Priory Hospital Lincolnshire

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

Safe –this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment, the rating has remained 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 assessed and managed risks to patients and themselves well. 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, administer, record and store medicines. The service managed patient safety incidents well.

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.

We scored the service as 3. 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.

Staff and leaders actively identified lessons from incidents, shared them with staff, and used them to improve care. When episodes of agitation or aggression occurred, staff responded promptly, reported them appropriately, and updated care and risk management plans accurately. After incidents, patients and staff participated in debrief meetings, while the psychology team facilitated individual or group reflective sessions and provided ad hoc support when needed.

Staff demonstrated a clear understanding of the duty of candour, speaking openly and honestly with patients and families when things went wrong, offering explanations and apologies where appropriate. Freedom to Speak Up (FTSU) champions were available to support staff as required.

Learning was embedded into daily practice through morning meetings, handovers, team meetings, and monthly operational reviews. Teams used both positive and negative feedback as opportunities to improve practice and enhance service delivery.

Managers and clinical leads provided staff with regular feedback following investigations. One staff member told us “Communication after incidents is very good. We are given debriefs and offered sessions with the psychology team. We are kept up to date of any updates during investigations and the learning from incidents is shared with all staff and patients if appropriate.”

We scored the service as 3. 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.

Staff and leaders had robust systems to ensure safe admissions, care transfers, and discharge planning. Referral documentation, including clinical history, risk assessments, and care plans, was reviewed thoroughly.Upon receiving a referral, the service arranged a face-to-face assessment with the patient. When required depending on the patient’s needs, a specialist nurse such as a learning disability or mental health nurse was always part of the assessment team. Staff explained that this process confirmed the patient’s suitability for the service and ensured their needs could be met safely. The staff team were provided with information about the patient prior to the admission, this aided in the team being able to provide a seamless level of care.

Patients felt supported and reassured throughout referral, admission, transfer, and discharge, helping to reduce anxiety during transitions. Information about care and treatment was provided in various formats to meet individual needs. A welcome pack was provided by the service to the patient which included toiletries and information of the service.

Staff followed a structured admission process, involving patients as much as possible. Comprehensive protocols were completed and reviewed regularly, with follow-up information used to support timely care planning and effective risk assessment.

Leaders emphasized early planning and clear communication across teams. Discharge planning included coordination with other services to ensure safe, supported transitions and continuity of care. Staff worked to avoid unnecessary delays and remained focused on achieving timely discharges wherever possible.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff showed a strong understanding of safeguarding, confidently identifying and addressing concerns to protect patients from harm. They acted promptly and appropriately to prevent abuse, neglect, or discrimination, and collaborated with external agencies, when necessary, such as the local authority safeguarding team.

Safeguarding issues were regularly discussed in daily morning meetings, dedicated safeguarding meetings, multidisciplinary team (MDT) meetings, and safety huddles. Staff were supported by safeguarding leads within the service.

They also demonstrated clear knowledge of the Deprivation of Liberty Safeguards (DoLS) and ensured patients understood their rights under the Mental Health Act 1983, the Mental Capacity Act 2005, and the Equality Act 2010.

The service had effective safeguarding systems, policies, and procedures in place that upheld patients' human rights and promoted a culture of safety. We reviewed the safeguarding incidents log for the period from August 2025 to October 2025 and found that concerns had been thoroughly investigated, escalated to the appropriate agencies in a timely manner with outcomes and learning shared across the hospital team.

Patients consistently reported feeling safe and confident to raise concerns, knowing staff would respond appropriately if they felt unsafe or had worries about others. The service encouraged and supported patients to take on roles as patient safety leads, empowering them to share their views on all aspects of safety within the service. Patients were actively involved, and their voices were heard. One patient told us “Whenever there’s an incident, staff are always about, and they help to keep us safe.

Leaders ensured staff had the knowledge, support, and confidence to act accordingly and promptly to safeguard the patients they cared for and supported. One staff member told us “You should always consider the patients capacity to understand and retain information. Always considering individual vulnerabilities, and potential safety issues.”

Restraint was only used as a last resort, documented accurately, proportionately, and in line with best practice. Care and treatment plans reflected any restrictions, which were based on individual risks to avoid blanket approaches. Staff considered equality and human rights legislation when applying any restrictions. Where rapid tranquilisation was required, it was used proportionately, documented accurately, and recorded in line with best practice.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff knew and understood patients’ individual risks, which ensured they intervened and responded quickly to support patients to minimise any distress and to decrease risk.

We reviewed 7 risk management plans and found they were person-centred with obvious patient and family involvement and were reviewed in line with organisational policy. One patient told us. One patient told us “I am involved; my sister is involved. I’ve got a fantastic Nurse, and 2 key workers who are there for me and help me to be involved.”

Staff took a proportionate and balanced approach to risk, welfare checks and observations were completed in line with the patients’ care plan and based on individual patient need. The patient records we reviewed showed observations were completed as prescribed.

Across the months of August, September and October 2025 there were 7 incidences of low-level restraint applied within the service. All 7 incidences were documented and were in line with the providers policies and procedures. Reviewing information across the same period, we found that there was no use of rapid tranquillisation or use of seclusion and long-term segregation.

Staff ensured patients’ physical and emotional needs were met in a positive way, while protecting their rights and dignity. They maintained a calm approach when supporting patients during episodes of distress, promoting safety and reducing the risk of escalation.

Patients and their families were actively involved in developing risk assessments. Care records reviewed showed clear evidence of full participation in multidisciplinary team (MDT) reviews. Families unable to attend in person were supported to join virtually, for example via Microsoft Teams.

Staff from different teams, such as the Psychology team, helped patients understand their risks and manage them positively. A range of communication methods was used to meet individual needs, including easy-read materials and picture-based emoji documentation for those with language barriers or complex needs.

At the point of admission, referrals were completed by primary nurses on behalf of the patient for Advocacy support. The allocated Advocate would then meet with patient as and when required including attending individual patients ward round meetings, care programme approach (CPAs) and Hospital Managers Hearing meetings. Advocacy posters and easy read documents for patients were visible within the wards. Staff members told us that that patients were regularly reminded of the advocate services that were available to them especially during 1:1 sessions and ward rounds.

We scored the service as 3. 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.

Ward teams carried out regular environmental risk assessments throughout the day and night. Consistent auditing ensured potential hazards were identified promptly, with actions taken to mitigate risks. Ligature risks were assessed, and appropriate measures were in place to manage and reduce any potential harm. CCTV was installed across the service to safeguard patients and staff and reduce blind spots.A designated security nurse completed safety audits during every shift and shared findings during handover meetings. This role ensured continuous monitoring of the environment and timely identification of any risks.

Patients and staff felt safe within the environment. The service maintained clean, well-equipped spaces that supported both physical and mental wellbeing and enabled the safe delivery of care. Equipment was properly maintained, stored securely, and used appropriately for its intended purpose.The service had a fire safety lead who also checked the environment on a shift-to-shift basis to ensure all fire safety and evacuation protocols could be met in the event of an emergency. One staff member told us “We have nurses who are in charge of security checks. They are very good and support staff and patients with the latest information and guidance”.

Staff carried personal alarms and used radio communication systems for safety. Patients had access to nurse call systems in bedrooms, bathrooms, and throughout the environment, ensuring they could request assistance whenever needed.

Clinic rooms were fully equipped with resuscitation equipment and emergency medicines, which staff checked and audited regularly to maintain readiness for any emergency.

Outdoor spaces were well-maintained, secure, and frequently used by patients. Doors to these areas remained unlocked, allowing free access while appropriate security measures ensured safety.

Equipment and technology were kept in good condition, enabling staff to deliver safe and effective care. The service had robust processes to monitor the safety and maintenance of the environment and premises.Staff understood what was required to provide and maintain environments that protect people from physical harm.

We scored the service as 3. 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.

Leaders regularly reviewed staffing levels to ensure they matched the needs of the service and patients. Through information shared by the service, it was highlighted that the service had been overstretched in terms of healthcare workers for the past 3 months of August, September and October of 2025 due to having 3 patients on Lancaster Ward being nursed on high level observations. This resulted in a high dependency in regular agency and bank staff to support with managing patient care as well as high observation levels on ward.

Agency staff completed organisational induction and mandatory training before starting work and were familiar with the patients and environment. They also undertook observational competency checks prior to commencing duties, ensuring adherence to correct processes and enhancing patient safety. Our review of vacancies, staff turnover, and sickness absence over the past 12 months raised no concerns. While there were some vacancies, recruitment was ongoing at the time of our visit.

Staff sickness and absence across the hospital had been relatively low apart from month of August 2025 where the service had a ward manager absent for 3 weeks and 1 housekeeping staff member absent. The service provided regular welfare checks and monthly absence review meetings with all staff who were on long-term sick. Occupational Health (OH) referrals were completed where appropriate, and risk assessments were completed in line with OH recommendations. A phased return process was in place to support the staff members back into work.

Recruitment processes were robust, ensuring all staff including bank staff had current Disclosure and Barring Service (DBS) checks, appropriate qualifications, experience, and competence. Disciplinary and capability procedures were proportionate, regularly reviewed, and free from bias related to protected characteristics.

Patients were well supported, with staff consistently present, visible, and available. Care records showed evidence of regular one-to-one sessions with named nurses, maintaining therapeutic relationships and continuity of care. Staff were present in communal areas and throughout the environment.

Medical cover was in place day and night, with doctors and an on-call pharmacist readily available to respond quickly in emergencies.

Staff reported feeling well supported by leadership and received regular clinical and managerial supervision on a monthly basis. All team members also participated in annual appraisals and personal development reviews. Our review of supervision and appraisal records showed they consistently met and often exceeded the organisation’s compliance standards.

Mandatory, role-specific training was completed and kept up to date by staff, with a current compliance rate of 90%. The training provided was appropriate for the patient group being cared for. Staff demonstrated both confidence and competence in delivering care. Learning and development opportunities were available to employees at all levels. Any instances of poor performance were addressed promptly and effectively.

We scored the service as 3. 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.

The service had clear processes for assessing and managing infection risks, fully aligned with current national guidance. Regular cleaning and infection prevention audits were carried out, and any concerns were addressed promptly. Information about infection risks was shared appropriately with staff, patients, visitors, and external partners. Roles and responsibilities for infection prevention and control were well-defined, and staff received ongoing training in line with organisational policy and best practice.

Each ward had an infection prevention and control (IPC) champion allocated on a daily basis on each shift. They were responsible of making sure that all daily and weekly cleaning checks and documentation were completed accordingly. All staff had the duty of reporting any IPC issues observed up on a daily basis. These were to be documented, shared with the ward manager and discussed in morning MDT meeting with actions to address the issue agreed and implemented immediately.

All ward areas were clean and well-maintained. Cleaning records were up to date and demonstrated consistent auditing, ensuring a hygienic and safe environment. Staff showed a strong understanding of their responsibilities in maintaining cleanliness.

Patients expressed confidence in the infection prevention and control (IPC) measures in place and felt reassured that staff were taking necessary precautions to protect them from infection and harm. One patient told us “It’s always clean and tidy; the cleaners are lovely, they’re busy, and always around. Staff also clean up and keep it nice.”

Staff adhered to IPC procedures, followed handwashing guidance, used personal protective equipment (PPE) appropriately, and cleaned equipment in line with best practice standards.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had robust systems for managing medicines working alongside an external pharmacy group. Ways of working were fully aligned with current best practice and national prescribing guidance. Any medication errors were promptly addressed, with appropriate actions taken to mitigate harm and prevent recurrence. Continuity of care during transitions was maintained through effective medicines reconciliation and clear documentation. Controlled drugs were managed safely, audited regularly, and any audit findings acted upon, promoting a learning culture through incident reporting and review. Staff received training and competency assessments to ensure the safe, effective, and appropriate use of medicines.

Safe practices were followed across all areas of medicines management, including storage, dispensing, administration, reconciliation, recording, and disposal. The service adhered to national guidance and demonstrated how patients, families, and carers were involved in discussions and decisions about treatment wherever possible. Staff regularly monitored the physical health of patients, particularly those prescribed high-dose antipsychotic medication, in line with NICE guidance.

Through joint working with the external pharmacy group, the service would receive monthly Pharmacy Prescriptions and Dialogue reports. These would help the service to compare how medicine management was being maintained between Priory Hospital Lincoln and other priory sites. Audit figures and lessons learned were explored with improvements discussed and implemented immediately. Priory Hospital Lincoln shared “we are proud to say, our site has always been an exemplary site when it comes to medicine.”

Patients were supported to participate in decisions about their medicines. For those with capacity, staff explained the purpose of medications and involved them in any treatment changes. Where patients lacked capacity due to diagnosis-related impairment, staff followed processes in line with the Mental Capacity Act 2005 and Mental Health Act 1983. Care plans reflected each person’s level of understanding and documented their involvement in decision-making.

Medicines, including controlled drugs, were stored securely and managed under the required legal frameworks. Fridge and room temperatures were checked daily, and all medications were in date. Expired or unused medicines were disposed of safely. Staff ensured medicines were used appropriately; when Pro Re Nata (PRN) or “as required” medicines were administered, records showed they were used correctly and not solely to manage behaviour.

The service administered medicines in line with Stopping Over-medication of People with a learning disability, autism, or both (STOMP). We reviewed all prescribing, and administration records and found no concerns.