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

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The policies and processes in place within the service ensured patients were treated in line with requirements under legal and human rights. The service met the needs of patients where reasonable adjustments were required.

Staff understood and worked in accordance with National Institute for Clinical Excellence best practice guidance around decision making and mental capacity.

Staff we spoke with demonstrated a clear understanding of the trust’s resuscitation policy and ‘ReSPECT’ documentation. The ReSPECT process creates personalised recommendations for a person’s clinical care and treatment in a future emergency in which they are unable to make or express choices.

A physiotherapist told us they had developed and were trying to improve systems where patients had a functional rehabilitation prior to their procedure. This included but was not limited to transferring from a bed to a chair, walking and general expectations following joint replacements. This was to ensure patients could manage expectations and achieve their goals post procedure.

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 a vision for what it wanted to achieve and a strategy to turn it into action. Their purpose was to provide the high quality, safe and compassionate care their patients needed and expected.

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Launched to BMI hospitals in March 2021, Circle Operating System was an established methodology that empowered all staff to work together to be safe and effective, recognizing everyone had a responsibility to contribute towards this goal. It focused on engagement, performance, clinical leadership, devolved power and continuous improvement methods.

Staff focused on the needs of patients receiving treatment and worked well together to ensure they achieved good outcomes for patients. The culture was centred on the needs and experience of people who used services. Staff told us they felt involved in decisions in the theatre and pre-assessment department and most staff we spoke to felt happy at work.

The hospital had a dedicated well-being room available for staff to use whenever they needed a moment to relax or take a break from their busy workday. This quiet space was designed to offer a peaceful retreat, providing employees with a calm environment where they could unwind, recharge, and practise selfcare. The well-being room served as an important resource for supporting the mental and emotional health of staff members.

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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 felt supported and guided by their leadership team. The leaders were available when they were needed and led by example. They were knowledgeable about the issues and priorities in the department and strived for change and improvement when needed. Staff told us leaders were approachable and visible across the department particularly within theatres where there had been a change in leadership.

Leaders had effective support and opportunities to develop and maintain their credibility and skills. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities.

The service had partnered with a leading provider in well-being support to provide staff with an employee assisted programme. Staff and their family members had access to a 24/7 emotional support including either face-to-face or online counselling support.

The hospital carried out an annual b-Heard staff survey which covered 8 key areas. Results of the staff survey showed team members and team leaders believed senior managers did more listening rather than telling, possibly because they felt confident in the leadership skills of the senior management team and thought senior managers were visible and approachable.

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

The hospital had 4 freedom to speak up guardians (FTSUG) across the hospital and staff were aware of who they were. FTSUGs held monthly sessions and reported directly to the executive director with corporate support. Leaders fostered a positive culture where people were encouraged to speak up if they had any concerns.

Managers told us the service was committed to continuously delivering high quality care, improving services for all patients and the working environment for staff and consultants.

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.

There were policies and processes in place to ensure the service was inclusive and fair in the way they operated. Staff received training in equality and diversity and had a good understanding of cultural, social and religious needs of patients and demonstrated these values in their work.

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Senior staff organised a 90-second endurance challenge on an exercise bike during the Mental Health Awareness Week. It provided a unique opportunity for staff to come together, boost team spirit, and helped foster a sense of solidarity and collective achievement.

The hospital partnered with a local football club and staff participated in a friendly competition on the pitch to engage in a supportive and fun environment.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was a clear management structure. Leaders monitored quality and operational processes and had systems to identify where action should be taken. A governance assurance framework which sets out a transparent governance from ward to board was launched in May 2021. There was an interactive guide on the intranet setting out full terms of reference.

The hospital’s governance framework was supported by a medical advisory committee (MAC) meeting and clinical governance committee meeting. We reviewed the MAC meeting minutes of July, September and November 2024 and there was evidence of actions taken to address compliance within the surgical service.

Staff told us there were governance, management, and accountability arrangements in place, and that they understood their role and responsibilities, what they were accountable for.

The service had a clinical strategy in place. To support and enhance their patient safety processes, they had implemented the patient safety framework and had developed local quality improvement programmes and engaged with corporate driven safety improvement programmes. They had rolled out a group digital transformation.

A local quality improvement plan (QIP) in preventing and managing hyponatremia (low blood sodium levels) in orthopaedic patients had been launched due to a recognised increase in recent months which could affect length of stay. The QIP was led by a physiotherapist.

Various quality and safety improvement programmes such as fluid management, effective handover, intentional rounding and safer surgery had been successfully rolled out and implemented within the hospital.

During our last assessment, we told the provider they should formalise on call arrangements with radiologists to ensure out-of-hour cover was always available when required. We saw there was now a service level arrangement in place for out-of-hours cover, providing out-of-hour service where reports were available within 1 hour in the event a consultant radiologist was not available at the Priory hospital. A total of 397 Consultants exercised practising privileges at the Priory hospital. The executive director carried out biannual reviews for all consultants after being granted practising privileges.

We told the provider they should review and update all policies in a timely manner during our last assessment. Policies were now updated on the hospital’s intranet and sent out in the weekly newsletter.

New policies and any changes to policies were discussed as an agenda item at monthly clinical governance meetings and disseminated to relevant departments. All staff had read and signed a policy letter which gave accountability and responsibility for each individual staff member to keep themselves updated.

Theatre department and ward minutes reviewed from October 2024 to January 2025 contained an action log and detailed actions staff should take. Senior staff held meetings to discuss policies and reviewed staffing every Wednesday.

Staff held theatre planning meetings which included minor and major surgeries. They held discussions around scheduling, theatre lists, staffing and physiotherapy. They also went through rigorous checks relating to equipment, beds and safety issues.

We reviewed the minutes of the mortality and morbidity meeting held during our onsite assessment and found a recent specific incident was discussed including staff education and a review of the process of access to bloods.

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 hospital partnered with a local organisation and had a yearly community day where members of the team spoke with members of the local community.

The hospital staff donated over 90 hampers to a local charity, and these were throughout the community. The hampers were used to directly support some of the most vulnerable and isolated older residents.

Staff worked with a local service to gain support for patients who presented to the service with a mental health concern.

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.

Recovery staff attended a project on recovery pain management and discussed fast acting pain relief protocols for pain management in recovery. There was work in progress between the theatre and pharmacy team to introduce a robust protocol to support the recovery pathway, following the introduction at a neighbouring hospital. Once finalised, this would be presented to the MAC for sign off to help with better pain management. This could reduce the time spent in hospital, improve patient recovery and reduce the use of anaesthetic gases and carbon footprint.

The anaesthetists identified appropriate patients and provided special instructions for the nursing teams. This had led to a reduction in the risk of dehydration in patients, provided comfort and helped reduce anxiety in the wait for surgery.

The theatre department held an audit afternoon each month. The team received monthly education through representatives and external companies. They had protected time during which no surgical cases were booked. This allowed the majority of the theatre team to come together for departmental meetings and continuous professional development.

The service had patient facing education boards as they believed patient education was a critical part of patient care, and that effective patient education could lead to better outcomes. Topics such as sepsis and national diabetes awareness month, prostate cancer awareness month were displayed and included instructions for patients on follow-up care, prevention, and how to take a proactive role in their own healthcare.

The service had its own individual strategy called wards and theatres quality quartet which was alongside the overall hospital strategy and vision. The service's strategy was framed around a quadruplet of patient experience, clinical outcomes, optimal value and staff engagement with each supported by the local strategic objectives. The purpose was to provide high quality, safe and compassionate care to patients based on what they needed and expected.

The service had introduced the Average Length of Stay (AVLOS) project as reduced length of stay had proven to enhance patients’ recovery, especially in orthopaedic patients. Many new initiatives to aid patients being discharged safely but sooner had been implemented. The AVLOS project improves patient mortality and morbidity, reduces risk of infection and promotes independence, getting patients back on their feet and back to “normal” in a faster timeframe.