The Priory Hospital

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse, and discrimination.

At our last assessment which took place in 2017, we rated this key question as inadequate. At this assessment, the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff told us there was a positive culture within the service, the relationships between the nursing and medical staff was positive.

Staff told us they were up to date with their training. The service had a 90% compliance for meeting mandatory training, which the service had met this target. The training was comprehensive and met the needs of patients and staff.

Staff had a good understanding of how to report incidents and told us they received feedback from management with outcomes and any learning from the incidents.

The service told us in the last 12 months they had only 1 serious incident which had occurred in February 2024 and was categorised as moderate harm. There was a system for recording and acting on serious incidents, evidence reviewed showed evidence of learning and dissemination of information to reduce likelihood of reoccurrence.

The service held daily huddles where the different departments would attend and discuss incidents and any learning and enable the service to make continuous improvements when incidents occurred.

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

The service had patients that were referred via the NHS and some patients would pay privately for their care and treatment.

The service used paper patient records, the 12 sets of records we reviewed, had the correct information collected. These were up to date and all entries were signed and dated by staff. All records were stored securely in a locked cupboard.

The service completed documentation audits. From April to July 2024 the compliance was 100% and from August to November 2024 the compliance was 95%.

The service could evidence collaborative working links with local GP’s, local mental health service, and the local authority. This was evidenced by sharing patients care and treatment with GPs to enable them to continue with the patients care. The service would consult with local mental health service to seek an advice or support when required for example, if a patient presented with mental health concerns.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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.

In the last 12 months, the service reported 2 notifications to the CQC, which related to seeing patients who were under 18 years of age, as they were not regulated to see children within the service. During our assessment we saw new systems were in place, and these were embedded to ensure patients under the age of 18 years are not seen in future at the service. There had been no reported safeguarding concerns within the service in the last 3 months.

The service had a safeguarding vulnerable adult at risk policy which had been implemented in April 2024, the review date was set for April 2027.

Staff were able to give examples of the different forms of abuse and neglect; they told us how they would escalate a safeguarding concern.

Staff had a good understanding of multi-agency working, including the police and local authority.

Staff had completed safeguarding adults’ training at level 2 and 3 depending on the staff role, with uptake rates of 100%. Staff also completed safeguarding children’s level 2 training; however, this was for children coming into the department with their parents as the service were not registered to treat children under 18 years of age.

Mental capacity act (MCA) and deprivation of liberty safeguards (DoLS) training was included with the safeguarding training.

The service had 2 senior managers that had been trained in safeguarding level 4. Staff could escalate concerns or seek advice from them.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

We spoke with 10 patients and observed 12 clinics with the patients’ consent, patients told us they had a good understanding of their care and treatment, and they felt they were able to ask questions if they did not understand what had been explained to them.

We were told once the patient had attended their appointment, they received a letter providing an overview of the appointment. This was further demonstrated when we reviewed patients record.

During the on-site assessment we were not able to observe any procedures as patients did not consent to a member of the team being present. However, we reviewed the World Health Organisation (WHO) check lists, these are checks the staff complete before any procedure takes place to ensure the correct procedure were being completed. These were completed in line with national guidance.

The service had completed WHO checklist audits and for the last 12 months, these were completed quarterly, the scores for overall compliance was 100%.

The service had local safety standards for invasive procedures (LocSSIPs) in place, which were implemented in January 2024 and due to be reviewed in January 2027.

The service had emergency equipment, policies, and processes in place for the managing and escalation of a deteriorating patient. This included a resident medical officer (doctor) being on-site and would assess patients and escalate care as appropriate. This may include an external transfer to a local NHS trust. Staff followed the care of the deteriorating patient policy, which had been issued in August 2024, with a review date of August 2027.

The service did not undertake a separate sepsis audit as this was built within the incident reporting system.

We observed 1 interaction where a consultant had insufficient time to discuss bad news with a patient, however, all other observed interactions showed doctors taking time to ensure patients were fully supported and understood information provided. 

There was a total of 11 staff that had completed adult immediate life support (ILS) with a compliance of 90% which met the sites target. There were 18 staff had completed adult basic life support (BLS) with a compliance of 100%.

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

The service had recently refurbished the department, which was over one level, based on the first floor, the rooms and corridors were spacious which was easily accessible to all patients.

The service had a spacious waiting room with enough seats, where patients were able to bring family members/ carers with them if required. The service had enough toilets, and disabled toilets facilities for patients and family members to use if required.

The service had clinic rooms; these were all equipped correctly, each room had clinical hand washing facilities.

They had hot and cold drinks machines available if patients required a drink.

There were fire evacuation plans within the service, firefighting equipment was clearly accessible and in date.

The minor operations room was used as a dual-purpose room with endoscopy services. Staff raised concerns in relation to the physical movement of equipment, the cleaning of the room and the equipment after use during our assessment. These concerns were raised to the senior management team during feedback. We requested for a risk assessment for the use of the minor operations room. The service shared a risk assessment issued on the 31 January 2025, which was after our assessment dates, which identified they were mitigating the risk.

The service offered chaperones for any patient who would like additional support to attend their appointments.

The service had a resuscitation trolley which had been tagged and cleaned, daily checks had been completed” 

All clinic rooms had emergency call bells if the consultant required support.

The service had a process and policy in place for management of patient safety alerts. Safety alerts were added to the electronic recording system and allocated to the relevant head of department. The quality and risk team tracked the progress of completing the safety alert. New or overdue safety alerts were discussed at daily morning huddles. The safety update document was shared with all staff at the end of each month, which included any new or updated safety alerts. Safety alerts were also discussed within the clinical and governance meetings.

The service provided data to evidence that all electrical equipment had been assessed and were safe to use.

Sharp bins were all dated and closed.

Clinical waste was appropriately bagged and removed when required by staff.

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

We spent time observing staff interacting with patients and there appeared to be enough staff at all levels and experience.

The service had processes in place to monitor staff absences; they also looked at clinics for the day, reviewed the daily planner to enable them to identify the number of staff required on each shift and adjust staffing levels as required.

Staff told us there were high level of sickness, and vacancies however, managers closely monitored this. For the months of October, November, and December 2024 the service did not use any agency staff, however, for the 3 same months the service used bank staff to cover any vacancies, annual leave, and sickness, to ensure shifts were covered.

During the annual year of 2024, the service had 9 staff leave the service. Which means there were annualised attrition scored 28.7%.

The service monitored staff sickness and in October 2024 these were 26.10, November 2024, there was a slight decrease to 25.93, for December 2024 this increased to 28.36. This calculated to 80.39 hours lost in 3 months equalling to 0.62%, which means during this time there had been continuous staff sickness.

The service told us the only vacancy they had was for 1 senior registered nurse, once this had been filled the service would have a full quota of staff.

Medical staff worked across several locations under practicing privileges arrangements.

The service had a safer staffing framework document which stated the purpose of the framework was to ensure the service had an evidence-based strategy for setting and reviewing minimum safe staffing levels and skill mix in line with national recommendations and guidance, which the service was meeting.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The outpatient department was visibly clean, and substances hazardous to health (COSHH), were stored in a locked cupboard. On checking the cleaning products, which was monitored by housekeeping staff, we identified a product was out of date, which we informed the team, and this was removed.

The service had a notice board for infection control information displayed on the office.

Each clinic room had personal protective equipment, accessible to all staff, this included aprons and gloves.

The waiting room had masks and wipes available for the patients who had the option to wear a mask or not.

Staff used “I am clean stickers” on equipment once cleaned as these are visible indicators equipment had been cleaned.

We spoke with housekeeping staff during the assessment, where we discussed cleaning rotas and how areas for cleaning were identified, and how they had a process of what needed to be cleaned daily, weekly, monthly, this had been clearly identified on the cleaning rotas.

The service used disposable curtains as required, these were last changed in November 2024, we saw there was a system in place to ensure these were changed at least every 6 months or earlier if needed.

The service had an infection prevention and control procedure in place which was issued on 14 November 2024, with a review date of December 2027.

Staff completed quarterly infection prevention and control (IPC) audits, for the quarter January to March 2024 the overall score was 97%, However, for all further audits in 2024 the overall score was 100%.

The service completed hand hygiene audits, these were completed quarterly, with each audit for 2024 being 100%.

Staff held IPC meetings; we saw the last IPC meeting took place 20 January 2025. There was an action plan with 20 actions identified from February 2024. The service used red, amber, and green (RAG) tool, 8 actions were green, 6 actions were amber, leaving 6 without a RAG rating.

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

The service held medicines; these were topped up weekly by a pharmacist. Staff could request medicines as and when required. Expiry dates on medicines were checked by pharmacy staff and clinical staff.

We observed the medicine cupboard was situated in a locked cupboard, which was also secured. There were no concerns on how the medicine had been held. The service did not hold controlled drugs (CD) and to take out (TTO) medicines were dispensed by pharmacy.

The service had policies and procedures in place, the policy for the safe management of medicine had been issued on 21 September 2024, with a review date of September 2027.

Medicines were signed out and into specific clinic rooms each day, by clinical staff.

Fridge temperatures were checked daily, recorded, and up to date, with instruction on action to take if there were any issues with temperatures outside of the recommended ranges. Staff would raise this when needed.

Private prescriptions were kept in a locked cupboard and only issued if requested. The service followed procedures and there was clear evidence of a record being completed of all prescriptions issued. We observed a doctor requesting a prescription, then the nurse providing this.

The service completed quarterly medicine audits, March to May 2024 scored 100%, June to August 2024 the score was 95%, and for September to November 2024 the score was 98%.

Staff held medicine management meetings. We reviewed the minutes of the meeting held on the 16 January 2025. The minutes detailed an action plan with 25 actions identified, there were 5 actions rated green RAG, 6 actions which were amber, and the other actions had no rating, as these were identified in the January 2025 meeting. There were plans in place to address the actions.

The service completed an antimicrobial stewardship audit in November 2024 and scored 100% and therefore ranked a full pass.