Priory Hospital Suttons Manor

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 rated Safe as Good.

Staff knew how to report incidents and lessons learnt were shared. Staff knew how to protect people from abuse and neglect. Staff completed and updated individual risk assessments. There were thorough environmental risk assessments in place and the use of restrictive interventions were low. There were enough suitably qualified and trained staff to keep patients safe and patients told us they felt safe.

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, in which concerns about safety were listened to. Safety incidents were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

There were systems in place for the recording and reporting of incidents. We reviewed incident data for the previous 3 months. This showed that incidents were recorded against different category types. We saw staff recorded immediate actions that had been taken and lessons learnt. There was evidence that changes had been made as a result of learning from incidents. All staff, including agency staff, had access to the electronic reporting incident system. Staff we spoke with knew what incidents to report and how to report them. At the time of assessment there were 2 incidents under investigation.

Staff received feedback from investigation of incidents, both internal and from other sites across the wider organisation. Staff met to discuss that feedback. We saw that lessons learnt feedback was a standing agenda item at staff team meetings. Staff told us lessons were shared at handovers by the nurse in charge and daily flash meetings. We observed a handover meeting and saw that individual risks and incidents were shared with staff.

Staff and patients were debriefed and received support after a serious incident.

The service worked with people and their partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The service ensured continuity of care, including when people move between different services.

The service had operational policies and procedures in place to support safe systems, transitions and pathways. Staff worked within multidisciplinary teams including, nursing staff, healthcare assistants, medical staff, occupational therapists, activities co-ordinators and social workers and worked well together to look at the patient pathway.

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 safely be met. There was a clear care pathway in place from admission through to discharge. The service had a referrals and admissions co-ordinator in post, working across services both internal and external to the hospital.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care.

The service worked with people to understand what being safe meant to them as well as with partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect and they made sure to share concerns quickly and appropriately.

The service’s processes promoted people living free from abuse, neglect, and avoidable harm. We saw evidence that there were systems, policies, and practices in place to make sure people were protected from abuse and neglect. The service had a comprehensive local safeguarding procedure and a range of policies to protect adults and children. The service had a visiting policy in place for children.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff knew how to identify adults and children at risk of, or suffering, significant harm.

Staff were kept up to date with mandatory training for safeguarding adults and children in levels 1, 2 and 3. Staff were kept up to date with both training on the Mental Capacity Act and Mental Health Act.

We reviewed the service safeguarding log which included the total number of safeguarding concerns raised and outcomes. This included working in partnership with other agencies.

The service worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that matter to them.

During the assessment we reviewed 4 risk assessments, positive behaviour support plans and care plans. We saw that risk assessments were thorough and updated after every incident.

Positive behaviour support plans and care plans were detailed and personalised. We saw evidence of patient involvement and examples where carers and family contributed to these.

Patients’ physical health was regularly monitored and checked. We saw examples of falls assessments and diet management plans within patient records.

The service had a reducing restrictive practice policy in place. Its aim was to support the reduction of restrictive practices to ensure that least restrictive principles and practices were supported.

We reviewed the service incident data, in the 6 months prior to assessment there had been 6 incidences of restraint on 3 individual patients. None of these incidents were in the prone position or resulted in the use of rapid tranquilisation. There had been no episodes of seclusion in the previous 6 months.

We saw the use of restrictive interventions and the use of any blanket restrictions on the ward were regularly reviewed by the clinical governance committee.

Staff received mandatory training on Reducing Restrictive Interventions. At the time of the assessment the training compliance rate was 88%.

There were clear procedures for security and observations, staff we spoke with knew these. There was a dedicated security nurse on the ward.

Staff enabled patients to give feedback on the service they received. We reviewed examples of community meeting minutes and patient survey results, including actions taken because of feedback.

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

Staff did regular risk assessments of the environment. They completed and regularly updated ligature risk assessments for all internal and external areas. Identified risks were removed or reduced. We saw examples of this and observed both wards to be clean, safe and well furnished. Staff we spoke with knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Staff assessed risk to patients and took action to reduce risks where possible.

Staff had easy access to alarms and patients had easy access to nurse call systems.

Staff told us that the dining area was not a suitable size for all patients to eat together comfortably. Some patients chose to eat separately away from others, this was risk assessed.

Managers made sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that met people’s individual needs.

The service had low vacancy rates. At the time of assessment, there were 4 vacancies for qualified nurses and no vacancies for Healthcare Assistants. The service had a turnover rate of 0.5% in the 3 months prior to assessment.

Managers had calculated the number and grade of nurses and healthcare assistants required. The ward manager could adjust staffing levels daily to take account of case mix. A qualified nurse was present in communal areas of the ward at all times.

When necessary, managers deployed bank and agency staff to maintain safe staffing levels. Managers tried to book regular bank and agency staff, when required. As part of the assessment, we reviewed ward staff rotas and found over a 6-week period that not all shifts were filled by permanent ward staff. However, these shifts were supported by the ward manager, on-call senior nurse or staff from other wards to meet safer staffing levels.

The service had adequate Registered General Nurse cover who had responsibility for physical health to meet patients’ physical health needs.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. However, at the time of assessment the responsible clinician (RC) role was vacant, with locum cover. The service had recruited to this role and a permanent responsible clinician was due to start their induction the following week.

Staffing levels allowed patients to have regular 1:1 time with their named nurse and participate in activities on and off the ward. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

There were enough staff to carry out physical interventions such as observations, restraint and seclusion if needed, safely. Staff received the necessary training and induction to do this effectively.

Staff had received and were up to date with all mandatory training courses. The training was appropriate for the patient group using the service.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

We observed all ward areas were clean, had good furnishings and were well-maintained.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences.

During assessment we reviewed 10 prescription charts. Staff followed good practice in medicines management and did it in line with national guidance.

Staff reviewed the effects of medication on patients’ physical health regularly.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

However, we found the fridge for storing medication on South Weald ward was showing an error message and there was nothing to show on the fridge plug that the fridge should not be unplugged. We raised this at the time of the assessment and following this, the Provider arranged for a new fridge to be delivered from another site.