The Priory Hospital Middleton St George

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• 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 requires improvement. At this assessment the rating has remained the same. The service was in breach of legal regulation in relation to safe care and treatment (regulation 12).

The service had made improvements and is no longer in breach of regulations identified at the last inspection. This meant all wards were clean, well equipped, well furnished, well maintained and fit for purpose. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well.

However, on Sycamore ward they were using plastic bags in areas accessible to patients.

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.

There was a clear commitment to a learning culture which was embedded through a structured process with monthly patient safety lessons learnt meetings. Senior managers attended these with ward managers to share lessons learned, review policy updates, and highlight positive practice. Staff reported that lessons from incidents were communicated through team meetings and handovers.

In the 12 months prior to our assessment, there had been one patient death following discharge. The service had completed a thematic review to ensure they identified any lessons that could be learnt. There had been no other serious incidents.

We saw that leaders ensured incidents were appropriately investigated and reported. We reviewed incident records and found that staff reported incidents correctly and managers investigated incidents when required.

There had been 15 incidents which the service had identified as requiring a duty of candour response in the 12 months prior to assessment. The service had complied with their responsibilities under their duty of candour requirements. Medication errors accounted for 14 incidents and the other was a lost sample.

We scored the service as 3. 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 structured pathways and governance systems designed to support safe and effective transitions for patients. The service’s referral and admission processes ensured that all essential information about the patient was received to determine if their needs could safely be met. There was evidence within the care records that information had been reviewed to ensure that staff had the necessary information ready to receive an admission of a patient to the ward, for example information about risks to self and others and physical health.

Staff involved all the necessary health and social care staff to ensure patients had continuity of safe care, both within the service and post-discharge. We could see that efforts were made to encourage the necessary professionals to attend multi-disciplinary meetings and that there was evidence of robust discharge plans being implemented.

We scored the service as 3.. The evidence showed staff did not always ensure patients received their rights under the Mental Health Act. However, the service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrate 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.

There had been 61 safeguarding referrals from the ward, all relating to adults.

All staff were trained (100%) in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Our review of records showed us that systems were working well and enabled all staff to submit alerts which would be reviewed and acted upon by other members of the team where necessary.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

Staff followed safe procedures for children and other people visiting the service.

All patients except one said they felt safe on the ward. It was clear that where patient related safety incidents took place, staff took appropriate action to protect all patients and to prevent further incidents.

Mental Capacity Act

96% of staff had received training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, particularly the five statutory principles.

The service had made no DOLS applications (safeguards to protect people without capacity to make decisions about their own care) in the previous 12 months.

Staff took practical steps to enable patients to make their own decisions. Patients were involved in the development of their care plans, and risk assessments.

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. We reviewed 10 patient records and saw that staff routinely carried out assessments of capacity. We found one record where a patient was not read their rights as they were assessed as not having capacity to understand them. However, there was no record that staff had continued to assess for capacity to receive their rights.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Where it had been agreed with the patient, staff consulted with family members who knew their relative well.

The service had arrangements to monitor adherence to the Mental Capacity Act. There were two Mental Health Act administrators who ensured that the correct procedures and paperwork were in place.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it. The Mental Health Act administrators sent emails to the registered clinician and nursing staff where corrective action was required.

We scored the service as 2. Evidence shows some shortfalls in the standard of care. The service did not always update risk assessments after incidents.

Staff completed risk assessments for all patients but did not always update them when required. Risk assessments were tailored to the patients’ specific needs and correlated with their assessment. The care plans we reviewed were sufficiently detailed to inform staff how best to support people with complex health conditions. We saw 2 instances where risk assessments were not updated after an incident, however we did find all risk assessments were updated weekly.

We looked at 10 patient risk assessments and risk management plans during the inspection. Staff involved patients in care planning and risk assessment. Staff encouraged patients to attend their multi-disciplinary team meetings and offered them copies of their care plans.

During the previous 12 months there had been 1690 incidences of restraint. At Chester ward this related to 1374 restraints, on Birch 200 and on Sycamore 116. Of the 1374 restraints on Chester, 6 patients accounted for 985 restraints. Only one of those patients was still admitted to the ward at the time of the assessment. We reviewed a number of restraints and were satisfied they were appropriate and safely managed. We also looked at how senior managers investigated these incidents and saw they did so robustly.

There had been no instances of prone (face down) restraint.

Staff administered rapid tranquilisation on 572 occasions in the 12 months prior to our assessment. Chester ward accounted for 494 occasions. Managers had reviewed this data and pointed to a changing patient population with new patients being admitted with high acuity. The data supported this with Chesters lowest three months having 2,4 and 7 incidents.

We reviewed incidents where rapid tranquilisation had been recorded, staff had attempted de-escalation and used rapid tranquilisation as a last result. We cross referenced these incidents and they had been recorded within the care records and handover briefings.

There had been 45 incidents of seclusion with 28 on Birch and 17 on Chester. We checked seclusion records and they were complete and evidenced that patients were kept in seclusion for the shortest period possible.

Staff enabled patients to give feedback on the service they received, for example, via community meetings or feedback forms. Patients felt able to feedback concerns. 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.

On Sycamore ward we found three bins that had plastic waste bags inside them. Two were in the communal dining/kitchen area and the other in the unlocked activity room, meaning that patients had access to plastic bags. Plastic bags could potentially be used by patients to ligature and therefore pose a significant risk to patient safety. We raised this with the provider, and they immediately removed the plastic bags and investigated why the bags were in situ. They were unable to produce a risk assessment for the presence of the bags.

Staff did daily safety walks to assess the ward environment, but on Sycamore they failed to identify the use of plastic bags in patient accessible waste bins. We saw evidence of maintenance work being carried out because of issues identified during these checks.

Health and safety checks were carried out and were up to date; these included regular audits of ligature risks, fire safety equipment and procedures, portable appliance tests and staff alarm systems.

Ward layout allowed staff to observe all parts of ward and there were staff working throughout the wards who were able to observe the patients. There were potential ligature anchor points which staff had identified with risks being mitigated adequately. This was managed on an individual basis, such as through individual observations.

Staff had easy access to alarms and patients had easy access to nurse call systems. Records showed that staff responded to incidents quickly. Staff said they felt well supported during incidents.

The seclusion room allowed clear observation and two-way communication and had an ensuite bathroom and a clock. There were controls for dimming the lighting and changing the temperature and there was access to an outside space so that patients could get fresh air and exercise.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We scored the service as 3. 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.

At Middleton St George the Acute/PICU service had consisted of 4 wards but prior to our assessment they had closed one of the acute wards. The closure was planned to facilitate the opening a new core service. Leaders had retained staff from the closed ward and were retraining them for the new service. As a result, during our assessment the wards were overstaffed. The service was now overstaffed by 35.52 working time equivalent posts.

We reviewed staffing levels for the 4 weeks before our assessment and saw staffing numbers above the minimum requirements. Where there was a shortfall, this had been the result of late notification of sickness and other staff had covered these absences.

Other roles such as consultants, occupational therapist, occupational therapy assistant, psychology and physical health nurse were fully staffed.

The service had used 23 hours of agency staff in the 4 weeks prior to the assessment.

The overall mandatory training figure was 98%. The lowest percentage of a mandatory training course was 94%.

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 adhered to infection control principles, including handwashing. They told us that they washed their hands to prevent infection, and that personal protective equipment was available if required.

All ward areas were clean, had good furnishings and were well-maintained. Managers had put in place audits to ensure staff cleaned all areas when required to do so and bedding and other soft furnishings were replaced according to the provider’s policy. Staff made sure cleaning records were up-to-date, and the premises were clean. We reviewed cleaning rotas and spoke with housekeeping staff who were able to show us up to date and comprehensive records. During the inspection we saw continuous cleaning activity, and the wards were clean and tidy.

We scored the service as 3. 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.
Medicines administration records were clearly completed and where needed the appropriate Mental Health Act authorities for prescribing were in place. People were supported to engage with reviews about their medicines. A self-reporting tool was used to monitor for potential side effects from antipsychotic medicines. Information about medicines was available in different formats and languages. Care plan audits included oversight of medicines related information to help ensure that relevant medicines risks and side effects were considered.
On discharge medicines information was sent to people’s GP and any relevant community teams to help support continuity of treatment. However, medicines for discharge were often prepared on the wards. This meant there was a risk that the labelling may be less complete than if the medicines were dispensed in a pharmacy. We raised this with the hospital managers. Prompt action was taken to review practice and implement local protocols.
Hospital managers monitored and reviewed the use of rapid tranquilisation. A recent significant increase in the use of rapid tranquilisation on a PICU ward in November and December 2025 had been explored. Overall usage was found to be comparable to other PICU’s in the provider group. An audit of rapid tranquilisation (February 2025) found that the rationale for using rapid tranquilisation was mostly recorded, however there were some shortfalls in recording patients’ physical health observations. An action plan was completed to support improvement, with plans for re-audit. We found that physical observations were generally recorded in the patient records we reviewed. The hospital had also developed a research proposal exploring the development of personalised risk ‘grab sheets’ to inform the proactive management of violence and aggression.
The hospital has contracted external pharmacy services supporting medicines management audit, training, responding to alerts and medicines governance. The pharmacist reviewed the electronic prescription charts and associated paperwork weekly, reporting on any areas for discussion. Medicines including controlled drugs were safely stored. Medicines audits and incidents were shared at the hospital clinical governance meeting and cascaded for action and learning by ward managers.