Priory Hospital Burgess Hill

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Requires improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm. All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe and administer medicines. The service managed patient safety incidents well.

However, the service did not always take a proportionate approach to imposing restrictions on patients. We found that patients did not always have access to drinks and snacks. Incidents entered on the provider’s electronic incident reporting system were not always informing risk assessments and care planning. The medicines stock management was not always safe.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed a good standard. 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.

The provider reported 23 serious incidents across the three wards that had been in operation between December 2024 and November 2025. Nine of them occurred in Venus ward and 14 in the two PICU wards. All staff knew what incidents to report and how to report them. Staff recorded incidents on an electronic incident reporting system.

Staff completed incident forms, patient safety fact finding and team incident review reports where appropriate. These included identified learning and action plans, and informed discussions in relevant meetings, such as patient safety and clinical governance meetings. A manager described in detail the steps the service took following an incident that had recently occurred. We saw that a debrief had been completed, the document was uploaded onto the service’s online incident reporting system, and learning was discussed in related meetings. We requested the provider to submit additional information for a serious incident we were informed of during our visit. This was provided in the form of a report.

Learning was embedded through structured processes. We observed a patient safety meeting and found it comprehensive. These were held monthly and incidents and lessons learnt were standard meeting agenda items. Regional and divisional learning was also shared and discussed.

Lessons were learned from safety incidents or complaints, resulting in changes that improved care for others. Staff received feedback from investigation of incidents, both internal and external to the service. For example, lessons learnt bulletins were issued monthly and the information was linked to the incident source and included learning identified locally or in other locations operated by the provider.

Changes had been made as a result of feedback. For example, we found that in Jupiter ward staff had implemented garden observations from a lesson learnt review.

The evidence showed a good standard. The service worked with people 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 people 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 safely be met. We reviewed seven patient records and found that staff had appropriately completed mental and physical health assessments for patients on admission. We observed structured processes for discussing admissions during morning multidisciplinary team (MDT) meetings. The morning meeting included doctors, managers, nurses, and occupational therapists, and each patient was discussed in detail, covering admission history, presentation, feedback from nursing and the wider MDT, physical health, medication, risks, and actions.

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. We attended a ward round for a Jupiter ward patient and observed that a doctor created an action for them to liaise with a pharmacist to discuss the medication needs of that patient. Staff told us that they were working closely with community teams to ensure that patients were moved on appropriately.

The evidence showed some shortfalls. While the service worked with people and healthcare partners to understand what being safe meant to them and to protect their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, the service did not always take a proportionate approach to imposing restrictions on patients.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Data submitted by the provider showed that all staff had completed safeguarding training appropriate to their role.

There was a clear process when raising a safeguarding concern. Staff reported all safeguarding concerns internally and would refer directly to the local authority safeguarding team, when needed. Staff discussed safeguarding concerns in daily flash meetings and monitored safeguarding trends through clinical governance meetings. Managers were able to explain their safeguarding processes and how they ensured oversight.

Staff demonstrated awareness of how to protect patients who were vulnerable. Staff we spoke with were clear about their responsibilities and described the process for escalating issues and knew how and when to contact safeguarding leads or the police. Information about safeguarding leads was displayed on notice boards.

However, the service did not always take a proportionate approach to imposing restrictions on patients. Blanket restrictions were in place on both wards. Patients were not always able to access snacks and drinks without staff support. Snacks, such as fresh fruit, were not readily available on both wards. We observed that on Venus ward cups were kept locked in the kitchen. This meant patients needed to ask staff anytime they wanted to make a drink. We reviewed the hospital’s register of active blanket restrictions and we found that there was no entry about patients on Venus ward having no access to snacks or cups for drinks. For Jupiter ward, there was an entry about patients having to ask staff for hot drinks as the machine had been out of use and in need of repairs. There was no entry about patients not having free access to snacks. Patients had also raised this as a concern during November’s 2025 patient forum. Patients raised the issue of cups being locked in the kitchen and requested to have paper cups available. Staff responded that they will ensure that such items were available. This action was shown as completed in the meeting minutes, however cups were still not accessible during our visit.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. Approximately 96% of Jupiter ward staff and 93% Venus ward staff had had up to date training in the Mental Capacity Act.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Doctors told us that mental capacity was reviewed on every ward round.

The evidence showed some shortfalls. While the service work well with people to understand and manage risks, incidents were not always informing patients’ risk assessments and care planning to ensure that the care provided was always safe and was meeting people’s needs.

Staff involved patients in care planning and risk assessment. We reviewed seven patient records and found that staff promptly completed risk assessments on admission and patients were involved in creating the risk assessment.

We observed multidisciplinary team meetings and ward rounds where discussions were patient focused with emphasis in involving patients and their families to manage risks.

The provider reported 10 incidents between September to November 2025 where rapid tranquilisation had been used. Six of these incidents were at the two wards we visited. The provider reported 40 incidents between September to November 2025 where restraint was used. There was only one recent episode of seclusion. A seclusion care plan was in place and seclusion reviews were appropriately completed. The service was working towards implementing the Safewards model, which is an evidence-based framework designed to reduce conflict, restraints and seclusions on psychiatric wards by improving staff-patient relationships and mitigating risks.

Staff ensured that patients could access advocacy and relevant information was displayed on notice boards. An Independent Mental Health Act advocate was visiting the service during our visit and gave positive feedback about the service mentioning good liaison with senior staff and managers.

However, incidents entered on the provider’s electronic incident reporting system were not always informing risk assessments and care planning. We reviewed a sample of six incidents and found that three had not been added on the patients’ care records and risk assessments. We also reviewed seven patient care records and found that four of them had no evidence that the risk management sections were being promptly updated in response to incidents. This meant that not all potential risks were always taken under consideration when staff were reviewing risk assessments and care plans. The provider took immediate action to address this. The provider submitted minutes from a staff team meeting which took place a few days after our inspection visit and included an action for staff to ensure that both the risk assessments and the care plans were updated after each incident.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises where patients received care were well equipped, well furnished, well maintained and fit for purpose. There were effective arrangements to monitor the safety and upkeep of the premises. The patients we spoke with told us that the premises were well maintained.

The design and layout of the wards meant that there were areas accessible to patients that were out of sight of the nurse station. Staff mitigated this by using convex mirrors positioned in corridors to reduce blind spots, through patient observations levels, and CCTV in communal areas.

Managers ensured that regular risk assessments of the care environment were carried out. Staff were completing environmental checks. The provider had a Minimising Harm from Ligatures procedure in place and staff carried out ligature point audits on an annual basis, following any changes to the environment, or when a ligature incident had occurred. The most recent audits had been completed in September and October 2025. While the audits were lengthy and covered all areas of the wards, the information about how potential ligature points were being managed and the associated risks mitigated, was limited.

Staff had easy access to alarms and patients had easy access to nurse call systems in bedroom and seclusion rooms.

Seclusion rooms allowed clear observation and two-way communication, rooms had toilet facilities and a clock. Staff had boards with information about seclusion positioned in a way that patients could see and be informed about when reviews were due, the name of the responsible clinician, and information about when a seclusion could be terminated.

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

The evidence showed a good standard. 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 people’s individual needs.

The service had low staff vacancies. A newly recruited registered nurse was undergoing pre-employment checks to cover the only vacancy. The staffing establishment for registered nurses was 19.2 full time equivalent and there were 17.94 in post. The staffing establishment for healthcare assistants was 34.2 full time equivalent and there were 32.05 in post.

Managers had calculated the number and grade of nurses and healthcare assistants required. They increased or decreased the minimum number of staff allocated to each shift depending on the number of patients on the wards.
When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. The service had a number of bank nurses and healthcare assistants who often covered shifts together with agency staff to meet acuity levels. The number of unfilled shifts was low. There were five unfilled shifts between June – November 2025. However, staff told us that the number of staff allocated to each shift was not always sufficient to ensure that staff were able to appropriately complete their tasks and engage in meaningful activities with patients.

Staff sickness was low. Data submitted by the provider showed that between December 2024 – November 2025 staff sickness was below 3% which was the target set by the provider.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. We reviewed a sample of thirteen completed induction packs and found that staff were completing inductions appropriate to their roles.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. There was a consultant psychiatrist for each ward and the medical director was also providing cover when needed. There were arrangements in place to access doctors out of hours during the week and weekends.
At the time of the assessment 96% of staff were up to date with mandatory training. The training was appropriate for the patient group using the service.

The evidence showed a good standard. 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.

All ward areas were clean, had good furnishings and were well-maintained. During our visit we saw housekeeping staff cleaning. All the patients we spoke with told us that the premises were cleaned and well maintained.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. The housekeeping team had cleaning schedules and rotas in place, and staff carried out audits to ensure that the cleaning was thorough.

Staff maintained equipment well and kept it clean. For example, staff were completing daily, weekly and monthly checks on the equipment kept in the clinic rooms.

Staff adhered to infection control principles, including handwashing. Staff were completing quarterly handwashing audits. There was a nominated infection prevention and control lead for the service.

The evidence showed some shortfalls. The service did not always make sure that the storing and recording of medicines was always safe.

Staff followed good practice in medicines management and did it in line with national guidance. The service’s medicines management was being supported by an external pharmacist. Medicines, including controlled drugs (medicines requiring additional control due to the potential for misuse), were stored securely. The clinic room was secure, clean and tidy, and staff recorded room and fridge temperatures. Controlled drugs were stored in line with safe custody requirements.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication. For example, we reviewed the care records of a patient who had recently administered rapid tranquilisation twice and found that appropriately physical checks had been completed following the administration of the medication. We attended a ward round and observed that the medication needs of a patient were discussed in detail and involved other professionals where appropriate.

However, we found that the medicines stock management was not always safe. Following the closure of the Neptune ward, all medicines had been transferred to Venus ward and were kept in a locked cabinet without being added to the Venus ward stock and there was no register for these medicines and management plans. An external pharmacist told us that they had created an action plan for the provider following them becoming aware of the issue, however no action had been taken by the provider. We informed the provider of our concerns and they took immediate action by creating a register of the medicines and ensured that these were appropriately managed.