashing audits had been completed and were 100% on all wards.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, they involved people in planning.

Staff mostly followed good practice in medicines management such as storage, administration, medicines reconciliation, recording and disposal, and did it in line with national guidance. We checked a sample of medicines which were in date, clearly labelled and securely stored.

Staff carried out medicines audits and produced action plans where issues were identified. The provider had links with a local pharmacy who also carried out medicines’ audits.

We reviewed 21 medicines charts, most of these were accurately completed. However, we found 1 medicines chart that had not recorded a patient’s adverse reactions to clozapine, however, there was no impact in relation to this as the patient had not been prescribed clozapine at the time of our inspection. We also found 1 medicine chart where staff had incorrectly recorded the patient’s date of birth.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance.

Staff completed regular medicines audits including controlled drugs audits, storage of medicines and completion of T2s and T3s which are legal documents required when administering medication to detained patients. Action plans were put in place where errors were identified.

Managers had completed a 7-minute briefing in response to incidents of missed medication due to medication being out of stock. This related to 114 occasions over a 2 month period where medication wasn’t given due to it being out of stock. Managers had developed a competency tracker to help them monitor medication competency and ensure this was up to date. The tracker also included bank and agency staff.