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 patients were safe and protected from bullying, harassment, avoidable harm, neglect, abuse, and discrimination. We also checked patients' 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 good. At this assessment, the rating stayed the same. This meant patients were safe and protected from avoidable harm.

Staff listened to concerns about safety and investigated and reported safety events.Patients were protected and kept safe. Staff understood and managed risks. They made sure equipment and facilities supported the delivery of safe care. 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 patients in planning any changes.

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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff knew what incidents to report and how to report them. Staff raised concerns and were encouraged to report incidents by their managers. The service had clear policies for incident management, which were accessible to all staff. They explained how to report, categorise, and investigate incidents. Incidents were discussed within governance meetings and team meetings.

Data from the service showed there were no serious incidents (no incidents defined as moderate to severe harm incidents) from March to August 2025. In the same reporting period, the service reported a total of 966 clinical incidents. Examples included clinical incidents, incidents linked to health and safety and information governance.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. We reviewed care records and saw evidence of when duty of candour had been exercised although there had been no serious incidents.

The hospital had implemented and followed the NHS England approach to reporting and investigating patient safety incidents in 2024 called Patient Safety Incident Response Framework (PSIRF). Staff were aware of the new process.

There was evidence that changes had been made as a result of identified learning. Staff identified several key learning and changes in nursing practice following a SWARM, "system, what happened, actions, reviews, and mitigation" regarding a medication dosing error. Staff received daily reminders to complete all pre-administration checks in the correct sequence and were instructed to escalate any issues immediately and on the day they occurred. A corporate flash alert email was disseminated to everyone and included actions to take.

Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

Senior staff shared safety alerts throughout the service and ensured actions were implemented in line with national guidance.

The service worked with patients 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 patients moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could be met safely. Staff were able to refer patients for mental health assessments and for psychological support where necessary.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Safety and continuity of care was a priority throughout patient’s care journey. This happened through a collaborative, joined-up approach to safety that involved them along with staff and other partners in their care.

The service had policies and processes in place to support the transfer of patient information. All patients that required transfer were followed up after a transfer to both NHS hospitals and the services own critical care unit to communicate any issues or concerns between staff.

Policies and processes about safety were aligned with other key partners who were involved in people’s care journey to enable shared learning and drive improvement. The hospital had a service level agreement with a local NHS trust for patients who clinically deteriorated, and when 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.

There was adequate 24-hour medical cover. For example, consultants or their consultants's cover arrangement were available 24 hours per day if required. There were 2 resident medical officers who worked 1 week on and 1 week off. Out of hours cover was available and arrangements were in place for the transfer of deteriorating patients to a local NHS trust.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patient’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 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.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Safeguarding adults level 3 had been completed by 98% of staff on oncology and endoscopy. Information was provided which demonstrated 99% of staff were trained in safeguarding children level 2. 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. The service had 2 staff members trained to safeguarding level 4 who were designated safeguarding leads for the hospital. Posters were displayed throughout the hospital with their contact details.

Patients were supported to understand their rights, including their human rights, under the MCA 2005 and their rights under the Equality Act 2010. Staff were aware of the MCA 2005 and completed patient assessments when concerns were identified about their capacity to make decisions about their care. There was an understanding of the Deprivation of Liberty Safeguards, and staff only used this in the best interests of their patients.

We saw evidence of up-to-date disclosure and barring service checks in all 6 staff files we checked.

They gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act 2010.

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

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs that was safe, supportive and enabled patients 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. NEWS2 audit carried out from January to April 2025 was at 94% and 92% from May to August 2025 respectively. Clinical performance for assessing and documenting NEWS2 identified opportunities for improvement mainly around staff documentation.

Risks were assessed and patients and staff understood them. Staff completed risk assessments for each patient on admission, using recognised tools, and reviewed these regularly, including after any incidents. These risk assessments included but were not limited to a patient’s risk of skin damage, stopping anticoagulant (blood thinning) medication, malnutrition risks, manual handling, venous thromboembolism (blood clots) risk and falls risk. Staff ensured patients attending for colonoscopy procedures had stopped taking their blood thinning medicines as per national guidance. Where this had not been stopped, they did not cancel the procedure but carried out only the diagnostic procedure and the patient would be informed that any therapeutic procedures, if required, would have to be undertaken at a future date. This was to keep the patient safe by reducing the risk of bleeding.

The service had a policy for the use of conscious sedation. Staff ensured patients who had received sedation were given information before and after the procedure. All sedated patients required an escort to ensure someone stayed with them following their procedure as per national guidance.

There was a strong awareness of the risks to patients across their care journeys. The approach to identifying and managing these risks was proactive and effective. For example, a hypersensitivity trolley was available on Highbury ward, and it contained medicines to use in the event of a hypersensitive reaction to chemotherapy. Staff followed a protocol for patients receiving the first or second cycle of chemotherapy. We observed a hypersensitivity reaction during our visit to the chemotherapy unit. Staff responded promptly and effectively to keep the patient safe. The incident was appropriately reported and shared across the hospital the following day to support learning and awareness.

Staff used a systemic anti-cancer therapy supportive treatment integrated care pathway. The pathway contained patient information on the front sheet and detailed all the risks, medication, weight, including a pre holistic assessment, activities of daily living and advice. Staff completed a United Kingdom Oncology Nursing Society (UKONS) toxicity assessment whenever patients attended for chemotherapy. This was completed in conjunction with a pre-administration checklist for chemotherapy.

There was a balanced and proportionate approach to risk that supported patients and respected the choices they made about their care. Patients were informed about any risks and how to keep themselves safe.

Arrangements were in place for people who become ill between visits to the hospital following a chemotherapy. Following chemotherapy, patients were advised to check their temperature at home and sensitised about the signs and symptoms of neutropenic sepsis which is a life-threatening reaction to an infection which can occur following chemotherapy. There was a standard operating procedure for management of neutropenic sepsis which included sepsis protective isolation. Staff ensured treatment for sepsis was given within an hour as per sepsis 6 pathway and recommended guidance.

Staff knew about and dealt with any specific risk issues. If staff in the endoscopy procedure room or the oncology service required extra assistance urgently, they used emergency call systems to summon assistance.

In addition to the national sepsis six bundle, staff followed the management of oncological emergencies in cancer patients’ policy to manage cancer emergencies such as neutropenic sepsis. The policy supported the prevention, recognition, and management of neutropenic sepsis. We saw an example of a patient who had been admitted with confirmed neutropenic sepsis. The patient records showed staff took necessary steps to keep the patient safe.

During systems engineering initiative for patient safety (SEIPS) investigations for admissions of oncology patients with potential neutropenic sepsis, it was identified that care could be enhanced further by escalating the patient’s condition and admission to the critical care outreach team. SEIPS investigation refers to using the systems engineering initiative for patient safety framework to investigate patient safety incidents.

A UKONS triage assessment tool was used to monitor toxicity symptoms for patients attending for chemotherapy.

The oncology department’s falls link nurse provided additional training to the team for the completion of falls risk assessments. This was identified as a requirement following a falls risk assessment audit that further education and support was needed for the staff.

The medical and nursing staff in endoscopy completed a modified ‘five steps to safer surgery’ checklist in endoscopy. This is a recognised system of checks before, during, and after surgery, designed to prevent avoidable harm and mistakes during surgical procedures. We observed staff performing the checklist correctly during our visit. These checks consisted of team briefing, sign in (before anaesthesia), time out (before surgery starts), sign out (at the end of the procedure) and debrief. World Health Organisation checklists and Local Safety Standards for Invasive Procedures were used within the endoscopy department and audits completed for compliance purposes. The results showed 100% compliance with the audits for the service.

Patients stayed for 1 hour after gastroscopy procedures. They received post procedure information including a follow up call after 24 hours.

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

The medical care service had suitable facilities to meet the needs of patients for the type of care delivered. The oncology day unit (Highbury ward) had 8 pods which each contained a recliner chair, access call bell, oxygen pods and access to suctioning for patients who deteriorated. There were 2 consultation rooms. The inpatient unit had 6 bedrooms which were all private en-suite rooms. The ward admitted medical oncology patients for symptom control, deteriorating patients and planned inpatient chemotherapy.

The endoscopy department was a 7 bedded day case unit which contained 7 cubicles with beds and trolleys. This area was shared with the day case for the outpatient’s department.

The design of the environment followed national guidance. The service had enough suitable equipment to help them to safely care for patients. We reviewed equipment servicing history and saw all equipment was in date. All equipment we checked onsite contained evidence of in date electrical safety testing and servicing. We saw service testing records for equipment.

There were processes to ensure equipment and the environment were well maintained and safely met the needs of the patients admitted to the area. Results of the resuscitation trolley audit was 100% at the time of our inspection.

Patients could reach call bells on the ward and told us staff responded quickly when called. All patient rooms were single occupancy to prevent any risks of cross infection.

There was a separate endoscopy decontamination hub which processed endoscopes and served 3 Circle Health hospitals. Endoscopes were initially washed manually and disinfected in a machine for 25 minutes. Decontaminated endoscopes were pressure wrapped and could be used within 28 days.

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 patient’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. Staffing was planned in advance and reviewed as part of daily huddles to identify upcoming shortages and on the day shortages such as unplanned sickness.

Managers had calculated the number and grade of nurses and healthcare assistants required. During our onsite inspection, we found the number of staff in endoscopy and oncology wards matched the planned numbers. We observed a morning huddle where staffing numbers for each department were discussed. Staff helped each other out and ensured they worked together to achieve safe care for the patients.

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

Staff received and kept up to date with their mandatory training. During our last inspection in May 2019, we told the provider they should consider their approach to providing all new staff with timely mandatory training when commencing employment at the Priory hospital. During this inspection, newly appointed staff attended induction days which were tailored to their requirements and sessions were over 3 to 4 days. Mandatory training compliance was 100%. The mandatory training was comprehensive and met the needs of patients and staff. The provider had a resuscitation committee which monitored resuscitation mandatory training compliance. Following the last committee, a "system, what happened, actions, review, and mitigation" was held to discuss how to increase compliance in mandatory training. This resulted in improved compliance.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. A total of 85% of contracted and bank staff had been trained to administer chemotherapy treatment and 2 members of staff had been booked to attend the training.

Managers provided new staff with appropriate induction. New starters including those working under bank received a local induction as part of the processes in place to ensure staff were safely inducted to the local area. All staff were assigned a buddy during their 90 days induction period. There was a supernumerary period of 2 weeks.

The service had robust arrangements in place for international nurses. We were informed of an example where additional mental health training had been offered to support their development.

Managers supported staff to develop through yearly, constructive appraisals of their work. During our last inspection in May 2019, we told the provider they should ensure an annual appraisal is provided to all staff. During this inspection, senior staff told us annual appraisals were monitored through ‘’learning space’’ and both the head of department and staff received a reminder email when it was due for completion. Appraisal rate was 100% at the time of our inspection.

The service had processes in place to monitor staff sickness, vacancies and turnover. From August 2024 to August 2025, there was no vacancies, and the service reported a turnover rate of 11% for oncology and 27% in endoscopy. They reported sickness rate of 3.5% in endoscopy and 5% in oncology.

Staff across various areas we visited told us they enjoyed working at the Priory hospital. However, we found some areas such as the endoscopy and decontamination unit had minimal staff assigned to the departments, meaning that any staff absences due to leave or illness could result in a risk of gaps in cover. However, staff within the main theatre department who hold endoscopy competencies were often assigned to endoscopy lists ensuring the department always had adequate staffing with the required skill mix.

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.

The service had an Infection Prevention and Control (IPC) policy, that reflected current guidance. Staff followed infection control principles including the use of personal protective equipment (PPE).

Staff followed infection control principles including the use of personal protective equipment. Staff had access to PPE including aprons, masks and gloves in a variety of sizes. Staff cleaned their hands before, during and after patient contact. We saw signs reminding patients to clean their hands in areas we visited. Hand sanitiser was available in every room and at the entrance to the endoscopy and oncology areas.

The hospital produced a video on the appropriate use of gloves, reinforcing when to use and when not to use gloves in clinical areas. This was shared across Circle Health Group.

Staff adhered to infection control principles, including hand washing. There were arrangements to clean endoscopes and equipment in line with guidance, including Health Technical Memorandum 01-06: decontamination of flexible endoscopes. For example, used scopes were placed in a tray with a red plastic cover to indicate potential hazard. There was a separate ‘dirty’ room where used endoscopes were cleaned and processed through a disinfecting machine.

Staff in the decontamination unit performed 2 manual washes of the endoscopes where a blood borne virus was either suspected or confirmed.

Information about the risk of infection was shared appropriately with relevant partners, including agencies, people using the service and visitors. We spoke with the infection prevention and control IPC lead who said the hospital had started an antimicrobial group where swab results were discussed. The IPC lead held bimonthly meetings with link staff of various areas. The IPC team had commenced a flu campaign in preparation for winter.

Patients who met the criteria were screened for Methicillin Resistant Staphylococcus Aureus, before admission.

We reviewed audits in IPC and saw that they were completed in line with policy. From June to August 2025, hand hygiene audits carried out in endoscopy and oncology revealed 99% of compliance. Where these audits identified areas of improvement, action plans were made with clear actions.

Staff maintained equipment well and kept them clean. Any ‘clean’ stickers were visible and in date. All areas were clean, had required furnishings and were well-maintained.

There were arrangements in the areas we assessed in medical services, to comply with infection prevention and control procedures. Water outlets and sinks were flushed to reduce the risk of legionella and pseudomonas build-up in line with the Health and Safety Executive guidance.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

The service had reliable systems to prevent and protect people from a healthcare-associated infection. Patients who needed a cannula or urinary catheter had their risk of infection minimised. This was done by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.

Staff disposed of clinical waste safely. We observed staff correctly segregating clinical and domestic waste. Waste bins were enclosed and foot operated. Sharps bins were correctly assembled and below the fill line. The management and disposal of sharps and waste was completed in accordance with the trust policy.

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

Staff followed systems and processes to prescribe and administer medicines safely. Consultants could prescribe chemotherapy remotely and pharmacists could see treatment lists for a week. This made it easy for them to order chemotherapy treatment in a timely manner.

Pharmacists used an electronic prescribing system to communicate with staff on the oncology ward. This enabled them to see what had been prescribed, review blood results, the treatment plan and if the patient was definitely coming in.

There were mostly appropriate arrangements for the safe management, use and oversight of controlled drugs. During gastroscopy procedures, medicines were administered and signed for by the consultant. In two instances, nursing staff had not countersigned the medicine charts to confirm witnessing the administration of controlled drugs (CDs). However, the CD register had been correctly signed by both nursing and medical staff.

The approach to medicines reflected current and relevant best practice and professional guidance. For example, a chemotherapy extravasation kit was available for staff to use on Highbury ward. A cytotoxic drug spillage kit was available, and porters had received training because they were responsible for collecting chemotherapy from the pharmacy.

Staff stored medicines in line with the manufacturer’s guidance. Medicines were stored in locked medicines trolleys.

The pharmacy team kept a chemotherapy excess and wastage list aimed to minimise overstocking and wastage of chemotherapy. There was a strict storage and handling requirement.

Medicines management audits carried out from March to May 2025 was 93% in endoscopy and 96% in oncology. Following a robust action plan and continuous monitoring to ensure there was improvement in performance from June to August 2025, endoscopy performance improved to 100% and 98% in oncology respectively.

Staff carried out antimicrobial audits to ensure there was sustained performance throughout as part of the overall quality and patient safety strategy. The results from December 2024 to May 2025 was 100%.

Pharmacy staff carried out a corporate audit of CD books every 3 months. The CD audit from April to June 2025 was 97% in oncology and 95% in endoscopy. Results of the audit were discussed in unit and local medicines management meetings. Any escalations fed into the hospital clinical governance committee and when necessary, these were discussed at corporate clinical governance committee meetings.

Accurate, up-to-date information about patient’s medicines was available. All patients were given a medicines helpline card for direct access to pharmacy and could call the helpline if they had any medication-related queries following chemotherapy. There was good multidisciplinary team working between the pharmacy, medical and nursing team.

Staff followed good practice in medicines management. The online weekly chemo tracker ensured accurate, timely orders were placed, allowing the monitoring of treatment cycles. This helped with inventory management and facilitated communication between technicians and pharmacists.

An oncology pharmacist was available to provide support on Highbury ward from Monday to Friday, when systemic anti-cancer therapy treatment was planned. The service introduced a ward-level preparation of monoclonal antibody drug (lab-made proteins that mimic the body's natural antibodies to treat diseases like cancer) project where 5 specific products were prepared on the ward this year. This addressed previous challenges associated with drug availability and delayed deliveries from third party suppliers. It also improved patient experience with just-in-time preparation and reduced wastage of sourced manufactured products from third party suppliers.

There was a clear process in place for managing and reporting any incidents involving medicines. A "system, what happened, actions, review, and mitigation" (SWARM) was conducted in June 2025 in response to an increase in incidents reported whereby medicines requiring refrigeration were incorrectly stored in medicine cupboards. Following this SWARM medications are now dispensed from pharmacy with yellow and blue stickers for easy visual identification. Upon delivery, nurses promptly place these medications in the fridge to ensure proper storage.

Pharmacists and Resident Medical Officers attended daily oncology inpatient ward rounds. This ensured all patients’ clinical status were regularly reviewed and concerns regarding medication management was discussed to assist improving the patient’s condition and symptoms.

The hospital introduced the British Oncology Pharmacy Association passport which was a structured framework to track competencies and development of oncology pharmacists.