The Priory Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred, and sustainable, and to reduce inequalities.

At our last assessment we rated this key question as requires improvement. At this assessment, the rating has changed to good. This meant there were good leaders in the service leadership team. Leaders and the culture they created assured the delivery of high-quality care.

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 shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had their own individual strategy called outpatients quality quartet this is alongside the overall hospital strategy and vision which was in place, the services purposes was to provide high quality, safe and compassionate care to patients based on what they need and expect, the strategy was implemented in June 2021. The service had 4 core principles and values which the service told us they continued to embed into the service.

Staff told us they understood and knew the principles and values, and they believed the service worked and thrived to achieve them.

Staff told us they felt there was a positive culture within the service, they told us they felt managers and senior managers were approachable and supportive.

We observed positive relationships between medical staff and nursing staff, with the patient at the centre of the service.

Data showed the staff survey was more positive, and scores had increased to reflect this. The service gained a 2-star company rating in 2023, with 3 stars being the highest.

The outpatients service only had 1 risk identified on their risk register, the managers had a good understanding of the risk identified and supported staff to manage and mitigate any the risks identified.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

Staff told us the ward and senior managers were supportive, compassionate, and approachable. Staff told us the registered manager was very visible, they stated, “she knows us all by name, and makes me feel valued.”

During the morning huddle managers spoke of positive work that an individual staff member had completed, and this would be fed back to them as recognition of their contribution.

Senior staff told us how they developed staff to obtain higher positions as part of succession planning and providing opportunities for growth. The service only used a few bank staff to ensure consistency for the patients.

The service had a clear staff structure in place. They had processes in place to recruit staff fairly and into the roles they were competent to do.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had 4 staff members identified as freedom to speak up guardians (FTSUG), across the hospital. Staff told us they held monthly sessions for staff with direct reporting to the Executive Director with corporate support.

Staff told us they were aware of the FTSUG, and they knew how to contact them if they needed to raise any concerns and wanted to raise this confidentially. However, they told us that they would raise any concerns with the outpatient manager, as they felt confident any concerns raised would be addressed by them.

There was a positive culture within the service and staff morale was high.

The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us they felt supported by manager and felt they could raise either work or personal concerns, as managers had an open-door policy.

The service had an inclusive staff team and worked within a diverse community. They ensured patients received information if their first language was not English, to enable them to make choices relating to their care and treatment.

The service also ensured they collaborated with staff, discussed staff wellbeing, and held a number of events to promote this.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment, and support. Staff act on the best information about risk, performance, and outcomes, and share this securely with others when appropriate.

The managers operated effective governance processes, throughout the service and with partner organisations.

Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss, and learn from the performance of the service.

The service had good governance systems for consultants who worked at other service. There were currently 397 consultants working on practicing privileges arrangements. The service completed biennial review questions for all consultants a review was also undertaken 12 months after being granted practising privileges, and the executive director met with all consultants for their first review.

The service had structures, processes, and systems of accountability in place, so all levels of the management knew and understood their roles and responsibilities.

The service held governance meetings, they discussed risks, incidents, complaints, safeguarding training, risk register, serious incidents, and clinical audit. The service updated and completed an action plan where risks were identified, and these were, RAG rated.

The service held monthly team meetings with the staff team, these highlighted any concerns raised, any areas for improvement and what worked well. The minutes were clearly documented, and actions were identified with named individuals responsible for completing specific actions.

The service identified only one risk on the risk register in relation to the minor operation dual use. This had a clear action, and measures put into place to mitigate the risk.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

The service worked with a local service to gain support as and when required to support patients for example, who presented to the service with a mental health concern.

The service offered free 30-minute physiotherapy consultations for musculoskeletal (MSK) concerns. Chaplaincy, an organisation dedicated to providing emotional, spiritual, and pastoral care to individuals and local community was also available.

The service offered a free Diabetes Prevention online seminar, where patients discovered the importance of diabetes prevention and learned about the signs to be aware of.

The staff donated items and created over 90 Christmas hampers for a local charity. These were distributed throughout the community, which received some positive feedback including “Your generosity has made an extraordinary impact on the lives of older people in our community this year.”

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. Staff actively contributed to safe, effective practice and research.

The service had evidenced learning and improved systems to ensure the service did not see any under 18 years old patients.

The pharmacy department had created a medicines helpline service to support all patients with medicine-related queries. The medicines helpline service ran from Monday to Friday from 9-5pm.

The service ensured medicines optimisation which highlight patients at risk of hyponatraemia/falls and chronic pain issues; the pharmacy team have begun supporting pre-assessment with pre-admission medicines reconciliation with patients.

The service had developed a monthly outpatient utilisation meeting which was attended by senior managers. The purpose of the group was to work collaboratively to review overall and individual consultant clinic usage to maximise available clinic times and increase the availability of appointments for patients. Where trends such as clinic delays had been identified, staff reviewed the reasons and actions were put in place to improve patient's overall experience. Another purpose of the meeting was to review new consultant clinic requests and consider whether any of these requests could be accommodated into the outpatient clinic.

The service reviewed any clinical and non-clinical feedback regarding opportunities to improve the service.

The service had support from cancer nurse specialists when breaking bad news, who was available to support the service for holistic counselling for patients and relatives when breaking bad news. The cancer nurse was also able to signpost patients to other areas of support, including within the hospital and community.

The service had a monthly minor operations working group which was attended by senior managers. The purpose of the group was to work collaboratively to review the overall utilisation of the minor operations room and consider how the room could be better used to offer more patients a walk-in walk-out pathway.

The service had introduced monthly internal newsletter called “Birmingham Bites”, which is shared with staff across the hospital and keeps all staff informed and engaged with the latest news, updates, and important information.