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 improved to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Staff and leaders demonstrated a positive, compassionate and listening culture. Leaders had the skills, knowledge, experience and credibility to lead effectively. The service had suitable arrangements for identifying, recording and mitigating risks. The senior management team had a good understanding of these risks which they regularly discussed.

This service scored 79 (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.

Leaders ensured there was a shared vision and strategy and that staff in all areas knew, understood and supported the vision, values and strategic goals and how their role helped in achieving them. 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. The provider’s principles and values was displayed on the wall in the Highbury ward area.

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service and was focused on learning and improvement.

Launched to Circle Health Group 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.

Staff at all levels had a well-developed understanding of equality, diversity and human rights and they prioritised safe, high quality and compassionate care. There were no concerns raised within the service about any types of bullying, harassment, or discriminative behaviours.

The service published the ‘’B Heard’’ staff engagement results in September 2025, which had an overall hospital response rate of 75.83%. The oncology department achieved 3 star within their survey results, which is the highest rating that can be awarded. Results showed most staff were happy with the balance between their work and home life and help was available to support their mental wellbeing. Action plans including ‘listening exercises’ were planned with lower scoring teams which included reports for the theatre/endoscopy team. Results of the survey showed staff felt positive and had confidence in the leadership of the senior management team. Staff responses showed leaders were visible and approachable.

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.

Leaders had the experience, capacity, capability and integrity to ensure the organisational vision could be delivered and risks were managed well. Staff felt supported and guided by their leadership team. They were knowledgeable about the issues and priorities in the department and strived for change and improvement when needed. Both the endoscopy and oncology units were led by clinical services managers.

Leaders at every level were visible and led by example, modelling inclusive behaviours. Staff told us most leaders including the hospital executive team were visible and supportive, and demonstrated behaviours which they looked up to. The executive director held a half day meeting once every 8 weeks for all site team leaders/sisters to cover points of news, management training and discussions relating to any issues.

The service published the ‘’B Heard’’ staff engagement results in September 2025. The results showed staff were strongly positive about the care their managers showed them as individuals and managers motivated them to give their best every day.

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

Staff and leaders acted with openness, honesty and transparency. 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.

Staff were encouraged to raise their concerns and those who did, were supported and did so without fear of detriment. 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.

The director of clinical services, the portering lead and the interim physiotherapy manager were the freedom to speak up champions. They had good relationship with staff in various areas.

When concerns were raised, leaders investigated them sensitively and confidentially. The hospital had a grievance policy which was the procedure designed to deal with instances where employees felt they had been unfairly treated. All staff were able to access the policy on the clinical intranet which advised the process to be followed to raise a grievance.

When something went wrong, patients received a sincere and timely apology and were informed of any actions being taken to prevent the same happening again. Staff were generally open and honest with patients in their care and gave them and their families an apology and a full explanation if things went wrong.

The ‘B Heard’ survey was undertaken in May 2025, and all contracted staff were encouraged to complete the survey. It provided the opportunity for staff to raise any concerns, improvements or suggestions. All comments were reviewed by the relevant head of department, and the senior management team. A bank staff survey was also issued in June 2025, providing bank staff with the same opportunity.

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 felt supported by their managers and could raise either work or personal concerns, as managers had an open-door policy.

The hospital’s Equality, Diversity and Inclusion group arranged the following wellbeing activities;

• Pride celebrations
• International Nurses Day
• Mental Health Awareness Week
• Chinese New Year
• Time to talk event
• Easter Bonnet competition

The service had an inclusive staff team and worked within a diverse community. They ensured that 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. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share 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.

Staff used a system to manage current and future performance and risks to the quality of the service and took a proportionate approach to managing risk. We told the provider they should review the process for recording risks related to medical care on the corporate risk register during our last inspection. During this inspection, risks in relation to medical care were reviewed by the area director of clinical performance and shared with the corporate team. The top 2 risks on the risk register included patient safety issues due to unreliable transmission of emergency alerts due to outdated resuscitation bleep infrastructure. The second risk was related to the resident medical officer following the pathway and risk escalation. The departmental risk registers were incorporated into the hospital risk register to allow oversight at all levels. Risk registers were reviewed regularly and updated with clear actions documented.

There were a range of other systems which supported the delivery of safe and high-quality care. These included daily management huddles which covered various clinical areas.

Staff understood their role and responsibilities. Managers were accountable for their actions, behaviours and performance of staff. There were clear and effective governance, management and accountability arrangements. The governance assurance framework set out the flow of information. Committee minutes were fed back to heads of departments.

There was a Circle Health Group (CHG) medical governance committee in place which the hospital escalated concerns relating to doctor's practise with the CHG who would lease with the doctor's responsible officer. There were 2 endoscopy user group meetings per year. Senior staff held weekly rapid response meetings where they discussed complaints, audits and incidents.

The hospital’s governance framework was supported by a medical advisory committee (MAC) meeting and clinical governance committee meeting. 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.

We reviewed the oncology specialty meeting minutes and endoscopy team meeting minutes from April to August 2025 which kept staff informed. They followed a standing agenda to ensure the most important updates were always provided.

Staff members discussed the Joint Advisory Group (JAG) submission during the endoscopy user group meeting held in March 2025. The service achieved re-accreditation for JAG in June 2025, which had been maintained since 2023.

We reviewed the minutes of the water safety committee meeting held in August 2025. Staff discussed water safety plans including endoscopy water reports and reviewed risk assessments and updates of action plans.

The service had plans for emergencies. There was a business continuity plan in place which was dated June 2021. It detailed primary actions staff should take in the event of an emergency and also included follow up actions required.

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.

Staff submitted data and notifications consistently to external organisations as required. This included but was not limited to national audit information, numbers of alert organism infections and notifications of deprivation of liberty safeguard applications.

There was an onsite laboratory to process blood results. Staff also used an external and a neighbouring hospital laboratory for histology and this contract was overseen by the corporate team. A local governance meeting had been introduced to discuss the service from the external supplier that processed biochemistry results.

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.

Staff worked in collaboration with other partner organisations to provide high quality of care. They shared information and carried out peer reviews to drive improvement.

The service arranged the following wellbeing activities with access to the community;

• Hampers to local care home
• Partnership with Sutton United Football Club
• Community days with Warwickshire County Cricket Club and Moseley Rugby Club
• Oncology staff took part in Cotswolds Mighty Hike
• Supported 202 MMR deployment to Kenya
• What’s your blood type” event with NHSBT

The service offered free 30-minute physiotherapy consultations for musculoskeletal (MSK) concerns, Capella 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 had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They actively contribute to safe and effective practice.

Staff and leaders had a good understanding of how to make improvement happen. The service was in breach of 2 regulations during our last inspection in May 2019. Improvements had been made during this inspection and they were no longer in breach.

The Priory hospital was in the process of purchasing a state-of-the-art colonoscope designed for improved detection, diagnosis and treatment of the colon. It featured advanced imaging technologies, like texture and colour enhancement imaging, narrow band imaging and dual focus to provide enhanced visibility of inflammation and lesions.

Staff were supported to prioritise time to develop their skills around improvement and innovation. Endoscopy telephone pre-assessments were normally undertaken by Circle Health Group’s national enquiry centre. Following a trend in incidents whereby patients were incorrectly prepared for endoscopy procedures, the endoscopy team had requested for their own staff to undertake the pre-assessments for their patients. This was to allow better communication and experience for their patients. To enable them develop an inhouse endoscopy preassessment team, a member of the endoscopy team started undertaking the pre-operative assessment course in September, and there was a plan for 2 more staff to complete the course in the near future.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. For example, an endoscopy consultant had invited staff members to attend an endoscopy symposium. This allowed the endoscopy team to meet other consultants and listen to talks about new practices and procedures. They shared their learning and experience with the wider hospital.

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 oncology 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.