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. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question as requires improvement. At this assessment, the rating improved and is now good. This meant people were safe and protected from avoidable harm.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications, and experience.

Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

This service scored 66 (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 were open, transparent, and honest about reporting incidents. They knew what incidents to report and how to report them. They raised concerns and reported incidents and near misses in line with the organisation's policy.

>

Records provided by the hospital showed there were 21 serious incidents from January to December 2024. Incidents were categorised into no harm, low, moderate harm, or death. The most common trends included surgical complications and clinical deterioration.

They noted areas for improvement and shared them with relevant departments. We saw audit results displayed on notice boards highlighting gaps and embedding good practice in areas we visited. For example, a quality improvement project had been carried out around fluid balance charts on Dudley ward.

>

Staff said they were encouraged to report incidents promptly. Staff we spoke with gave an example of a historic never event relating to a block. They told us following this incident, senior staff reiterated checking process around blocks. We saw evidence learning from incidents was shared with staff through daily huddles and monthly departmental meetings.

>

There was a duty of candour policy and staff understood the importance of duty of candour. People or those who represented them were given an apology and an explanation of the event, and people were given a timely response. We saw evidence of a duty of candour letter sent to a patient following an arthroscopic repair. Staff carried out an investigation to identify any service delivery issues.

>

There were policies and processes for staff to follow when reporting incidents. They explained how to report, categorise, and investigate incidents. When things went wrong, staff apologised and gave patients and families honest information and suitable support.

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.

Staff held regular and effective multidisciplinary meetings to discuss all patients and improve their care. Patients had their care pathway reviewed by relevant consultants depending on their care pathway.

>

Staff referred patients for mental health assessments when they showed signs of mental ill health, for example depression. Staff were able to refer patients for mental health assessments and for psychological support where necessary.

>

The hospital had a service level agreement with a local NHS trust for patients who clinically deteriorated, and staff were unable to appropriately manage them on site. A standard operating procedure was in place which detailed a formal process for staff to follow if a patient needed to be transferred to the local NHS trust in the event of an emergency.

During our last assessment, we told the provider they must ensure that patients records were always stored securely on the surgical wards, we saw patient notes were now being stored securely on the surgical wards next to the nursing station in a cupboard. This cupboard had a keypad lock with restricted access.

>

We reviewed patient records and found specific assessment screening questionnaire for obstructive sleep apnoea. There was a scoring system, and we found a patient was scored as having intermediate risk of sleep apnoea and this was actioned appropriately. The patient met the admission criteria for the service.

>

There was a combined risk assessment preoperative baseline which entailed a malnutritional screening tool, a pressure ulcer risk score, a falls risk assessment, a manual handling assessment and health promotion advice.

>

There was a system for checking patient safety prior to commencement of surgery. A minor operations proforma was used for minor operations. The surgeon, scrub nurse and circulator conducted a visual check prior to opening a prosthesis during a check we observed. This was in line with standard practice.

>

The service had various safety checklists such as specific World Health Organisation (WHO) safer surgery checklists for interventional procedures, cataract and team briefing checklists.

>

During our last assessment, we told the provider they must ensure the WHO five steps to safety surgery checklist was completed fully for each patient. We found WHO observational audit was now being completed monthly. Staff audited 20 sets of patient notes per month, and compliance stayed at 95%. WHO audit for both minor and major surgery was at 100% from April to November 2024 respectively. Staff discussed the results of the audit during unit meetings and any escalations fed into the hospital clinical governance committee. Pre-assessment staff ensured patients received a pre-assessment within 28 days of their surgery.

From February 2024 to January 2025, the service had carried out 25 cardiac surgeries which included 5 aortic valve replacements. We reviewed preassessment record for an aortic valve replacement and found the assessment record comprehensive.

>

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.

There was a strong understanding of safeguarding and how to take appropriate action. Staff we spoke with understood how to protect patients at risk of, or suffering, significant harm. The service worked well with other agencies to do so, and staff knew how to escalate safeguarding concerns to the ward manager.

There were 2 reported safeguarding incidents for the surgery service in the previous 12 months prior to our assessment. Records showed that safeguarding incidents were discussed to share the learning with all staff.

>

Staff had updated training on how to recognise and report abuse, and they knew how to apply it. They completed safeguarding adults' level 2 and 3 depending on the staff role, which the scores were 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 regulated to treat children under 18 years of age.

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

>

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. Staff received training specific for their role on how to recognise and report abuse.

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.

Staff used the National Early Warning Score (NEWS2) to identify deteriorating patients and escalated them appropriately. Staff were knowledgeable and understood their responsibilities for assessing and reporting patients' observations and NEWS2.

>

They consistently carried out NEWS2 audits and results from audits showed 100% from January to April, 89% from May to August and 82% from September to December 2024. Senior staff put actions in place such as discussing general standards of recording during team huddles, sending emails to all staff, and liaising with practice-based educators to improve compliance.

People were aware of risks related to their care and felt risks were managed in a safe way. Staff carried out discharge audits of for example, follow-up appointments offered to patients, support provided to patients within the first 24 hours and skin integrity checks carried out prior to discharge.

>

All pre-operative clinical tests were completed in line with the National Institute for Health and Care Excellence (NICE) guidelines.

>

During our last assessment, we told the provider they should ensure venous thromboembolism (VTE) risk assessments for surgical patients continue to be completed. There was evidence that risk assessments were carried out and monitored through VTE audits within the service's clinical audit timetable.

>

Risk assessments of a patient's risk of developing blood clots while in hospital and after surgery were always completed in records we looked at. From January to December 2024, a total of 9 confirmed VTE incidents were reported. Following a review of extended stays in the hospital and some confirmed deep vein thrombosis post discharge, it was highlighted that patients may have been becoming unnecessarily dehydrated prior to surgery due to being nil by mouth. As a result, the service introduced safer sips to surgery which allowed identified patients to sip water up until they were collected for theatre.

>

Staff carried out a bladder scan on a patient who had not passed urine after surgery. The scanner revealed over 680 milliliters of urine but no action was taken. The next entry in the nursing notes showed the patient was passing urine. There was a potential risk of infection and a risk of urinary retention. We raised this with senior staff at the time of our assessment. We found inconsistencies in the recording of observations on the same patient. However, there were no gaps in other patient records we reviewed.

Staff carried out continuous monitoring on the compliance of notes documentation. Clinical performance was continuously audited and monitored to ensure sustained performance as part of the overall quality and patient safety strategy. Documentation audit from April to November 2024 was at 97.5% and this was better than their target of 95%. Some training was organised directly from the Royal College of Nursing who conducted multiple sessions on documentation, record keeping and accountability to support clinical staff.

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

The surgery service had suitable facilities to meet the needs of patients for the type of care delivered. The service had 5 theatres with 8 recovery bays which included suction, oxygen and monitors. Theatres 1, 4 and 5 were equipped with laminar air flow and staff used these for both orthopaedic and cardiac procedures.

There was a 7 bedded day case, 2 inpatient surgical wards which comprised of Aston ward with 21 beds and Dudley ward with 23 beds. Minor operations such as arthroscopies and cystoscopies performed under local anaesthesia were carried out on the endoscopy unit which was shared with outpatients. The pre-assessment area was open from 7.30am till 5pm and had 5 pre-assessment rooms.

We observed an area with a gentle slope in the pre-assessment building. Following our assessment, the service provided a risk assessment for the building accessibility. Staff carried out accessibility audits to establish how well the environment performed in terms of access and ease of use by a wide range of potential users, including people with disabilities.

The maintenance team carried out water sampling every 6 months. We reviewed water sampling test results, and they were satisfactory over 18 months. The results were sent to the infection prevention and control team who actioned any missed sampling and maintained oversight.

>

A company had been contracted to carry annual checks of ventilation airflow systems as required by the Health Technical Memorandum (HTM03-01). Results of the checks carried out in January 2025 showed they were compliant in all aspects.

A central store was kept for all equipment of the Circle Health Group. Staff requested equipment automatically through a surgery coding system and this was confirmed on site by the team. Equipment mostly arrived on time for surgical procedures and any equipment which did not arrive on time prior to surgery was reported as an incident.

>

Both wards and the theatre suite had resuscitation trolleys which were secured with anti-tamper tags making it clear if someone had accessed the equipment. Staff performed daily checks on the resuscitation equipment stored on top of the resuscitation trolleys and monthly checks on the contents. The theatre suite had a difficult airways trolley which was checked weekly. Records we reviewed during our assessment showed all equipment checks were carried out. This showed there was a consistent and regular approach to safety checks.

>

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.

The service had enough nursing and medical staff with the right qualifications, skills, training, and experience to provide the right care and treatment. The theatres were staffed in accordance with the Association for Perioperative Practice guidelines.

>

There were enough staff on duty during the patient's surgical procedure, which included surgeons, anaesthetists, and operating department practitioners. We reviewed staffing rotas on the wards and found no staffing gaps. Ward staff worked from 7am till 7.30pm for day shifts and from 7pm till 7.30am for night shifts. Staff received their rotas 1 month in advance.

Data shared with us following our assessment showed a vacancy rate of 0.02% across the surgery service. They reported a turnover rate of 11%. From October to December 2024 staff sickness rates for both wards and theatres was at 3.4%. Theatre staff told us there was a high turnover rate for managers and the current clinical service manager had been in post for 14 months. A learning to lead course was available and senior staff encouraged theatre practitioners to attend.

The service reported agency use of 0.3% in October, 1.4% in November and 0.26% in December respectively. Figures provided following our assessment showed bank use at 4.04 % in October, 5.7% in November and 3.9% in December.

Consultants were not directly employed but had practising privileges at the hospital and would make arrangements individually to review their patients when they were on the ward. Nurses were able to contact consultants about their patients if needed when they were off site.

During our last assessment, we told the provider they must ensure that a staff member trained to advanced life support (ALS) was immediately available to attend the recovery area in theatres. This had improved and a daily resuscitation huddle was completed each morning which was well attended. There were 29 ALS trained staff (94.7%) and 98.3% staff were trained to provide immediate life support and during the huddle, ALS trained staff were identified in each clinical area.

>

The hospital offered a care of a deteriorating patients training and data seen during our assessment revealed 94.7% of staff had attended this training in January 2025.

We told the provider they must ensure staff completed the mandatory training assigned to them during our last assessment. The service had introduced a new induction programme that all new starters attended which was run by the practice-based educator. Many of the mandatory courses were covered within this induction period and this had a positive impact on the overall hospital training compliance which was 95%.

Managers supported staff to develop through yearly, constructive appraisals of their work. A formal appraisal system was in place and 99% of staff had received an appraisal.

A team away day which focused on all team members looking at objectives and identifying opportunities of working together more effectively was facilitated by an external company to look and review the staffing establishment.

>

Staff attended specialist training such as temperature monitoring surgical safety guardian, isolation of electrical points and access and laser training.

There was an in-house practice-based educator who delivered a variety of both mandatory and role specific training on an ad-hoc basis. Where any gaps in clinical staff knowledge were identified, they conducted some in-house training with the teams. For example, they had recently delivered training on the correct completion of fluid balance chart and the correct completion and understanding of the venous thromboembolism risk assessment.

Staff completed a pre-operative competency-based programme prior to carrying out pre-operative assessments.

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

Staff mostly followed infection control principles including the use of personal protective equipment. For example, we found dust under shelves in the central sterile services department. This was raised at the time of our assessment and was dealt with immediately.

>

Staff had placed new toilet seat raisers on the floor in the sluice which posed a risk of contamination. They were found directly under the sink on Dudley ward. This was raised at the time of our assessment and was dealt with immediately.

>

We also found boxes stored directly on the floor in theatres. We raised this with the infection prevention and control nurse at the time of our assessment. They said they would take action to remove the risk.

Patients told us the areas they had been in appeared to be clean and well-maintained. Staff used "I am clean" stickers to indicate they had cleaned the equipment recently and it was ready for use with another patient.

Audits were completed to assess staffs' compliance with infection prevention and control (IPC) standards and guidance. The audit covered results from January 2024 and was scheduled bi-monthly last year. Hand hygiene audits from December 2023 to November 2024 was at 99%. Results of audits were discussed in unit meetings and any escalations fed into the hospital clinical governance committee. When necessary, these were also discussed at corporate clinical governance committee.

The patient survey and patient satisfaction data for quarter 4 in 2024 showed 95% overall impression of housekeeping and cleanliness was overall `very good' or `excellent'.

Control measures to prevent the spread of infection and communicable diseases were in place. Personal protective equipment in a range of sizes and hand sanitizer was available in all areas of the hospital we visited.

>

Theatres and ward areas were noted to be visibly clean and well-organised. All the staff we saw during our assessment were `bare below their elbows' and dressed in line with the service's policy.

>

We saw staff cleaning down equipment appropriately following theatre cases. There were separate scrub, anaesthetic, and preparation rooms for each theatre. There were cleaning records available in each area in theatre, and we identified no gaps in cleaning.

The service monitored surgical site infection (SSI) data and reported this to the UK Health Security Agency. The data indicated normal performance for hip and knee SSIs against national benchmarks. Data for spinal SSIs was collected and monitored, although no national benchmark was in place at the time of this assessment. From January to December 2024, a total of 22 SSIs were identified.

Infection prevention and control staff carried out antibiotics audits and staff achieved 100% compliance in theatres.

A criteria for Methicillin Resistance Staphylococcus Aureus swabbing was available for staff to follow. We observed a pre-assessment appointment and staff discussed past medical history, current medication and carried out general risk assessments with the patient.

Leaders reviewed all incidents of surgical site infection, comparing the service's performance against organisational and national benchmarks. They met with key stakeholders to ensure they took appropriate actions when care was not delivered as expected and made improvements.

The service did not always make sure medicines were stored safely.

Patients told us staff were responsive to requests for pain relief. Staff interacted with people kindly and provided support when medicines were administered.

Medicines were generally stored securely and safely, and temperatures were monitored where they were stored, to ensure their safety when used. However, we found an open bottle of Oramorph (Liquid pain relief) with no opening date recorded in Dudley Ward. This was not in line with guidance which required liquid medicines to be dated when started to ensure the medicine remained within its shelf life. There was a risk that the medicine had become less potent.

>

We observed medicines stored alphabetically with no strips out of boxes on Dudley ward.

We saw intravenous fluids had been decanted out of their manufacturer's storage boxes. We found several bags of fluid stored in a drawer on Dudley ward, and this was not in line with national guidance.

>

There were effective processes for the supply of medicines. Staff followed the hospital's policies and procedures when prescribing, administering, recording, and storing medicines. The service had systems to ensure staff knew about safety alerts and incidents, so patients received their medicines safely.

The service set a target of 95% for medicines management audit and results from March to November 2024 showed a compliance of 97.7%. Departmental audit leads carried out these audits and based them on a thorough review on the safety, security, supply, and administration of medicines. Staff discussed audit results during unit and local medicines management meetings. Any escalation fed into the hospital's clinical governance committee.

Patient survey satisfaction results from August 2024 to January 2025 showed a total of 95% of patients were told about the side effects of their medication.

Patients own medications were recorded upon admission and locked safely in a medicine cabinet in their room.

Pharmacy support was available Monday to Friday 8am to 6pm and weekends 9am to 1pm. On-call pharmacy support was available either over the phone or could attend site to provide out of hours support if necessary.