Priory Hospital Suttons Manor

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 rated Well-led as Good.

Staff knew who the senior leaders where and told us the senior leaders were visible, and staff demonstrated the vision and values for the service. There were policies, procedures and processes in place to oversee good governance and management of the services, including mechanisms for learning lessons from safety incidents and complaints, processes for ensuring staff received mandatory training, appraisals and supervision.

The service had an equality, diversity, and inclusion policy to ensure people were treated with respect and dignity. The service worked in partnership with other agencies.

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.

The provider’s senior leadership team had communicated the provider’s vision and values to the frontline staff in this service. Most staff knew and understood the provider’s vision and values and they were all clear about the aims of their service.

Staff described a positive culture within their own team and across the wider service. They were proud of their work.

The service set out a clear patient pathway and philosophy for their care and treatment which staff demonstrated.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and supported and embodied the culture and values of their workforce and organisation. They had the skills, knowledge and experience to lead effectively.

Staff and leaders were clear, and they understood their roles, responsibilities and accountabilities.

Staff spoke positively about local and senior leadership. Staff felt valued, respected and supported by their managers. Staff said that senior leaders were visible on the wards.

The service had checks in place to ensure leaders and managers had the correct qualifications, skills, training and competencies to fulfill their role.

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

Staff said they knew how to raise a concern and would feel comfortable to do so. They were aware of the service’s whistleblowing policy.

Patients and carers had opportunities to give feedback on the service. We saw examples of these.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service had an Equality, Diversity, and Inclusion policy and colleague charter in place. Staff had completed mandatory diversity and inclusion training. At the time of the assessment, 96% of staff had received this training.

The service used surveys to gather feedback from staff on their commitment to equality and diversity in the workplace. Most staff agreed there had been improvements made.

There were equality and diversity networks within the service for example; LGBTQ+, REACH (Race, Equality and Cultural Heritage) and Disability and Difference.

The provider undertook equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

The service had clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We reviewed examples of governance and staff meeting minutes. There was a clear framework of what must be discussed at staff and team meetings to ensure that essential information, such as learning from incidents and complaints, was shared.

Staff had implemented actions from reviews of incidents, complaints and safeguarding alerts at the service level. We could see actions and lessons learnt from the incidents, complaints and safeguarding logs we reviewed as part of the assessment.

Staff understood the arrangements for working with other teams, both within the service and wider provider organisation, to meet the needs of the patients.

Managers maintained and had access to the risk register. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register.

The service had plans in place for emergencies including major incident contingency plans.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, generally worked well and helped to improve the quality of care. However, staff told us internet connectivity could be slow in some areas.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

Information was in an accessible format, and was timely, accurate and identified areas for improvement. Managers told us they had effective systems to help monitor the care given through regular governance meetings and the use of dashboards to provide essential information.

Information governance systems included confidentiality of patient records. Patient records were stored securely.

However, on the day of the on-site assessment, we had difficulty locating patient consent to treatment forms and staff we spoke with were unable to find these. Following the assessment, the Provider sent additional information, and we were assured the service held the correct information.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Leaders engaged with external stakeholders such as commissioners and external partners. Staff maintained relationships with the local authority and police liaison. Managers said they had good working relationships with these services.

Staff worked with partners to help patients access and move into the community when ready to do so. They encouraged patients to access local organisations for social engagement for example, community centres, local religious/cultural groups, recovery colleges, and vocational services.

The service encouraged continuous learning, innovation and improvement.

Staff could access professional development opportunities. For example, some of the Registered General Nurses were being supported to do Mental Health Nurse training and Healthcare Assistants were supported to do nurse training.

Wards participated in accreditation schemes relevant to the service. The service was accredited with The Quality Network for Forensic Mental Health Services (QNFMHS).

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. We saw examples of quality improvement initiatives including improving the accessibility of patient information and the introduction of a patient-led patient safety temperature check tool.

Staff told us they were given opportunities to share their ideas around innovation and improvements at staff meetings and community meetings.