The Care Quality Commission
  • Mental Health
  • Independent mental health service

The Priory Hospital Roehampton

Overall: Requires improvement read more about inspection ratings

Priory Lane, London, SW15 5JJ (020) 8876 8261

Provided and run by:
Priory Healthcare Limited

All Inspections

31 January, 1 February and 8 February 2023

During an inspection looking at part of the service

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

  • This was a comprehensive inspection where we looked at the relevant key questions in full for acute wards for adults of working age and child and adolescent mental health wards. As a result of this inspection, the overall ratings for these two core services went down, from good to requires improvement. When combined with our ratings from previous inspections for the two other core services delivered at this site (hospital inpatient-based substance misuse services and specialist eating disorder services), we have rated two of the four core services provided at The Priory Hospital Roehampton as requires improvement. This means the rating for The Priory Hospital Roehampton has changed from good to requires improvement. We rated the hospital as requires improvement overall and rated the domain of safe, caring and well-led as requires improvement. Effective and responsive are rated as good.
  • The service had made changes since our last inspection in February 2022 of the child and adolescent wards, but further work was needed to fully address the breach of regulation and to ensure that areas required for improvement were fully completed, embedded and sustained, particularly in relation to competence of agency staff and ensuring a strong leadership presence on the wards. Managerial and clinical leadership on the wards was in a state of ongoing change while permanent staff were recruited. This was having an impact on the leadership of the hospital while senior staff covered vacant posts.
  • The service had some staffing challenges. They did not have enough permanent members of staff to cover all shifts in the child and adolescent wards. Managers covered vacancies using agency members of staff, but these staff were not always familiar with young people’s needs. Patients also told us that agency staff did not always understand their personal space, and some carers said agency staff did not always communicate effectively with them.
  • The service did not ensure that staff managed risks in the environment. Ligature risks and blind spots in the acute wards were not always well mitigated. Staff were not always present in inpatient areas to observe and mitigate risk. Some staff were not aware of what a ligature point was and therefore their mitigations. Whilst some parts of the wards had CCTV, these cameras did not always cover all communal areas of the wards.
  • The child and adolescent wards were not always clean. Although the hospital kept cleaning records for the ward areas, these were not always effective, as parts of the ward environment on Lower Court were visibly dusty and cluttered. We found expired food in patient kitchens across all four wards inspected.
  • At the time of inspection, staff had not completed all mandatory training. Some face-to-face training modules, such as immediate life support training and restraint, had low completion rates. The service did, however, have a plan to ensure staff completed the training. All staff were booked to complete training by May 2023.
  • Team meetings on Garden Wing and Upper Court did not always cover all standard agenda points. Whilst lessons learned from incidents were shared across the hospital by senior staff, some staff we spoke with were unable to recall any learning from recent incidents. Handovers on Lower Court lacked structure.
  • Staff did not always complete physical health checks. On Lower Court, staff did not always complete food and fluid charts for young people who had been identified as needing them. There were gaps noted when reviewing patient’s medication administration charts on the acute wards. A patient who was on high dose antipsychotics did not have a completed form to show the patient’s physical health was being monitored.
  • Some staff felt it was sometimes difficult to work on the ward due to the difference in cultures. One staff member felt some staff were on Garden Wing were unprofessional. They felt managers who were not from an ethnic minority did not understand the problems they felt. However, managers attempted to support the team’s cultures to blend, and they felt able to speak to managers with any concerns.
  • Not all patients and carers were adequately involved in services they received. For example, on the acute wards some patients were not adequately involved in decisions about their care, some did not have a copy of their care plan and ward community meetings were not always taking place regularly. On the child and adolescent mental health wards some carers we spoke with said that staff did not always keep them informed about their relatives’ care and treatment, and generally communication was inconsistent.
  • There was an overly restrictive blanket restriction in regard to leave for patients on the acute wards. Patients, including informal patients, on 4 hourly observations only had access to escorted leave If an informal patient wanted unescorted leave, this had to be assessed by a doctor, which meant a significant delay before a patient, for whom no legal authority for detention is in place, is allowed to exercise a legal right.
  • On Upper Court did not have information on advocacy services available to patients. Signs explaining informal patient rights were not visible on either ward.
  • Our findings from other key questions demonstrated that governance processes did not always operate effectively across the four wards inspected. For example, on the child and adolescent mental health wards, the provider’s housekeeping procedures did not ensure all ward areas were effectively cleaned. There were lapses in recording of restraint and food and fluid chart documentation. On the acute wards, governance processes had not identified the areas needed for improvement on the wards. Staff participated in clinical audit, but where actions were identified, specific plans to address these areas were not made. Across both wards, there were no systems in place to ensure patient food had not expired in patient kitchens.

However:

  • Since our last inspection of child and adolescent mental health wards in February 2022, some changes required from this inspection had been made. Agency staff now had access to patient records and regular supervision, staff had access to regular staff meetings and debriefs following incidents, there was now a clear care pathway in place to support admissions, and there were robust systems in place to learn from incidents. Despite these improvements, the provider’s governance processes highlighted that Lower Court still required significant improvement during an internal assessment of the ward in December 2022. Senior management put an immediate action plan in place to support the performance of the ward. We found that the changes made had led to improvements, but time was required to ensure they were embedded consistently.
  • The service was working hard to recruit and retain staff and they had an on-going recruitment plan in place. Staff block booked regular agency to support consistency on the wards.
  • Staff assessed most risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and rapid tranquilisation only after attempts at de-escalation had failed. However, staff did not always record details about how physical restraint had been used.
  • The ward teams had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received supervision and appraisal. 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 understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Most staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients in care decisions. We observed caring and jovial interactions between staff and patients on Lower Court and Richmond Court.
  • Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed. They were visible in the service and approachable for patients and staff.

1 and 3 February 2022

During an inspection looking at part of the service

Priory Hospital Roehampton provides inpatient child and adolescent mental health services. The service provides mental health care and treatment for children and young people aged between 12 and 18.

We did not re-rate the overall service following this inspection. It remained good overall. At our inspection in April 2021 we rated the domain of safe as requires improvement. We rated effective, caring, responsive and well-led as good.

This was a focused inspection that covered specific aspects of safe, effective, caring, responsive and well-led. We undertook a short announced focused inspection of this service due to the increase in the number of self-harm incidents reported to the CQC by the provider and to follow up on the actions taken by the service to address the breach of regulation from our previous inspection.

The service had made many improvements since our last inspection in April 2021, but further work was needed to fully address the breach of regulation and to ensure that improvements were embedded and sustained.

The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. There was now a clinical psychologist, deputy ward manager and ward consultant for Lower Court. Managers ensured that these staff received training and supervision. The ward staff worked well together as a multidisciplinary team.

The ward environments were safe and clean.

Staff assessed and managed risk well. They minimised the use of restrictive practices and had arrangements in place for safeguarding.

Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed.

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.

Staff treated patients with kindness and respect.

The service was well led. Governance processes had been strengthened and mostly operated effectively and performance and risk were managed well.

Staff feedback was positive, they reported that morale and the culture within the service were improving. Staff felt respected, supported and valued. They could raise any concerns without fear and reported that their concerns were taken seriously. Leaders were visible in the service and approachable for patients and staff.

However:

Whilst the service had a robust improvement plan for the recruitment, retention and development of qualified, non-qualified and therapy staff, there was still a significant use of agency staff. Vacancy rates for nurses and the use of agency staff were slowly reducing.

Not all agency staff were aware of the potential environmental risks. The quality of induction for agency staff was not consistent across the service. Not all agency staff had a full understanding of safeguarding in relation to children and young people. Agency staff who were not registered nurses did not have the opportunity to routinely access and review patient records. Regular agency staff did not receive supervision.

Regular staff meetings and debriefs following incidents on Lower Court did not take place.

Systems to ensure that learning from incidents were not fully developed to ensure that learning was fully embedded.

The care pathway on Lower Court was not clear. The service had commenced a strategic review of the CAMHS service.

19 and 23 April 2021

During an inspection looking at part of the service

Priory Hosptial Roehampton provides inpatient child and adolescent mental health services. The service provides mental health care and treatment for children and young people aged between 12 and 18.

Our overall rating of this service stayed the same. We rated it as good because:

  • The ward environments were safe and clean. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided some treatments suitable to the needs of the children and young people and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • Managers ensured that permanent staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team.
  • Staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of young people. They actively involved young people and families and carers in care decisions.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly.

However,

  • The service did not always provide safe care. The wards did not have enough permanent nurses and doctors. The service did not always have sufficient staff to meet the safer staffing numbers. Agency staff were not always familiar with young people’s needs. Permanent staff did not always have confidence in the competency of agency staff.
  • The ward teams did not include the full range of specialists required to meet the needs of young people on the wards. There had been no psychologist in post almost a year.

15-29 September 2020

During an inspection looking at part of the service

This was a focused inspection on the Adult Eating Disorder Service that covered aspects of safe, caring, responsive and well-led. The rating of safe changed from good to requires improvement.

We undertook an unannounced focused inspection of this ward due to an incident that had occurred on the ward in which a patient had their hair cut by staff. At the time of writing this report, we were considering our regulatory response to this incident using our specific incident guidance. We will add full information about our regulatory response to a final version of this report, which we will publish in due course. As part of the inspection, we reviewed the management of patient risk, involvement of families and carers, how the staff maintained patients’ privacy and dignity, and the culture and leadership of the ward.

We found:

  • Staff had acted inappropriately when they cut a patient’s hair against their will under restraint. They had not exhausted all other options and had not involved the patient and their family fully in taking this decision. The patient felt this had a significant negative effect on their mental health and was not proportional to their level of risk. This meant the service had not safeguarded the patient from improper treatment which was degrading.
  • On the night we visited the ward, there were no permanent members of the ward staff working on the night shift. The team working consisted of agency members of staff and members of staff that usually worked on other wards at the hospital. However, the staff that we spoke to on the ward were knowledgeable about the patients and had a detailed handover at the start of their shift. Patients fed back that it would be nicer to have more permanent staff.
  • On the night we visited the ward, there was one nurse working on the night shift. An additional nurse was available to the ward to support with medication and if there were any incidents. However, the staff member was also covering the entire hospital site, so would not always be available to assist on the ward.

However:

  • The ward environments were safe and clean. The wards had enough nurses and doctors; however, there were two shifts between 14 September 2020 and 4 October 2020 where there were no permanent staff working on the ward. Staff assessed and managed risk well.
  • Overall, patients were positive about the staff on the ward. Patients enjoyed the therapies that were available on the ward and felt that permanent staff on the ward were kind and approachable. One patient said that there was always a member of staff to talk to. However, four of the six patients we spoke to felt they should have been more supported after the recent incident in which staff cut a patient’s hair. The service was well led and the governance processes ensured that ward procedures ran smoothly.

5-6 March 2019

During a routine inspection

We rated The Priory Hospital Roehampton as good because:

  • Staff provided emotional and practical support for patients. Staff took the time to understand patients and their needs and were sensitive, discreet and compassionate when providing care. Patients reported that staff were polite and helpful and treated them with kindness and respect.
  • Staff undertook a comprehensive risk assessment of all patients when they were admitted. Specific areas of potential risk were highlighted and staff put in place effective risk management plans. Potential patient risks were reviewed during nursing handovers and multidisciplinary meetings. Patients had comprehensive mental and physical health assessments when they were admitted to the hospital. Patients mental and physical health were reviewed regularly during their admission.
  • Patients’ treatment followed best practice guidance, including guidance from the National Institute for Health and Care Excellence (NICE). Patients had access to a range of evidence-based psychological treatment and therapy.
  • Patients were involved in their care. They developed their own care plans and their individual needs were met. Staff involved patients’ relatives or carers in their care and treatment, if the patient consented.
  • The hospital safeguarding lead was a qualified social worker. They met with the substance misuse therapy team each week to discuss patients. The aim of this meeting was to identify if any safeguarding issues had arisen during patient therapy groups.
  • The acute wards provided support groups for the family members and carers of patients. These included sessions with and without the patient being present.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. We saw examples of where staff had made improvements to the service as a result of feedback from patients, families and carers.
  • Senior leaders provided strong leadership. Two new senior managers had, in a short space of time, made a demonstrable impact to the safety and quality of care provided to patients. Staff found ward managers and senior managers accessible and approachable. Staff felt confident that they could raise concerns. Staff spoke highly of the management team and their colleagues, and felt respected, supported and valued. Senior managers met monthly with staff for breakfast. This provided an opportunity for informal conversations to generate ideas and discuss issues.
  • There was a comprehensive governance system to monitor the quality and safety of services. This included a system of audits, procedures and practices which monitored the safety and quality of care. For example, the system of audits for patients having substance misuse detoxification was detailed and ensured best practice guidance was followed at each stage of treatment. Significant amounts of managers’ time was focused on identifying how the safety and quality of care could be improved. Incidents and mistakes were viewed as learning opportunities and there was shared learning across the services. There was a culture of openness and transparency.

However:

  • Staff did not provide written information to patients that left alcohol or drug detoxification treatment early. Patients were verbally given advice from staff regarding their reduced tolerance and complications of alcohol withdrawal such as seizures. The ward manager planned to produce written information for patients shortly after the inspection.
  • Although Lower Court filled shifts for registered nurses with bank and agency staff, there were five registered nurse posts vacant at the time of the inspection. There was potential for this to affect the consistency of care to young people.
  • Some patients being admitted for alcohol or drug detoxification did not provide consent for hospital staff to contact their GPs. This meant information concerning potential risks in detoxification treatment was only based on information the patient provided. However, patients had a comprehensive assessment on admission and their detoxification was monitored closely. Any risks to the patient during treatment were identified quickly.
  • For two hours a day, young people on Lower Court could only access their bedrooms with the support of staff using a fob system. This restriction meant young people could not get to their bedrooms without staff assisting.
  • The garden on East Wing was bare with high fences. The garden lacked comfort and did not allow for a therapeutic atmosphere.
  • Three young people on the child and adolescent eating disorders ward, Priory Court, said that some staff were rude and made inappropriate comments.
  • Four young people on the child and adolescent mental health ward, Lower Court, said that staff did not always knock on their bedroom doors before entering.
  • Some young people on Priory Court described a lack of activities at weekends which led to them becoming bored.

17 January 2018

During a routine inspection

We inspected this service in November 2017 as part of our on-going comprehensive mental health inspection programme. As a result of our findings at the inspection in November 2017, we served the provider with a letter of intent to take immediate enforcement action under section 31 of the Health and Social Care Act 2008 regarding the safety of patients receiving treatment for drug and alcohol use on West Wing.

The provider voluntarily suspended the admission of new patients requiring medically assisted withdrawal to the service and submitted an action plan to the CQC.

We carried out this focussed inspection on 17 January 2018 to check that the provider had followed their action plan and had addressed the issues outlined in the letter of intent.

Immediately following this inspection, we informed the provider that they had made sufficient progress to improve patient safety and they could start admitting patients who required medically assisted withdrawal from 18 January 2018.

At the November 2017 inspection we found the following concerns:

  • Staff had not completed comprehensive physical health checks and drug testing prior to treatment commencing. This included staff carrying out relevant blood tests and pregnancy tests.

  • Staff had not comprehensively assessed and appropriately managed patient risk on admission. This included assessing for alcohol related seizures and delirium tremens, completing cognitive assessments prior to treatment commencing and assessing whether the patient is in contact with dependent adults or children.

  • Nursing staff had not received specialist training including substance misuse awareness training.

  • Nursing staff did not have the correct skills, knowledge and competence to recognise withdrawal symptoms and complete relevant withdrawal tools accurately. This included staff recording how they come to a decision to administer a specific dose to a patient requiring PRN (as required) medication.

  • The service did not have governance systems to assess, monitor and improve the quality and safety of the service.

At this inspection, we found that the service had made the following improvements:

  • Staff completed drug testing on admission and then randomly on a twice weekly basis.

  • Staff completed comprehensive physical health checks on admission including blood tests and pregnancy tests.

  • The provider had developed a pre-admission in-patient risk screen and updated the nursing and doctor’s admission checklists. Doctors would complete a face-to-face assessment prior to admission. The provider had also developed an addictions nursing assessment aide memoir.

  • The provider had developed “see the adult, see the child” guidance to assess safeguarding risks for patients in contact with children. The provider updated the pre-admission in-patient risk screening to assess whether the patient had children and any current safeguarding issues. In the three patient records we reviewed, staff had documented whether there were any safeguarding concerns; however, staff had not always completed the record on admission.

  • Nursing staff completed one-day training on substance misuse. However, the provider must ensure they deliver training on a regular basis and includes specialist information on substance misuse.

  • The provider had developed an algorithm to use with a withdrawal tool to provide nursing staff with guidance on the administration of PRN (as required) medication. Nursing staff completed a medically assisted withdrawal competency checklist and were knowledgeable about when to administer PRN medication.

  • The provider completed regular emergency scenarios with staff on the ward.

  • The provider had implemented governance systems to assess, monitor and improve the quality of the service including regular audits, internal compliance reviews, reviewing risk at the clinical governance meeting and quality at the weekly learning outcomes group.

We also found the service should continue to make the following improvements:

  • As the provider had only recently ratified their updated withdrawal policy, the provider needed to ensure staff understood and applied the new policies and procedures in practice.

  • As the provider had voluntarily stopped admitting new patients who required medically assisted withdrawal, the provider needed to embed the implementation of the new admission process and monitor the staff team’s ability to support patients undergoing the new withdrawal process.

  • The provider also needed to embed the implementation of the new governance systems to assess, monitor and improve the quality of the service.

  • Ensure learning and improvements are shared across the provider’s other residential detoxification services.

9, 10 & 21 November 2017

During a routine inspection

We rated this service as requires improvement. This was based on the aggregated ratings from our inspections of the acute, eating disorder and children’s and young people’s services. We also inspected the substance misuse services, but do not yet rate these services. There were a number of significant concerns, particularly about the acute wards and substance misuse service provided at the hospital.

We found the following areas needed improvement:

  • The current layout of the three acute wards presented potential risks to the safety of the patients admitted to these wards. The risks to patient safety were greatest on East Wing, on which the layout over four floors made it hard for staff to observe the multitude of risk areas, but were also present on West Wing and Garden Wing including in the garden areas. The potential risks were a result of poor lines of sight and the presence of multiple ligature points. The hospital was working to mitigate these risks through consultants reviewing the appropriateness of admissions before they were agreed, ensuring prompt assessments at the time of the admission, observing patients based on their individual needs, providing bedrooms with enhanced safety features, restricting access to parts of the wards and the use of technology through specially designed camera surveillance to monitor patient movement. They had also provided training for staff on relational security. Despite all these mitigations, the current physical environment of the building was not suitable for adults with acute mental health needs. The hospital had recognised this and had stated its intention to relocate the service on East Wing and completely redevelop the West Wing and Garden Wing environments. The work was due to be completed by mid-November 2018. East Wing service needed to be relocated as a matter of urgency and the provider needed to review if they could continue to provide a safe service on West Wing and Garden Wing until the redevelopment work had been completed.

  • At the previous inspection in August 2017, we identified concerns about the safety on Garden Wing, largely as a result of patients, visitors and staff passing through this ward to reach other parts of the hospital. At this inspection, steps had been taken to improve the safety of the ward such as two additional staff worked during the day to monitor access to the ward and to observe and engage with patients in the corridor leading to the garden area. Despite these measures, staff who were not working on the ward continued to walk through Garden Wing to access other areas of the hospital. This compromised the privacy and dignity of patients on the ward.

  • Staff changes and the high use of agency staff who were unfamiliar with the wards continued to be an issue and impacted on the consistency of care. Patients told us that they did not like it when agency staff were on shift as they were unfamiliar to their needs. There was a high turnover of staff on Garden Wing, which impacted on the morale on the remaining staff. However, the hospital had recently introduced 3-month block booking of agency staff to assist with improving the consistency of care.

  • Staff did not always manage medicines safely. Staff did not always record a clear rationale as to why staff administered a certain dose of PRN (as and when) medication.

  • In August 2017, we found the dining room on Upper Court was too small and did not provide a positive therapeutic environment for patients with an eating disorder and that some patients were eating in a restaurant area next to the Garden Wing. At this inspection, the work was still not complete and was agreed to be completed by the end of August 2018.

  • In August 2017, we found that work was on-going on the self-soothe room on Priory Court and there was no suitable environment for the physical examination of patients on Garden Wing other than patients’ bedrooms. Since the inspection, the provider had proposed environmental work on the self-soothe room on Priory Court to be completed by December 2017 and had proposed environmental plans to provide an examination room on Garden Wing by 31 August 2018. Until this work was complete, there was still an on-going impact on the privacy and dignity of patients.

At this inspection, we also inspected the substance misuse services. We do not currently rate substance misuse services. We wrote to the provider expressing our concerns about the safety of the patients undergoing medically assisted withdrawal and they voluntarily agreed to suspend admissions until these concerns were addressed as follows:

  • The provider did not ensure staff had the necessary skills and followed safe policies and procedures when supporting patients undergoing medically assisted withdrawal.

  • Staff did not always assess patients fully prior to undertaking medically assisted withdrawals. They did not always ensure that they explored all areas of risk that could be affected by the detoxification programme or complete brief cognitive assessments. This meant that patients may be at risk of not receiving appropriate support.

  • Staff did not always ensure that they sufficiently recorded the decision making process for the administration of medicine to a patient. The lack of recording of the decision-making process meant that the patient could be at risk of not receiving the correct medication in order to stop the progression of alcohol withdrawal symptoms.

  • Nursing staff supporting patients with substance misuse had not received specialist training. Some staff did not have a good understanding of the tools used to monitor patients. Following our inspection, the provider implemented a new nursing competency checklist.

  • The provider did not robustly monitor the quality of the service provided in the substance misuse services. The governance processes had not identified the areas of concern to provide assurance.

  • However, since the August 2017 inspection, we found the following areas of improvement:

  • The hospital now had a system in place to monitor how long patients waited to be assessed following admission.

  • Staff now completed physical health assessments and monitored vital signs for all patients following rapid tranquilisation. However, there was room for improvement in the quality of recording to evidence that staff attempted to monitor patients’ vital signs on more than one occasion if they refused.

  • On the eating disorder wards, staff accurately recorded patients’ physical health observations as prescribed and escalated any concerns identified. The nasogastric feeding rooms on Priory Court and Upper Court provided safe and clean environments.

  • Items in the emergency bags were in date on Priory, Upper Court and Garden Wing.

  • The provider had provided physical health training to staff to ensure they understood how to calibrate the blood glucose monitoring machines. Staff now calibrated these machines correctly.

  • Staff consulted with patients to improve the interior design in the nasogastric feeding rooms and work was due to be completed by December 2017.

  • Permanent staff did not share their computer log-in details with agency staff. They could access the patient records as needed. Staff on all wards knew what to do in the event of a computer outage.

  • Following a previous serious incident at the hospital, the provider stated that admissions to Garden Wing and West Wing should not take place out of hours as there was reduced access to regular skilled staff, including medical staff compared to usual working hours. They had identified this as a risk to patients and outlined it in their action plan. At this inspection, out of hours admissions were still taking place. This was due to some patients turning up later than the agreed admission time. There were measures in place to ensure these admissions took place safely.

We found these areas of good practice:

  • All patients had current risk assessments, and those we checked were detailed and clear. Staff had undertaken training in relational security, and found this helpful in working on the wards. Extra staffing on all of the acute wards enabled more observations and interactions with patients, so that patients felt better supported.

  • Care plans were holistic, personalised and demonstrated patient involvement. There was evidence of good physical health care management.

  • Staff demonstrated effective relationships with other services and organisations. The safeguarding lead had good working relationships with the local authority. Lower Court was part of the new models of care pilot, in partnership with two London NHS trusts to improve the CAMHS care pathway.

  • The hospital sought to improve and keep up with best practice. Wards were providing treatment in line with NICE guidance. The CAMHS and eating disorder ward were part of national recognised accreditation schemes to learn and share practice.

  • There was excellent involvement of young people on Lower Court. Patients sat on CAMHS staff interview panels and were involved in the development of their therapeutic programme. Staff were responsive to patient feedback. For example, staff provided young people with Bluetooth cordless headsets, as normal headphones with cords were not allowed.

  • Patients spoke positively about staff interactions with them, and we observed staff engaging with patients discreetly and respectfully. Patients said the food was good quality. Patients particularly appreciated the hospital gym and were satisfied with the hospital accommodation.

  • The hospital had strong and responsive leadership. Senior management were visible on the wards and consulted with staff regarding changes to services. Senior management had good oversight of the wards and had systems in place to track staff supervision, incidents, safeguarding and complaints for each ward.

3 & 4 August 2017

During an inspection looking at part of the service

As this was a focussed inspection, the provider’s overall inspection rating or core service ratings were not altered.

We undertook this inspection to check the progress the provider had made in addressing the breaches of regulation identified at the previous inspection in October 2016. We also report on new issues found during our focussed inspection.

We found the following areas for improvement:

  • Garden Wing did not provide a safe environment for patients. The ward layout made it difficult for staff to observe patients clearly.The door between the hospital’s restaurant and Garden Wing did not have a secured entry system. Visitors, non-clinical staff and other patients accessed the ward. Staff found it hard to manage the acuity of patients on the ward within the current environment. At the October 2016 inspection, staff and patients from other wards accessed the dining area through Garden Wing, which impacted negatively on the privacy and dignity of patients. At the August 2017 inspection, the hospital had put an alternative route in place for staff and patients. However, we observed staff and patients from other wards continue to use Garden Wing as a thoroughfare.
  • Physical health assessments and monitoring of patients’ vital signs after rapid tranquilisation was not always taking place. At the October 2016 inspection, there were gaps in physical health assessments, and monitoring of patients’ vital signs following rapid tranquilisation. At the August 2017 inspection, the hospital had failed to take sufficient steps to ensure that all staff completed physical health assessments and monitored vital signs for all patients following rapid tranquilisation.
  • Patients’ physical health observations on Priory Court and Upper Court had not always been accurately recorded as prescribed, or physical health deterioration escalated by staff when needed.
  • Some clinical equipment was not being checked appropriately to ensure it was operating correctly. At the October 2016 inspection, on Priory Court and Upper Court clinical equipment was not checked, maintained and calibrated regularly. At the August 2017 inspection, whilst the service had put in place a contract with an external providerto service clinical equipment, some staff lacked an understanding on how to use and calibrate blood glucose monitoring machines on a daily basis. On Upper Court, staff did not record that they completed weekly testing for the blood pressure machine. Emergency bags on Upper Court, Priory Court and Garden Wing contained some out of date items.
  • The nasogastric feeding rooms on Priory Court and Upper Court were not safe or clean environments. On Priory Court, the nasogastric seating and trolley were visibly unclean. On Upper Court, there was no adequate space for staff to prepare the nasogastric feeds. At the October 2016 inspection, on Upper Court nasogastric feeding was being carried out in a therapy room, not a clinical area, with no appropriate seating in place. At the August 2017 inspection, this was no longer the case and there was a separate nasogastric feeding room with suitable seating arrangements.
  • Some environments in the hospital needed updating and did not provide a therapeutic environment. On Upper Court and Priory Court the nasogastric feeding rooms were decorated in a way that was not therapeutic to patients. They were very clinical and sparse, with no pictures or decoration on the walls. At the October 2016 inspection, the small dining room on Upper Court was in need of updating in order to provide a positive therapeutic environment. At the August 2017 inspection, the planned work was still ongoing. The hospital estates plan aimed to complete this work by the end of October 2017. At the October 2016 inspection, there were no quiet areas available and no privacy for patients who were distressed on Priory Court. At the August 2017 inspection, the planned work was still ongoing. The hospital estates plan aimed to complete this work by the end of October 2017.
  • Governance processes to monitor the time patients were waiting for a full initial assessment following admission, were not yet operating effectively. At the October 2016 inspection, the provider had no system in place to monitor waiting times for new patients to be assessed by nursing and medical staff from their time of arrival on the ward. At the August 2017 inspection, the provider had failed to take sufficient steps to ensure that there was a system in place to monitor the time new patients waited before staff completed a full initial assessment on admission to the acute wards.
  • Access to patient information was not always managed appropriately. At the October 2016 inspection, permanent staff shared login details with agency staff. At the August 2017 inspection, the provider had made some improvements, but there were two occasions when student nurses used permanent staff log-ins. At the October 2016 inspection, staff on the wards were not aware of contingency plans to address unexpected downtime of the computerised records system. At the August 2017 inspection, some improvements had been made, but some staff on the acute wards were still unaware of the contingency plans.

We found the following areas of improvement since the last inspection:

  • Staffing had improved on the wards and staff received training to undertake their role. At the October 2016 inspection, the hospital had a high number of staff vacancies, a high use of temporary staff and significant staff turnover. At the August 2017 inspection, the hospital had made improvements having the required level of staffing for day and night shifts for all wards. Agency usage had dropped, staff turnover had improved and vacancy rates for nurses and healthcare assistants had improved. At the October 2016 inspection, staff compliance with mandatory training was low at 73%, and staff were not trained in intermediate life support. At the August 2017 inspection, there had been an improvement with a compliance rate of 87% for mandatory training and 84% of relevant staff had been trained in intermediate life support.
  • The provider had completed work to ensure rooms that were safer for high-risk patients. At the October 2016 inspection, the hospital environment, particularly on the acute wards, was unsafe. At the August 2017 inspection, the provider had completed work to ensure safer rooms did not contain ligature anchor point risks and were completed to specification. All wards had ligature risk assessments in place that identified ligature anchor points. All wards apart from Garden Wing had a separate CCTV system that monitored areas of potential risk, in communal areas and bedrooms, to reduce ligature risk.
  • The provider had completed work to ensure a safe environment for patient physical examinations and safe storage of medicines. At the October 2016 inspection, there was no clinical room available for staff to conduct physical examination of patients on Upper Court and East Wing. At the August 2017 inspection, this was no longer the case and patients received physical examinations in a clinical room on the ward. At the October 2016 inspection, the medicines fridge on Priory Court had not been working since 28 August 2016, although it was still being used to store medicines. At the August 2017 inspection, the medicines fridge on Priory Court was fit for purpose.
  • Staff undertook risk assessments for patients and developed individualised care plans with patient involvement. They delivered care that was personalised without blanket restrictions. At the October 2016 inspection, risk assessments varied in consistency and detail for acute wards. At the August 2017 inspection, we found a general improvement in the quality of the risk assessments for patients on acute wards. At the October 2016 inspection, care plans varied in consistency and detail across acute wards. At the August 2017 inspection, we found an improvement in the quality of the care plans for patients. At the October 2016 inspection, care plans did not show patient involvement in the development of care plans. At the August 2017 inspection, we found an improvement in care plans that showed evidence of patient involvement. At the October 2016 inspection, the provider placed blanket restrictions on patients on Priory Court and most patients were not able to access their bedrooms during the day. At the August 2017 inspection, we found this was no longer the case and bedrooms were open and available to patients.
  • The provider displayed CQC core service ratings correctly. At the October 2016 inspection, the provider had not displayed the core service ratings in a prominent place. At the August 2017 inspection, the provider displayed CQC core service ratings in the main reception area.  

19, 20, 24 & 26 October 2016

During a routine inspection

We rated this service as requires improvement.

  • At the previous inspection in February - March 2016, we identified that there were insufficient staff employed and deployed at the hospital to ensure the safety and consistency of patient care. At the current inspection there remained high vacancy rates for nurses across the hospital and particularly on the eating disorder service. This resulted in high use of bank and agency staff and there were also a significant number of shifts with below safe staffing levels. Records indicated that there were more incidents on shifts with insufficient staff on Priory Court, the eating disorders unit for children and adolescents. There had been 95 incidents on Priory Court in the six months prior to the inspection. Following the inspection the provider sent us revised data indicated higher staffing levels than recorded above. We undertook enforcement action against the provider serving a warning notice regarding staffing levels. Staff compliance with mandatory training was low.
  • At the previous inspection in February - March 2016, we identified that the hospital environment was unsafe for patients at risk of suicide or self-harm. The provider sent us an action plan, with some improvements to the environment not due to be completed until 31 December 2016. At the current inspection, the hospital environment, particularly on the acute wards, remained unsafe, due to poor sight lines, ligature anchor points, and access to vacant corridors and staff offices. The hospital had introduced ‘safer rooms’ to accommodate patients presenting a heightened level of risk, but these were not yet completed to full specification. Risk assessments of the safety on wards were not sufficiently robust to include all areas of high risk. Risk assessments and care plans varied in consistency and detail, so that there was a risk that staff would not meet patients’ needs.
  • At the previous inspection in February - March 2016, we identified that staff undertook naso-gastric feeding in an inappropriate environment, and there were insufficient facilities across the hospital, for the physical examination of patients. At the current inspection, we found that on Upper Court, staff  carried out naso-gastric feeding in a therapy room. This was in line with the action plan provided indicating that this would  be completed by 31 March 2017. However, there was no appropriate seating provided for the purpose in the therapy room being used. On East Wing and Upper Court there were no clinical rooms available for staff to conduct physical examination of patients. This usually took place in their bedrooms.
  • At the previous inspection in February - March 2016, we found that agency staff used log-in details of permanent staff on shift. This was still happening at the current inspection.
  • Feedback from patients on Priory Court was that seeing staff restrain other patients on the ward distressed them. Staff and patients from other wards walking through Garden Wing to access the canteen, affected the privacy and dignity of patients on Garden Wing. There were no quiet areas available to patients on Priory Court, and no privacy for patients who were distressed. Restraint of patients took place in full view of other patients. There were blanket restrictions on patients on Priory Court. For example, most patients were not able to access their bedrooms during the day.

  • Staff undertook checks of emergency drugs and equipment sporadically on the eating disorder units, and there was no documentation to show that they cleaned equipment in the clinic rooms regularly. Staff did not carry out and record observations of patients’ vital signs routinely and at regular intervals after administering rapid tranquilisation.
  • Staff did not always record patients’ involvement in their care plans to ensure that their views were taken into account.

  • The provider had not displayed the current CQC inspection rating for each core service prominently as required.

However:

  • At the previous inspection in February - March 2016, we identified that improvements were required in reporting and learning from incidents. The hospital had introduced a new system to ensure that staff recorded serious incidents quickly and consistently. Managers held a ‘learning and outcomes’ group once a month to review all incidents that had taken place and identify areas for improvement.
  • At the previous inspection in February - March 2016, we identified that staff engagement should be reviewed to ensure that staff working on the acute wards are able to raise concerns. This had improved at the current inspection. Senior managers regularly visited the wards and there was a governance system in place to monitor the quality and safety of care provided. There were daily meetings of senior managers to discuss incidents and immediate issues of concern.
  • An occupational therapist on Priory Court was helping patients to create self-soothing boxes with items the patient found comforting and could distract them from distress. Upper Court had recently achieved accreditation by the Quality Network for Eating disorders.

  • At our previous inspection in February - March 2016, we identified that the provider should consider whether they should admit patients with a high risk of self-harm to an environment where it is hard for staff to observe patients. At the current inspection, we noted that the provider had implemented a pre-admission risk assessment. This included a handover system for ensuring staff noted risks.

  • The wards provided a comprehensive range of psychological therapies, including dialectical behavioural therapy, mindfulness, and family therapy. Occupational therapists and dietitians facilitated activities and discussion groups.

  • At the previous inspection in February - March 2016, we identified that informal patients were not always able to leave the hospital in line with their legal status. This had improved at the current inspection

23-25 February and 2-3 March 2016

During a routine inspection

We rated the Priory Hospital, Roehampton as requires improvement because:

  • There had been a very high turnover of staff and high use of temporary staff. This impacted on the consistency of care provided to the patients.
  • The layout of the hospital and the wards made it very hard for staff to observe patients who were at risk of self-harm. There were ligature risks throughout the hospital. There were a high number of incidents in the last year involving ligatures. Whilst the provider was taking steps to improve the safety of the physical environment there remained a high level of risk to patients’ safety. Many of the patients were assessed as being at risk of self-harm and the hospital may not be able to meet their needs safely.
  • Incident reports did not include a detailed description of the incident or information about the lessons learnt. This meant that it was hard to monitor the incidents and whether the lessons were being addressed. Whilst there were systems to ensure that learning from incidents took place within each ward, learning was not always shared across wards.
  • On the wards for adults, informal patients were only allowed to leave the ward if they had leave authorised by their psychiatrist. We did not find evidence to show that patients were consenting to the restriction being placed on their freedom.
  • On the acute wards, despite staff engagement arrangements being in place, there were significant numbers of staff with low morale, who had not felt that their concerns about staffing arrangements and safety for patients and staff had been listened to.
  • There were insufficient facilities for physical examinations and nasogastric feeding on Upper Court.

However,

  • Patients said that permanent staff were kind, caring and understanding. There were opportunities for patients and their relatives and carers to be involved in decisions about their care. There was a full range of therapies available. Care and treatment was delivered in line with best practice. The hospital was keen to make improvements and was working towards accreditation with the Royal College of Psychiatrists quality network for eating disorder services.

20 August 2014

During a routine inspection

We carried out an inspection at The Priory Hospital, Roehampton and visited Emerald ward which is a ward for adults with personality disorders and was due to close the week after our inspection visit, Upper Garden Court which is an acute mental health admission and treatment ward, the Adolescent Eating Disorders Unit and West Wing which accommodated people receiving treatments for addictions and adults with eating disorders. We spoke with people who used the service and a range of staff across the units we visited as well as speaking with the hospital manager. We also requested information from the provider which was sent to us following the inspection.

People we spoke in all the areas we visited spoke positively about the support they received. We found that people were involved in the planning and organisation of their care. People told us that they had the opportunity to provide feedback and felt listened to. People told us that they felt staff were skilled and caring. Records, including medication charts were up to date and completed. We saw that medicines were stored appropriately.

There were sufficient numbers of staff on duty to support people with their needs. Staff received support and training to ensure that they were competent to meet people's needs. The provider had governance systems in place to ensure that learning took place from incidents, complaints and comments.

12 March 2014

During an inspection looking at part of the service

We spoke with two people using the service during our inspection. They told us that "staff are good", "the ward manager is brilliant", and that they had no problems with their medication.

We observed how medicines were administered to two people and saw that medicines were explained to them and that nurses observed that they were swallowed before recording that they had been given. We looked at seven drug charts and consent forms to give medication and saw that all medicines listed as given were signed and dated and correlated with the consent forms.

We observed that the prescription charts were checked by the pharmacist for accuracy and if a medicine was omitted the gap was identified and appropriate action taken. We saw that there was a regular audit of the charts and the results were recorded in an audit book.

Ward managers confirmed that there had been a recruitment drive in the past few months. One person told us "we have had new staff inducted to the ward". Another staff told us "we always call bank staff if possible, it's very rare that we use agency" and "you see familiar faces now".

The Human Resources (HR) department had taken steps to try and improve the recruitment process for new staff. Where agency or bank staff were used, core competencies and revised induction had been implemented to ensure that the quality of staffing was of an acceptable standard.

24 October 2013

During an inspection in response to concerns

We spoke with people using the service on East Wing and Priory Court. People felt involved in their care and told us they met with their key worker regularly. One person said their families were kept involved. Some of the comments included "generally the care is very good" and "they are strict but they have to be". One person told us the admission process was smooth and straightforward.

Risk management plans were updated and clinical decisions recorded when people were moved from one to one to zonal observation. Care plans recorded issues around restraint, the risk of absconsion and self harm.

Permanent staff on East Wing were issued with basic emergency equipment such as ligature cutters and gloves. Staff were aware of the location of the emergency kit on the wards. Training records showed that staff received Basic Life Support and defibrillator training as a yearly classroom session.

Staff on both East Wing and Priory Court told us that on each shift there were at least two staff that were restraint trained. We saw these staff were allocated on the records that we saw.

Staff described their induction programme. One person said that HR staff went through policies in an interactive way. They said that more training had been booked for them in the future, including first aid and restraint training. New staff told us they had "settled in well" and staff were "supportive". Other comments included "got a good team here" and "I'm happy we have a core team".

25 June and 3 July 2013

During a routine inspection

During the inspection we visited the East Wing for women with personality disorders, the West Wing for people with addictions and Priory Court for adults and adolescents with eating disorders. We spoke with staff working in different roles across all three units. We observed interactions on the wards and reviewed a number of records, including care plans, training records, and policies.

People using the service told us they were given written information on arrival, however some found the number of forms to fill in 'overwhelming'. Staff told us that people were 'given a hospital booklet' and a 'conditions of admission' form which they had to sign. A key worker was then assigned to them 'soon after they joined'. One nurse said 'we are non-judgemental and try and nurse them through their crisis'.

We saw a number of leaflets and posters advertising an independent mental health advocacy service. People could express their views in key worker or community meetings.

Care plans were completed well and reviewed regularly. Care plan reviews were updated electronically and a copy offered to the patient. There was a varied timetable of activities and a staff member told us 'we try and develop a structure to support the patients'. People that we spoke with were happy with the activities.

People were happy with the support from permanent staff but concerns were raised around the high use of agency staff. This impacted on other areas such as medication and staff morale.

9 May 2012

During a routine inspection

During our visit we spoke to a number of people who use the service and staff on the addictions unit, garden wing and the child and adolescence mental health service unit (CAMHS). The feedback we received from people who use the service was positive, where they said they felt respected and involved in planning their care. One person said 'this is a lovely unit, the staff are really great', whereas another commented that 'they do fantastic work here'.

People told us that they get a good service which meets their needs. They said that generally all of the staff were respectful and caring towards them.

People told us they felt supported by staff and that there was generally always someone available for them to talk to.

People told us that staff acted swiftly on occasions where they felt anxious and at risk.

27 June 2011

During a routine inspection

People have varying experiences of the service. Some people feel that they are involved in identifying their needs and treatment, whereas others say that they are not involved in the care provided to them.

Similarly, people have differing experiences of the staff. Some people told us that they find the staff to be very skilled and knowledgeable, yet others felt that the staff had no understanding of their needs or of how to meet them.

People told us that they feel safe, and that there are some opportunities for them to raise any issues they have about the ward.

Mental Health Act Commissioner reports

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.