Priory Hospital Enfield

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

Prior to the inspection we received anonymous whistleblowing concerns about the overuse of restrictive practices within the hospital and insufficient oversight of physical health effects of medicines. We did not find evidence of this during our inspection. We did find some gaps in seclusion records and an area of improvement of the level of detail included in eyesight observation records, to reflect best practice.

Staff reported incidents and were aware of the learning from recent incident reports including improved handover information. Staff were aware of the need to always be open and transparent, including after an incident. Staff were trained in safeguarding and knew how to make safeguarding alerts. At the time of the inspection 93% of staff were trained in safeguarding adults and safeguarding children. Staff also attended brief training sessions in related areas including barriers to reporting concerns and abuse, domestic abuse, financial and material abuse, neglect and acts of omission. Appropriate safeguarding concerns were raised by the wards relating to patients and led to protection plans being put into place when needed.

Staff completed targeted searches if there were specific risks identified. Staff applied blanket restrictions on patients’ freedom only when justified, such as items that they were not allowed to bring on the ward.

Staff completed comprehensive risk assessments using a structured judgment tool to assess the risks for each patient on admission and reviewed these regularly as needed. For most risks identified, patients had care plans in place to address these. However, we found some patients with physical health risks, who did not have a care plan in place to address this.

There were systems in place for staff to follow before patients went out on unescorted leave. Staff recorded what patients were wearing and checked on how they were feeling and presenting before going out. As recommended at the last inspection, the provider had embedded its reducing restrictive practice programme to help ensure patients were treated with the least restrictive intervention being applied to them as possible.

The ward environments were visibly clean and well maintained, although we did find 2 mattresses that were not clean and internal audits indicated this as an area for improvement. Relevant health and safety environmental checks were in place across the wards.

Staff were supported by CCTV and concave mirrors around the wards to observe patients and ensure their safety. Staff were located in areas identified as having reduced sightlines. All members of staff carried a personal alarm, and there were wall-based alarms throughout the ward as well as in patient bedrooms.

There had been significant recruitment of staff within the hospital, with few vacant posts and reduced use of agency staff. Safe staffing levels (for registered and non-registered nurses) at the time of the inspection had been assessed for each ward.

Overall compliance with mandatory training was 90%. Staff also completed specialist training in diabetes awareness, epilepsy awareness, rapid tranquilisation and sepsis.

Staff understood how to use sedative medicines safely. They used de-escalation techniques and oral medicines first and only used rapid tranquilisation (RT) as a last resort.

At the previous inspection we found that staff were not always completing the necessary physical health monitoring of patients who receive medicines by intramuscular RT, to protect patients from significant physical health deterioration. At the current inspection we found overall improvement in this area, although some areas still needed addressing. We found some discrepancies between patients’ records where it was unclear if they had been administered RT or given oral medication, which the provider had not identified themselves. Records did not always clearly show why ‘when required’ (PRN) medicines were used on the wards to manage anxiety or agitation or if they worked. Some expired medicines were found in clinic rooms. These had not been removed despite being picked up in audits.

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 service had a proactive and positive culture of incident reporting and learning. The service listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew what incidents to report and how to report them. Ward managers reviewed incident reports and completed a fact finder report where required to ensure that rapid learning could take place. Where needed, a more detailed incident investigation was carried out. Incidents were discussed at handover meetings, in team meetings and supervision sessions. Staff were aware of learning from incidents shared by the provider to highlight recent incidents and learning. They gave examples of learning from incidents including improved handover information and recording of physical health checks. Staff noted that learning from incidents included a change in protocol for staff conducting individual observations of patients, so that staff changed over after a maximum of one hour.

We saw appropriate examples of learning from incidents, and actions being put in place to prevent recurrence. All staff we spoke with were aware of incidents that had taken place in the last year.

Duty of candour is a legal requirement, which means providers must be open and transparent with patients about their care and treatment. This includes a duty to be honest with patients when something goes wrong. Staff were aware of the need to always be open and transparent, including after an incident.

The average length of stay across the forensic wards was between 3 – 5 years. Staff advised that the targeted length of stay usually depended on how a patient responded to treatment and other clinical related factors. They indicated that there were currently no patients facing a delayed discharge from the wards.

The hospital held a meeting each week to discuss referrals, transfers and discharges. Transfers from the wards could occur if a patient required a higher level of supervision, and if there was safeguarding incident between two or more patients on a ward. Staff ensured that when they transferred or discharged patients that this was always at an appropriate time of day, except in the event of an emergency.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff could give examples of safeguarding alerts they had made. Ward managers and the allocated social worker kept a safeguarding tracker and completed level 4 training in safeguarding.

Appropriate safeguarding concerns were raised by the wards relating to patients and led to protection plans being put into place when needed. Staff gave an example of a patient who had been involved in financial transactions with other patients, and how this had been addressed to ensure that all monies were returned.

Children visiting the service were not permitted on the ward. Instead, patients could see children, if this was identified in their risk assessment as being appropriate, away from the ward in a visitors’ room.

Prior to the inspection we received a number of anonymous whistleblowing concerns about the overuse of restrictive practices within the hospital, and insufficient oversight of physical health effects of medicines. We did not find evidence of this during the inspection.

Staff completed a comprehensive risk assessment using a structured judgment tool to assess the risks for each patient. This was completed on admission and then reviewed regularly as needed. We saw detailed risk assessments in place for patients on the wards. Recording and management of risk on the ward largely used a stratification approach (Red Amber Green rating) but included further information about each risk to identify protective factors, and times when risks would be increased.

For most risks identified, patients had care plans in place to address these. However, we found some patients with physical health risks, who did not have a care plan in place to address this. For example, for patients on Lithium or high dose antipsychotics.

Staff followed policies and procedures for the use of observation. However, observation records at night did not always include the side the patient was facing when lying down, in line with best practice.

As recommended at the last inspection, the provider had embedded its reducing restrictive practice programme to help ensure patients were treated with the least restrictive intervention being applied to them as possible. However, during this inspection we found a lack of readily available records for incidents of seclusion and restrictive practice. There were significant gaps in 2 out of 3 seclusion records we checked. We also found that in the seclusion audits we reviewed, in 4 out of 5 cases, the 2 hourly nursing reviews were not always completed within the 2-hour window expected. We did not find evidence that patients had debriefs after seclusion.

The provider’s own audits indicated that there were 9 cases of seclusion between January and July 2025. They found a need for the doctor comments section to be completed and an overall 89% compliance in recording.

Staff completed targeted searches if there were specific risks identified. Staff applied blanket restrictions on patients’ freedom only when justified, such as items that they were not allowed to bring on the ward.

There were systems in place for staff to follow before patients went out on unescorted leave. Staff recorded what patients were wearing and checked on how they were feeling and presenting before going out.

Staff undertook regular risk assessments of the care environment and recorded and reported on any areas that required attention. For example, broken items of equipment.

Staff were supported by CCTV and concave mirrors around the wards to observe patients and ensure their safety. Staff were located in areas identified as having reduced sightlines. Staff knew about potential ligature anchor points and told us how they mitigated the risks to keep patients safe. They were clear about where to access ligature cutters if needed and a current ligature assessment of the wards was available.

The wards were for male patients only, and patients shared bathroom facilities.

All members of staff carried a personal alarm, and there were wall-based alarms throughout the ward as well as in patient bedrooms.

The provider undertook weekly fire alarm tests and regular fire drills.

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.

There had been significant recruitment of staff within the hospital, with few vacant posts and reduced use of agency staff. At the time of the inspection there were 7 full time equivalent (FTE) vacant posts for registered nurses. The service was overstaffed by 4.7 FTE for non-registered nurses which meant fewer agency staff were needed. The hospital had a rolling 12-monthly turnover of 15.8% of staff.

Safe staffing levels (for registered and non-registered nurses) at the time of the inspection had been assessed for each ward. Byron Ward with a maximum of 10 patients and had 2 registered and 2 non-registered nurses during the day and an extra staff member during the week, reducing by 1 registered nurse at night. Coleridge Ward, with a maximum of 16 patients, had 2 registered, and 5 non-registered nurses during the day reducing to 4 non-registered nurses at night. Keats Ward with a maximum of 15 patients had 2 registered and 4 non-registered nurses, reducing to 2 non-registered nurses at night. Extra staff were provided when enhanced observations were needed on a ward.

Staff knew patients well and said that they were supported by their colleagues and managers. When temporary nursing staff were used, those staff received an induction to familiarise them with the ward and policies. The temporary staff completed a checklist to demonstrate they had been inducted to the ward.

Staff told us that there was adequate medical cover to meet the needs of patients. A duty doctor and an on-call consultant were available out of hours.

Most staff had received and were up to date with their mandatory and statutory training courses as at the time of the inspection. Overall compliance with mandatory training was 90%. Staff also completed specialist training in diabetes awareness, epilepsy awareness, rapid tranquilisation and sepsis.

The ward environments were visibly clean and well maintained. Relevant health and safety environmental checks were in place across the wards. Staff and patients said that the level of cleanliness on the wards was good. However, on Coleridge Ward we found that 2 mattresses were unclean. The most recent audits for mattress cleanliness indicated only 50% compliance on Coleridge and Blake wards at the time of the inspection.

Staff adhered to infection control principles, including hand-washing and wearing appropriate personal protective equipment such as disposable gloves.

Staff completed monthly infection control assessments, and hand hygiene audits.

There was a maintenance log in place for the ward, and we noted that issues reported were responded to swiftly.

Staff ordered, stored, dispensed and disposed of medicines safely. Medicines were stored at the correct temperatures to remain effective. Staff monitored the fridge and room temperature where medicines were stored daily. Controlled drugs were stored and managed appropriately.

We reviewed the medicine administration records. These were completed appropriately. Staff signed when they administered medicines or recorded why not, in accordance with provider policy. Staff noted allergies and potential adverse reactions on the patients’ records.

At the previous inspection we found that staff were not always completing the necessary physical health monitoring of patients who receive medicines by intramuscular rapid tranquilisation (RT), to protect patients from significant physical health deterioration. At the current inspection we found one case of intramuscular RT administered to a patient on Keats Ward with no recording of any post administration monitoring of vital signs. This put the person at risk of avoidable harm if they experienced an adverse reaction to those medicines. During the inspection, we found several other cases across the hospital but later found that vital signs monitoring had taken place but was recorded in the Datix report rather than the patient notes. We also found several patients’ records where it appeared they had been administered rapid tranquilisation, but on further review it appeared that these entries had been made in error, where an oral tablet was given instead. The provider had not identified these potential errors prior to the inspection. We could not be assured that staff were always accurately recording when giving medicines or that the service had robust processes in place to identify when this may have happened.

Despite the above, we found that following the last inspection, the service had significantly improved scrutiny in this area, with targeted staff training indicating a positive improvement going forward. There were regular audits of RT cases, with learning in place when there were gaps in monitoring.

Records did not always clearly show why ‘when required’ (PRN) medicines were used on the wards to manage anxiety or agitation or if they worked. Records did not consistently explain the reason for these medicines needing to be used. We could not be assured these were always being used appropriately, and were concerned that this had not been picked up by the provider’s own auditing.

Some expired medicines were found in clinic rooms. These had not been removed despite being picked up in audits.

Staff understood how to use sedative medicines safely. They used deescalation techniques and oral medicines first and only used rapid tranquilisation as a last resort. Data on use of rapid tranquilisation on all the wards showed it was not used frequently. Staff worked with medical teams to review treatment each week.

There were robust care plans in place for patients prescribed the anti-psychotic medicine clozapine. Staff completed checks before and after each dose to monitor for risks and side effects.