Priory Wellbeing Centre-Harley Street

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 good. At this assessment the rating has changed to requires improvement.

This indicated that some aspects of the service were not consistently safe, and assurance about safety was limited. There was an increased risk that people could be harmed.

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.

Whilst the service had a proactive and positive culture of safety based on openness and honesty, learning processes were not consistently captured to identify and embed good practice.

The service had no serious incidents in the last 12 months

The service had a proactive and open safety culture, and staff consistently reported incidents using the provider’s electronic system. In the past 12 months, 70 incidents were logged, including safeguarding concerns, patient distress, and welfare checks.

Staff understood and applied the duty of candour, offering transparent explanations to patients and families when things went wrong.

Staff received debriefs and peer support following incidents, but opportunities to embed good practice were not consistently taken forward.

Although staff described an open reporting culture and duty of candour processes, the minutes from the July and September 2025 clinical governance meetings did not record the actions taken or learning shared. This meant improvements in safety practices were not consistently captured.

Although the service ensured that essential patient information was received during the referral and admission process, it did not consistently upload referral forms for medical treatment. This inconsistency could impact safe care coordination.

Referrals were received through the provider’s single point of access team. Patients either self-referred, referred from private insurance or were referred by another specialist clinician.

Once a referral was received via the online system, administrative staff forwarded it to the relevant medical secretary. Visiting consultants then reviewed the referral to decide whether they could assess the patient for treatment. The service applied a risk exclusion criterion to ensure it could safely meet patients’ needs.

Staff held regular referrals meetings to discuss new patients on the therapy pathway. However, they did not meet regularly to review patients referred for medical treatment. Staff did not routinely upload patient referral forms for medical treatment to the patient’s care records on the providers electronic system. There was a risk that this could lead to delays in treatment planning or reduced oversight of patient safety and care coordination.

At the time of the inspection, 30 patients were awaiting their first medical appointment. Of these, 24 had booked appointments, while the remaining 6 were pending further documentation from the patient before booking. Twelve patients were awaiting their initial therapy appointment and staff were working on their pre-assessment paperwork.

Staff worked with healthcare and social care partners to ensure patients received safe, continuous care – both during their time with the service and after discharge.

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 understood safeguarding responsibilities and acted appropriately to protect people from harm. Most staff had completed level 2 and level 3 safeguarding vulnerable adults and children. One staff member was due to complete a refresher course in level 3.

Staff could identify adults and children at risk of significant harm and worked effectively with other agencies to manage concerns.

In the last 6 months, staff raised 5 safeguarding alerts. These were discussed in team meetings, and staff described how they collaborated with local agencies to safeguard patients.

While the service took a holistic approach to managing risks with patients, recording of risk assessments required improvement. Staff did not consistently record patients physical health checks.

We reviewed 13 risk assessments and risk management plans during the inspection. Staff did not use a recognised risk assessment tool, and for patients receiving medical treatment, visiting consultants recorded risk levels in clinic letters to the persons GP rather than structured assessments. In 4 of the 13 records risk levels were noted without any explanation of how these levels were determined.

Staff did not always take appropriate steps to safeguard people’s physical health. In four records, there was not evidence that an initial physical health check had been completed. For example, one patient being started on antipsychotic medication had no documented baseline health check. Another patient’s physical health section was missing from their GP letter. A third patient’s notes did not confirm whether blood pressure was measured before prescribing ADHD medication. This was not in line with the provider’s record keeping policy, which required physical health monitoring plans to be documented in the GP letter. These gaps may have compromised safe prescribing and continuity of care.

Despite this, staff demonstrated a good understanding of individual patient needs and took action to manage risks. This included regular welfare calls to patients, follow-up checks for missed appointments and informing patients about risks and how to stay safe.

Patients reported being involved in their care and said consultants reviewed them every 2-4 weeks during the early stages of treatment. Staff only treated patients who consented to share information with their GP, and consent forms were completed appropriately. Where patients did not give consent, the provider had a clear protocol for staff to follow.

Staff continually monitored patients on waiting lists for changes in their level of risk and responded when risk increased. They also followed lone working protocols to ensure staff safety, including avoiding working alone on the premises and ensuring others were present during office hours.

The service did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff regularly completed and updated environmental risk assessments, and all areas were clean, well maintained, well-furnished and fit for purpose.

However, equipment maintenance was inconsistent. For example, weighing scales in one consultation room had not been calibrated, and the issue was not identified in the environmental risk assessments. This could affect the accuracy of physical health monitoring.

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 were 13 permanent staff employed at the service. This included the centre manager, a newly appointed deputy manager, 2 administrators and 9 therapists. In addition, the service had 28 sessional therapists.

At the time of the assessment, a further 2 administrators were beginning the process of recruitment checks to start employment. Another therapist was due to start to support with a weekend clinic.

The service had 8 visiting consultants working under practicing privileges. This is where a medical practitioner is granted permission to work in a private clinic in independent private practice, or within the provision of community services. The visiting consultants and sessional therapists delivered treatment under various part time hours according to their own availability. The visiting consultants worked in a permanent setting for their other employers such as the NHS or the provider’s other inpatient services.

The manager maintained a spreadsheet to track visiting consultants’ employment records. This included up-to-date documentation such as insurance, professional registration, and disclosure and barring checks. We reviewed three signed and dated practicing privileges agreements. The manager began overseeing these records in July 2025, when gaps in documentation were identified as a risk to the service.

Staff completed the mandatory training relevant to their roles, achieving an overall compliance rate of 90%. This was lower than the provider’s target of 90%, primarily due to the low compliance with the safe handling of medicines course, which was not applicable to the roles of the staff group.

The training was appropriate for the patient group using the service, including safeguarding vulnerable adults and children level 3, fire safety and breakaway training.

The service assessed and managed the risk of infection.

The premises were clean, had good furnishings and were well-maintained. The main reception area, waiting rooms and consultation rooms were well maintained. Patients and visitors signed in and out at the main reception.

Infection control practices, including handwashing and cleaning records, were consistently followed.

Staff engaged patients in planning their treatment and communicated clearly when changes occurred. Staff reconciled patients' medicines before they commenced treatment. However, electronic prescription forms were not always stored in the same location and staff did not consistently monitor their use.

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.

Staff reconciled patients' medicines before they commenced treatment. The prescribing doctor ensured they received the patients’ medicines history from their GP before they were prescribed any medicines from the service. This ensured safe prescribing.

The service had arrangements in place for the safe management and control of prescription forms in line with national guidance; however, these were not consistently applied. Prescriptions forms were not always stored in the same location and staff did not consistently monitor their use.

Visiting consultants used different formats for issuing prescriptions – some scanned electronic prescriptions into patient records, while others used paper prescriptions stored in a locked container. This inconsistency in practice reduced assurance around medicines management.