All inspections: Priory Hospital Burgess Hill

The Priory Hospital Burgess Hill is an independent hospital which provides inpatient mental health treatment to adults. We undertook an unannounced comprehensive inspection to review the standard of patient care and to check if the service had made the improvements, we told them they must make from the previous inspection.

Our rating of this location went down. We rated it as requires improvement because:

Although we found the hospital had made a number of improvements since our last inspection, there were still a number of outstanding improvements that had not been made. In addition, we identified some additional areas of concern.

The ward environments were not always safe or well maintained. Bedrooms and ward areas on Michael Shepherd ward had fixed ligature anchor points. The wards were generally in need of refurbishment.
Staff did not assess and manage risk well. Patient risk assessments were not always reviewed regularly, including after any incident, and patient observations were missed on Edith Cavell ward.
Vacancy rates remained high for permanent registered nurses.
Patients reported that their section 17 leave had been cancelled at short notice. Staff did not always document the rationale for the cancellation.
Patients on Michael Shepherd ward reported the food was not always tasteful.
Managers did not always ensure all staff had an appraisal.
The hospital did not actively support patients on the forensic inpatients and secure ward to access opportunities for work and education.
Governance processes did not always ensure that ward procedures ran smoothly and did not identify issues around lack of coordination between the various systems and processes in place.

However:

Staff managed medicines safely and followed good practice with respect to safeguarding.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training and supervision.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff were generally kind and supportive. Patients said they felt safe on the wards.
The service managed beds well so that a bed was always available locally to a person who would benefit from admission.
Staff assessed the physical and mental health of all patients on admission. Staff from different disciplines worked together as a multidisciplinary team to benefit patients.

We carried out a focused unannounced inspection on 5 and 7 May 2021 of two wards at Priory Hospital Burgess Hill. We inspected the female specialist personality disorder ward (Amy Johnson) and the forensic low secure inpatient ward (Michael Shepherd). We specifically looked at some aspects of the key questions of safe, effective and well-led, because of concerning information we had received about patient safety.

During the inspection we found a number of areas of concern. Following this inspection, we wrote to the provider and told them that we required them to provide us with assurance that they would make immediate and ongoing improvements, otherwise we would use our powers under Section 31 of the Health and Social Care Act 2008. Section 31 of the Act allows CQC to impose conditions on a provider's registration. The provider responded to us and provided an action plan that told us what they would do to address our concerns. In addition, the provider decided to close two hospital wards (the female psychiatric intensive care and female personality disorder wards) in order to ensure they could staff the three remaining wards safely.

CQC reviewed the provider’s action plan and felt that the actions the provider was taking reduced the risks sufficiently enough that urgent enforcement action was not necessary. However, CQC will continue to closely monitor the hospital on a weekly basis until the risk had further reduced.

Following our inspection, we suspended the ratings for the hospital. Due to the closure of two wards the ratings were no longer a true reflection of the service provided. We will return to inspect the hospital in due course and rate the hospital accordingly.

We found:

• The wards we inspected did not have enough experienced and skilled staff to manage all the risks on the wards. The service had high vacancy rates and used many agency staff. This meant that there were not enough staff who knew the patients well enough to keep them safe from avoidable harm.

• Staff did not assess and manage risk well. Staff were not consistently undertaking risk assessments of all patients’ identified risks and they did not clearly identify the severity of these risks.

• The levels of restrictive practices on Amy Johnson ward were high. Staff did not achieve the right balance between maintaining safety and providing the least restrictive environment possible in order to facilitate patients’ recovery.

• Staff did not always develop holistic, recovery-oriented care plans and engage in audit to evaluate the quality of care they provided. This meant that care plans did not always reflect patients’ assessed needs and were not personalised.

• The service did not always ensure that information about patient behaviours was effectively shared between all staff. Sometimes staff did not have access to patients’ care plans and risk assessments due to frequent problems with the electronic system. Staff that did not regularly work at the hospital did not have log in details, so they could not easily access patient information.

• Governance processes were not always robust enough to identify issues around lack of coordination between the various systems and processes and to facilitate effective risk management. The service did not always capture and act on patient feedback. Multidisciplinary team meetings did not thoroughly and effectively discuss patient safety and risk management. There was no evidence or clear process of how incidents were recorded, investigated and learning shared. This meant that the provider did not always know whether staff were delivering safe care that met individual needs.

However:

• Staff provided a range of treatments such as dialectical behavioural therapy and cognitive behavioural therapy suitable to the needs of the patients cared for in the Amy Johnson rehabilitation ward.

• Leaders had the skills, knowledge and experience to perform their roles, were visible in the service and approachable for patients and staff.

We carried out a focused inspection of two wards at Priory Hospital Burgess Hill. We visited a psychiatric intensive care ward (Elizabeth Anderson) and a forensic low secure inpatient ward (Michael Shepherd). The inspection took place during the COVID-19 pandemic and was unannounced. We focussed on areas of the key question of safe. During the inspection we identified concerns which required us to take enforcement action. Due to this we provided a new rating for safe of requires improvement. However, our overall rating of this service stayed the same.

We found:

• At the time of our inspection 87% of registered nursing posts, and 45% of healthcare assistant positions were unfilled at the hospital. There was high use of agency staff on both wards and patients told us these staff did not always know who they were, or how to meet their needs. This impacted upon the consistency of care available to patients and the hospitals ability to safely manage some risks, such as self-harm.

• Care records across both wards were not sufficiently detailed and did not contain all the required information staff needed to keep patients safe. Seclusion records did not demonstrate that patients were safely observed throughout their time in seclusion.

• Some staff did not understand or follow the hospital’s established policies and procedures for managing the environment and patients’ safety. Staff did not always follow the hospital’s processes and the relevant records were not always properly completed or were inaccurate. This included signing patients in and out for leave and documentation about risk items on the ward, such as crockery.

• Staff did not always complete records of physical health monitoring following use of rapid tranquilisation. Most records showed that one or two attempts had been made to record physical health after the administration of a medicine, but this did not follow the policy of the provider or national recommendation.

• Mental Health Act documentation to authorise treatment was not always available in patients’ medicine administration folders. This meant that staff administering medicines would not know if a medicine could legally be given to a patient. Prescribing did not always follow national guidance and the provider lacked a clear process to ensure that this was reviewed and challenged.

However:

• Patients described staff as kind, supportive and respectful.

• The ward environments were clean and well maintained. Staff observed the environment and cameras and mirrors had been installed to reduce the risk blind spots posed. Staff worked towards providing the least restrictive environment possible in order to safely facilitate patients’ recovery.

• Patients received regular physical health checks and were able to access a range of specialists when needed. This included access to an annual dental review and other national screening programmes.

We rated Priory Hospital Burgess Hill as good because:

The service provided safe care. The ward environments were safe and had enough nurses and doctors. Staff assessed, managed and mitigated risks well. They were actively minimising the use of restrictive practices and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided and developed sufficient action plans to address issues.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that all substantive, bank or locum staff received training, supervision and appraisals. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act. Staff had a good understanding of the Mental Capacity Act.
Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of their patients. They involved patients and families and carers in care decisions.
The service worked to a recognised treatment model appropriate to the patient group. It was well led and the governance processes ensured that ward procedures ran smoothly.

However:

On the rehabilitation ward staff were not consistently following the hospital policy for medical monitoring of patients using the ward’s seclusion facilities. On one occasion staff had not followed up the physical health concerns of a secluded patient.

The service had regular medicine errors highlighted by monthly pharmacy audits although there was learning from this and the incidents were reducing. Additionally, medicine labelling and patient information for medicines that patients took when transferred or discharged was not appropriate. Clinic room refrigerators were dirty on Michael Shepherd ward and their cleaning records showed several dates missing within the previous month. Expired medicines were not being disposed of in accordance with hospital policy.

Priory Hospital Burgess Hill was well maintained and cleaned to a good standard.
Staff were aware of their roles and responsibilities and took appropriate measures to safeguard clients from avoidable harm and/or abuse.
The hospital had identified staffing as a high-risk issue on the hospital risk register and were ensuring wards did not run under their safe staffing numbers by using locum agency staff, while full time positions were recruited to.

Morale amongst staff was good. Staff felt proud and valued to work at the service. Relationships amongst staff were strong and supportive.
Physical healthcare was integrated into the care plans and the practice nurse was closely involved across the hospital in supporting the patients.

There was an induction and annual training programme for all staff that specifically addresses issues of relational security.

There was a designated safeguarding lead for both children and adults

However:

Staff were not aware they could refer a safeguarding matter straight to the local authority without requiring it to be reviewed by the Priory Hospital Burgess Hill Safeguarding Lead first.
Senior support workers and nurses did not have the opportunity to meet regularly as a hospital wide clinical reflective group to review case studies and how situations were being managed across different wards within the hospital.

On the evening of April 4 2018 and during the day on April 5 2018 we undertook an unannounced, focussed inspection of three wards at The Dene. We found the following areas of good practice:

Each ward managed their environmental security by having a security lead for each shift who was responsible for the security of the ward. Staff carried alarms at all times which they signed in and out from the hospital reception at the start and end of each shift.
Each ward had assessed risk posed by blind spots and ligatures and had detailed blind spot and ligature risk assessments. Each had an accompanying action plan to mitigate identified risks.
All wards were clean, spacious and well maintained. Each ward had sufficient rooms and spaces for patients to use which provided a quiet space. These were all clean and had suitable furnishings. Clinic rooms on each ward were clean and had accessible resuscitation equipment that was checked regularly.
Mandatory training was up to date across all wards. Staff were alerted when their training was due to expire so they could book on the relevant course. Bank or locum staff were not booked to work on the wards until all mandatory training had been completed. All staff had received safeguarding training and were aware of how to make a safeguarding alert to the local authority.
Staff updated risk assessments following incidents and completed a risk assessment of each patient on admission. Staff followed appropriate observation policies. If staff felt a patient required additional levels of observation then the nurse in charge could increase the level, and request additional staff if any additional one to one observations were needed.
Interactions between staff and patients were positive. Patients reported that staff treated them well and that they felt safe and well looked after. Each ward had a weekly community meeting for patients to give feedback on the service they were receiving and make suggestions. The wards also had ‘you said, we did’ boards to highlight areas where changes had been made as a result of patient feedback.

However:

Seclusion paperwork was not always completed fully and did not always correspond with what was recorded in the patient electronic record.
Staff did not always complete follow up physical health checks on patients if this was indicated by their physical health scores.
Not all staff reported being aware of outcomes of incidents or lessons learned from these.
Not all patients we spoke with had a copy of their care plan.

We rated acute wards for adults of working age and psychiatric intensive care units, and forensic inpatient/secure wards as good overall because:

Following our inspection in October 2016, we rated the service as good for effective, caring, responsive and well led. Since that inspection we have received no information that would cause us to re-inspect these key questions or change the ratings.

During this inspection, we found that the service had addressed the issues that had caused us to rate safe as requires improvement following the October 2016 inspection.

The acute wards for adults of working age and psychiatric intensive care units, and forensic inpatient/secure wards were now meeting Regulations 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

This overall rating has not changed from the rating given following the previous comprehensive inspection in October 2016.

We rated The Dene as good because:

Staff completed patient risk assessments in a timely manner using recognised tools, such as the historic, clinical risk management – 20.
Shifts were very rarely understaffed and where agency staff were used, the same staff were requested on a longer term basis to ensure continuity of care for patients. There was always a minimum of two qualified nursing staff on each shift and enough staff to allow patients one to one time. The hospital was using innovative schemes to recruit to vacant nursing posts and had employed a recruitment consultant to assist with this.
Staff monitored patients’ physical healthcare and they could access specialist physical health services when needed. The hospital had service level agreements with the tissue viability service, dentistry and speech and language therapy. A GP provided regular physical health monitoring. Staff used appropriate measures such as the malnutrition universal screening tool. Staff met patients nutritional and hydration needs and there was good liaison between ward staff and the catering team.
Staff engagement with patients was positive. Patients told us they felt safe on the ward and there was good staff presence at all times. Patients were very complimentary about staff and we observed many positive and engaging interactions between staff and patients. Staff demonstrated a clear understanding of individual patient’s needs. Each ward held weekly community meetings for patients to raise any issues or concerns with the staff team.
There were regular and effective multidisciplinary team meetings occurring that involved a good selection of health care professionals. Staff reported senior managers were visible on the wards and they felt well supported by managers. Staff spoke of their pride in working for the service and high levels of job satisfaction.
Each ward had a full range of rooms to support patients’ treatment and care including clinic rooms, a quiet room, art therapy rooms and a hospital gym. Patients had easy access to spiritual care and chaplaincy.
Patients’ had good access to psychological therapies with individual one to one sessions occurring regularly. Occupational therapy was also provided on each ward. The hospital was accredited with the Oxford, Cambridge RSA examinations service so that patients could study to take exams on the ward.
There was a clear complaints procedure in place and the hospital responded well to these in a timely manner. There was an efficient system of reporting incidents and we saw clear cascading of learning from these to ward staff.
The service had good governance systems in place reflected in the high rates of staff training, supervisions and appraisals. All staff were trained in adult and children safeguarding and demonstrated a good knowledge of the safeguarding procedures for the hospital.

However:

The ligature audit was basic and had no plan in place to mitigate the identified risk.
There were some blanket restrictions on some wards regarding snacks, hot drinks and garden access.

Some informal patients told us they were not aware they could leave the ward. However there were notices displayed on the wards explaining patients' rights, including the right to leave.
We saw one example of Mental Health Act paperwork not being appropriately completed when using section 5(4).
Patient involvement in their care planning was minimal.
Patients on secure and high dependency wards access to the gardens was limited to set times.
The activity programme did not offer meaningful and engaging activities at weekends.

The three wards we visited (Michael Shepherd, Wendy Orr and Amy Johnson) had made improvements with physical health care of patients since the previous inspection.
The hospital had a practice nurse in post to review physical health care across the hospital.
All staff had completed mandatory training.
Staff monitored patients’ physical health daily. All staff,including healthcare assistants, were trained to complete physical observations.
Patients reported staff listened to them and involved them in their care planning.
Care plans were holistic, person centred and recovery focused. Staff completed assessments within appropriate timescales.
There were good medicines management processes in place and good links with the pharmacy service that provided medicines for the hospital.
The hospital was 100% compliant with CQUIN (Commissioning for Quality and Innovation) for physical health care.

This inspection was a focussed inspection to follow up concerns we had received in relation to the physical healthcare provided to patients.

Our findings were that:

Staff were not trained to manage and deliver many aspects of patients physical health needs and this care was not delivered in accordance with national guidance. Staff did not escalate concerns about their inability to meet patient needs.

There was a lack of appropriate dressings and patients were at risk of cross contamination from poor wound management.

The provider failed to ensure that there was learning from their own investigations following a serious event.

There were high levels of agency staff employed who did not have the required training or expertise in managing chronic physical health conditions.their needs.

However:

All the wards in the hospital were single gender which meant that the provider complied with government guidance in respect of same sex accommodation.

The resuscitation equipment was checked daily on each ward.

The purpose of this inspection was to follow up on widespread non-compliance identified during our last visit to The Dene on 30 April 2013.

It is noted that since that inspection, there has been an open and honest acknowledgement by the provider of the shortfalls and a commitment to address these issues. The Regional Executive Director told us there was 'A need to facilitate a culture shift to improve both patient and staff engagement and this will take some time and sustained effort.'

The inspection team comprised four Compliance Inspectors, a Pharmacist Inspector, a Specialist Advisor and an Expert by Experience.

We visited all five wards, observed care practices, examined a range of documentation and spoke with patients, nursing and care staff and senior managers.

We found that a lot of hard work and significant improvements had taken place since our previous inspection. These included changes to the management structure, the relocating of the acute admission wards, more support and involvement of patients in their care and treatment planning and improved communication, staff support systems ' and staff morale.

We found that before patients received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Consent forms had been completed appropriately.

We saw that patients' privacy, dignity and independence were respected. We saw that staff were friendly and kind and responded to patients' needs. We saw that people were supported to make choices, including how they spent their time, and that their choices were respected. A care worker told us 'We ask patients instead of telling them and try to prompt rather than do things for them - it puts the power back to them. The managers are very hot on things like that.'

One patient told us 'Generally all of the staff are very caring. They are trying to give us much more support. They're here for me whenever I need them.' Another person told us, 'It's the best hospital I've been in. I have the support of the staff and the psychologist. There are people helping you all the time. I feel safe here.'

We found that improved systems were in place to ensure there were sufficient numbers of staff on duty to meet the assessed care and support needs of the patients. Staff were supported and received appropriate professional development.

Despite on-going issues with the electronic patients records, we found that significant improvements had been made regarding the accuracy and consistency of the records maintained.

On the day of our inspection we were accompanied by Mental Health Act commissioners (MHAC), a Pharmacist Inspector and an Expert by Experience. We visited three wards (Edith Cavell, Helen Keller and Michael Shepherd) to monitor compliance and the use of the Mental Health Act 1983 (MHA) to provide a safeguard for individual patients whose rights are restricted under the Act.

We found that informal patients on an admission ward alongside detained patients were subjected to the same restrictions, which consequently infringed their rights. Patients also raised concerns about the lack of privacy and dignity.

The registered manager told us that the service had transferred much of its documentation, including individual care and treatment plans to an electronic system of recording.

Record keeping, including care plans, risk assessments and staff interventions were found to be inconsistent and inadequately maintained. Consent to treatment forms were not always in place.

One patient we spoke with on Michael Shepherd Ward told us 'It would be good to have a few more staff around so we can get out more. Other than that I haven't got a bad word to say about the place'.

We found that the service did not protect patients against the risks associated with the unsafe use and management of medication.

We found that patients' safety, welfare and their opportunity for leave was often compromised by insufficient staff on duty.

It is to be noted that on the day of our inspection we were accompanied by a Mental Health Act Commissioner (MHAC). They visited one ward (Amy Johnson) to monitor the use of the Mental Health Act 1983 (MHA) to provide a safeguard for individual patients whose rights are restricted under the Act. Their findings on this ward, including in relation to privacy and dignity and activities differed from our experience throughout the rest of the hospital. The MHAC identified issues which were specific to Amy Johnson Ward and these have been recorded and addressed under their own monitoring process.

We found that individual care plans included a section which incorporated the patient's view and experience of various aspects of service provision.

We found that the service did not protect patients against the risks associated with the unsafe use and management of medication by means of appropriate arrangements for the obtaining, recording, using, safe keeping and safe administration of medicines.

The registered manager told us that staffing levels throughout The Dene were now closely monitored to ensure that they reflected the assessed treatment and support needs of patients.

We spoke to a Senior Support Worker who had worked at The Dene for many years who stated, 'I feel supported by my managers, I have no issues and have regular supervisions. If I do need to raise an issue I will speak to my managers - or other staff on other wards.'

Residents generally felt safe and well cared for, and that consultations such as the recent meeting on smoking breaks had been helpful.

People felt staff worked hard but that at times there weren't enough staff, which impacted on them and what they could and couldn't do.

Privacy and dignity issues raised by residents included lack of access to their bedrooms during the day, food being cold and a lack of menu choice, and having to get up in the morning earlier than they would want to.

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

These older reports are from our old approaches to inspection, including those from before CQC was created.

Priory Hospital Burgess Hill

All Inspections

10 & 11 August 2021

During a routine inspection

5 & 7 May 2021

During an inspection looking at part of the service

11 August 2020

During an inspection looking at part of the service

24 and 25 April

During a routine inspection

25 and 26 September 2018

During an inspection looking at part of the service

4-5 April 2018

During an inspection looking at part of the service

7 June 2017

During an inspection looking at part of the service

11-13 October 2016

During a routine inspection

6 May 2016

During an inspection looking at part of the service

26, 27 January 2016

During an inspection looking at part of the service

14-16 July 2015

During a routine inspection

30 October 2013

During an inspection looking at part of the service

30 April 2013

During a routine inspection

20 November 2012

During a routine inspection

30 November 2011

During an inspection in response to concerns

Mental Health Act Commissioner reports

Reports under our old system of regulation