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

The Priory Ticehurst House

Overall: Good read more about inspection ratings

Ticehurst, Wadhurst, East Sussex, TN5 7HU (01580) 200391

Provided and run by:
Priory Healthcare Limited

All Inspections

7 and 8 April 2021

During a routine inspection

The Priory Ticehurst House is an independent hospital which provides inpatient mental health treatment to adults and young people.

We undertook an unannounced comprehensive inspection to determine if the service was providing safe and good care to patients and young people and to check if the service had made improvements, we told them they must make.

Since this inspection, the provider decided to close the two child and adolescent mental health wards of the hospital. This was because the provider was experiencing issues recruiting enough nursing and medical staff for this service. This decision was not related to our inspection activity.

The acute wards for adults of working age remain open.

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

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. 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. However, on the adult wards, some of the patients’ care plans were more basic and generic than others. Staff provided a range of treatments suitable to the needs of the patients 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.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training. The ward staff worked well together as a multidisciplinary team and had effective working relationships with external teams and organisations. Most staff told us they felt supported and could speak with their manager when they needed to.
  • Staff treated patients and young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients and young people. They actively involved patients and families and carers in care decisions. Staff on the children and adolescent wards interacted with young people in a way that appealed to their age group and empowered young people to be partners in their care.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
  • The service was well-led, and the governance processes mostly ensured that ward procedures ran smoothly.

However:

Staff did not understand or discharge their roles and responsibilities under the Mental Capacity Act 2005. Capacity to consent assessments and recording was not always in line with current legislation. Staff did not document their rationales for the decisions they made, and they did not support people who lacked capacity through best interest decisions.

9 December 2020

During an inspection looking at part of the service

The Priory Ticehurst House is an independent hospital which provides inpatients mental health treatment to adults and young people. At this inspection, we only inspected the child and adolescent mental health (CAMHS) wards; Upper Court and Keystone.

This was an unannounced, focused inspection and we specifically looked at some aspects of the key questions, ‘are services safe and well-led’. We had previously rated both of these key questions as inadequate and still had some concerns because of information we had received from young people and parents about whether services were safe. The purpose of this inspection was to determine if the service was providing safe and good care to young people and whether it had made any of the improvements that we had told it must be made.

The service was previously inspected in September 2019 and December 2019.

Following the September 2019 inspection, we issued a warning notice because the provider did not have effective governance systems in place to assure itself that the environment was safe, that risks were assessed and managed appropriately, that incidents were investigated, and improvements made as a result of findings to ensure care was safe.

We returned in December 2019 and found that the provider had made some improvements to their audit and governance systems and processes relating to risks and incidents and was taking action to reduce environmental risks on Upper Court. We were satisfied that the provider had met the requirements of the warning notice and we therefore lifted the warning notice. However, we found that there was still more to do to ensure sustained and continued improvements. We have been monitoring the service closely since.

We did not rerate the service during this inspection as we only looked at specific key lines of enquiry in the key questions are services safe, effective and well led. Therefore, the previous rating of inadequate remains in place.

We found:

The provider had reviewed all environmental risk assessments, and these were now accurate, up-to-date and appropriate action had been taken to reduce, mitigate or remove risks. The ward environments were safe and Upper Court had been refurbished.

Staff assessed and managed risks to young people 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 service had improved the way they managed patient safety incidents. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave young people honest information and suitable support.

There was a comprehensive activity programme in place covering evenings and weekends so young people were kept engaged in meaningful activity.

There was adequate medical cover for both wards. There was one locum speciality doctor on Keystone ward and Upper Court had a full time Speciality Doctor in situ.

The ward manager that had oversight of both wards was leaving. A new ward manager had been appointed to Upper Court and had recently started and a ward manager had been appointed to take over Keystone ward and was due to start in April. In addition, deputy ward managers had been allocated to both wards

In response to concerns raised by staff and external stakeholders about the ability to deliver safe care to young people the provider had reduced the number of young people it would take on each ward.

Most governance processes operated effectively at ward level and there was generally adequate oversight of performance and risk.  There was a framework of the information that was discussed at a senior management and ward level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

However:

We found that there was a lack of effective oversight of the use of CCTV in young people’s bedrooms. Staff did not always provide young people with enough detailed explanation about the use of CCTV and were not seeking consent appropriately. Young people told us that staff told them they needed to have the cameras activated to keep them safe and they were made to feel they had to agree to this. Staff did not discuss the impact on their privacy with them and did not provide alternatives or adjustments. If young people detained under the MHA did not agree to have CCTV activated in their bedroom, the responsible clinician would override this decision saying it was in the interests of the young person’s safety”. However, this decision-making was not documented, and young people were not part of this decision making.

9 September to 11 September 2019

During an inspection looking at part of the service

We undertook an unannounced, focused inspection of the child and adolescent mental health wards at The Priory Ticehurst House because we had received concerns from stakeholders, members of the public and carers. Concerns included poor staffing levels, the high use of agency staff, poor medicines management and the number of incidents occurring at the service.

The Priory Ticehurst House was last inspected as a full comprehensive inspection in November 2018, when it was rated ‘good’ in safe, effective, caring, responsive and well led. However, the service was issued with a requirement notice that related to regulation 18 of CQC (Registration) Regulations 2009. This was because the inspection found that the service did not make sure they informed CQC of notifiable events.

During this focused inspection we inspected the safe and well led key questions for the children and adolescent mental health wards. The rating for the safe and well led domain went down to inadequate since our last comprehensive inspection. Our overall rating of this service went down.

After our inspection, we issued the provider with a warning notice against regulation 17, good governance. This was because we were not assured that the provider operated effective audit and governance systems and / or processes to make sure they assessed and monitored the service in response to the environment, risks and incidents. The provider had not acted on risks identified about the environment for several months. There was not effective scrutiny of incidents and safeguarding to make sure that patients received safe care and treatment.

We returned to The Priory Ticehurst House on 12 December to check that the provider had complied with the requirements of the warning notice. We found that the provider had put in place some improvements to their audit and governance systems and processes relating to risks and incidents and was taking action to reduce environmental risks on Upper Court. We were satisfied that the provider had met the requirements of the warning notice and we have therefore lifted the warning notice. It will take time for the improved audit and governance systems and processes to demonstrate sustained improvement in learning from incidents and risk management.

We rated the children and adolescent mental health wards as inadequate because:

  • The environment on Upper Court had blind spots that did not allow for clear lines of sight. There were risks rated red on the environmental risk assessment in January 2019 that had not had the identified actions taken to mitigate the risks. Two windows and a door had been damaged the night before our inspection. The on-call maintenance team had used perspex over the windows and doors as a temporary measure to make safe. The risks concerning the windows and doors had not been added to the assessment. The ward and communal areas were tired.
  • Patients on Upper Court had to walk some distance to reach the designated outside area. The journey involved walking down narrow staircases, past the main reception and the outside areas of male and female wards. Fences had been covered to protect dignity and provide an enclosed area.
  • A number of experienced staff had moved from Upper Court to Keystone ward when it opened in April 2019. In the previous 12 months, there had been seven consultant psychiatrists providing clinical care on Upper Court.
  • There had been a gradual increase in incidents of behaviours that challenge involving physical restraint since April 2019. Data provided by the service showed that most incidents occurred after 6pm. There was no evidence of the provider acting on or learning from a recent spate of incidents involving the same patients. Patients said they were bored and that little or no activities took place outside of school hours.
  • There was evidence of a lack of management review for incidents. There were inconsistencies in the detail and information recorded on the incident reporting tool. Missing information included the risk level and whether external agencies had been notified. Incidents were scored between one and five, with five being the lowest harm and one being the highest. Information was only cascaded to senior managers if a risk level had been recorded three or lower. None of the incidents we reviewed had been rated below four, despite some requiring police attendance. Managers had not reviewed many of the incidents for several weeks. Staff said that learning from incidents was not shared.
  • The governance processes did not ensure that wards ran smoothly. There was insufficient oversight and scrutiny by senior managers to ensure actions identified in the environmental risk assessment had been carried out, risks were reviewed and learning was implemented. There was a lack of preventative action to avoid recurrence of incidents.
  • Audits had not been updated to reflect the change from Upper Court’s change from a high dependency unit to a tier four service.
  • There was low morale of staff on Upper Court ward. Some staff said they felt unable to raise concerns without fear of retribution.

However:

  • The environment on Keystone ward was safe, clean, well equipped, well furnished, well maintained and fit for purpose.
  • Both Keystone ward and Upper Court had enough nursing staff. Most of the nurses on both wards were regular agency staff.
  • The social worker was shared across Keystone ward and Upper Court. There was a social worker assistant in post. There was a part time psychologist, an art therapist and family therapist available for the wards. A vacancy for a part time psychologist and assistant psychologist was being advertised. There was an occupational therapy assistant on the ward. The occupational therapist was shared across both wards.
  • Patient risk assessments were comprehensive and up to date in all eight care records reviewed.
  • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s physical health.
  • Managers ensured staff received appropriate training and supervision.

14 and 15 November 2018

During a routine inspection

We rated The Priory Ticehurst House as good because:

  • The service provided safe care. The ward environments were safe and clean and wards met the requirements set out in national guidance on mixed sex accommodation.
  • Staff assessed and managed risk well. All patient records that we reviewed had a current and up to date risk assessment in place. Staff demonstrated a good knowledge of their patients and their associated risks. The service minimised the use of restrictive practices and followed good practice with respect to safeguarding.
  • 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. Medicines were appropriately stored, administered and reconciled on all wards. All medicine was in date and labelled.
  • Staff monitored patients’ physical health regularly and managed patients’ physical health needs well across all wards.
  • The wards had enough staff on shifts. The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisals. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed and were visible in the service and approachable for patients and staff.
  • The service demonstrated that governance processes operated effectively at ward level and that performance and risk were managed well.

However:

  • The provider failed to notify the CQC of incidents, including those that involved the police, as required by regulations set out in the Health and Social Care Act.
  • Spare alarms were not consistently stored on the wards or accounted for on handover sheets. Staff alarms were not routinely tested to ensure their efficiency.
  • The clinic room on Newington Court One had thick dust on medical appliances. The medicine cabinet in the child and adolescent ward clinic room was in reach of patients waiting outside.
  • Whilst improvements were noted since the last inspection, not all agency health care assistants on the child and adolescent mental health wards had their induction checklists completed before working independently.
  • On the child and adolescent mental health ward, some staff were unclear about what to do in the event of a fire.
  • Whilst a comprehensive ligature point audit had been carried out and staff aware of the risks, the remedial works action plan did not indicate whether the work had been completed where the expected date of completion had passed.

22 June 2018

During an inspection looking at part of the service

On 22 June 2018 we undertook a focussed inspection on Upper Court ward. Concerns had been raised with us about the care and treatment of young people who had been accommodated on Upper Court toward the end of 2017. The concerns related to incidents of young people self harming and an alleged lack of staff skills in responding to these incidents. It was alleged staff were not adequately inducted to undertake their role and as a consequence of this young people were put at risk of harm. As this was not a comprehensive inspection we focussed the inspection on the areas of concern.

We found the following issues the provider needs to improve upon:

  • Young people’s physical health was not adequately monitored following the use of rapid tranquilisation. Records of the physical health checks were not always completed.
  • Records about potential risks for each young person were not always consistent and this could result in them not receiving an appropriate level of observation.
  • Permanent and agency staff had not received an induction appropriate to the roles they were to undertake on the ward.
  • Records relating to agency staff inductions and staff rotas were poorly maintained.
  • Not all staff had received regular supervision.
  • The provider did have governance systems in place to monitor and assess the service but where areas needed to improve these were not fully implemented.
  • The provider failed to notify CQC of notifiable events concerning the wellbeing of young people.

We found the provider to be in breach of regulation 12, safe care and treatment, regulation 18 staffing and regulation 18 (registration) notification of other incidents.

17 & 18 April 2018

During a routine inspection

We rated The Priory Ticehurst House good because:

  • The hospital had appropriate staffing levels to meet the care and treatment needs of patients and young people. Staff used good levels of observation to mitigate against risks identified on all the wards. Staff demonstrated a good understanding of how to identify abuse or if patients were at risk of harm.
  • Staff involved patients and young people in the assessment and planning of their care. The physical healthcare needs of patients and young people were assessed and monitored regularly. Staff followed National Institute for Health and Care Excellence (NICE) guidance when prescribing medicines. A full range of qualified health care professionals including psychologists, consultants, occupational therapists and nurses were available to deliver care and treatment on the wards.
  • Throughout our inspection across all wards we observed examples of staff interacting positively with patients and young people in a way that was both respectful and caring. Patients and young people were involved in planning their care and attended weekly community meeting which provided a forum to feedback about the hospital.
  • On four of the wards patients and young people could meet their visitors in a quiet space and there were rooms off the ward to meet with families and carers. Patients and young people knew how to make a complaint.
  • Ward managers had the necessary skills, experience and knowledge to perform their roles competently. Staff spoke highly of the support provided by their ward managers. Ward managers had dashboards to support them in their management role. They could access staff training, supervision and appraisal information.
  • There was learning from incidents on the wards across the hospital.

However:

  • The physical environment on Lowlands was not suitable for the needs of the patients accommodated there. The unit was small and cramped which made wheelchair accessibility very difficult. There was no clinic room so patients medicines and the ward’s emergency medical equipment were held in a small office.
  • There was no meaningful rehabilitation or recovery program in place on Lowlands ward.

13-14 June 2017

During an inspection looking at part of the service

We retained our rating of the long stay/rehabilitation mental health wards for working-age adults at the Priory Ticehurst House as requires improvement because:

  • Patient care plans were not based on building on the strengths of patients and lacked a recovery or rehabilitation focus. The majority of care plans contained reference to providing patients with a meaningful and purposeful life, but did not show how this would be achieved. There was little evidence of discharge planning and how staff would support patients to lead a more independent life in the community.
  • The therapeutic and developmental quality of the overall activity program was limited. The type of activities on offer were of an entertainment type, rather than assisting patients to recover or rehabilitate.
  • The ability of staff to observe all parts of the units was restricted. There were blind spots on all three units. The controls in place for managing or minimising idenitifed ligature risks lacked substance and were generic in nature. There were no notes to describe how each identified risk was to be reduced or eliminated.
  • The environment on Highlands was not appropriate for people with restricted mobility. There were narrow corridors that had uneven flooring and a number of tight corners. The clinic rooms on each unit were small and did not have sufficient space for an examination couch. As a result, staff had to carry out some duties (for example administration of medicines, health checks and electrocardiograms) in patients’ bedrooms.
  • Staff turnover levels were high, at 36% during the period 01 June 2016 to 31 May 2017.
  • Not all staff had completed every mandatory training subject within the last 12 months.
  • There were no rooms allocated for patients to spend time with visitors. They either used the patient’s own bedroom, an activity room, or the quiet lounge on Highlands.

However:

  • Individual risk assessments were thorough and tailored to each patient. They were completed at the point of admission and appropriately updated thereafter. Staff used tools appropriate to the age and abilities of the patient group, such as the malnutrition universal screening tool and falls risk assessments.
  • Staff met the physical health needs of patients. Ongoing general monitoring of physical health monitoring was carried out and appropriately recorded. Patient records also showed evidence of ongoing physical health monitoring in respect of known conditions such as epilepsy and diabetes. Every patient medicines chart showed evidence of following National Institute for Health and Care Excellence guidance in prescribing medicines.
  • Staff we spoke with knew how to make an incident report and what types of incident they should report. We saw evidence that learning from previous incidents was being shared, both at unit level and at managerial level.
  • The units were compliant with Department of Health same sex accommodation guidance. Since our last inspection in January 2016, the service had moved to make all three units single gender patient groups.

19 - 21 January 2016

During a routine inspection

We rated the Priory Ticehurst House as requires improvement because:

  • The mixed gender accommodation on Highlands ward was not meeting guidance on gender segregation.

  • There was no defibrillator on the Lodge. Response time to an emergency drill was well in excess of Royal College of Psychiatry guidelines.

  • Feedback to staff following incidents and safeguarding alerts was poor on the long stay rehabilitation wards. There were inconsistencies between paper and electronic incident reports on the long stay rehabilitation wards.

  • Staff supervision was variable for staff on rehabilitation wards.

  • There was a lack of meaningful rehabilitation on Highlands and the Lodge.

  • Not all staff on the rehabilitation wards could access computer systems to record and access patient information.

  • There was an inconsistent knowledge of the Mental Health Act, Mental Capacity Act and Deprivation of Liberty Safeguards on the long stay rehabilitation wards.
  • The temperature on the CAMHS ward was cold.
  • There were blanket restrictions on CAMHS ward.
  • The hospital was undertaking ligature risk audits, however, we found not all risks were identified and mitigated on all wards.

However:

  • Medications management throughout the hospital was well managed.

  • Patients received thorough assessments on admission to the hospital.

  • There was a high compliance with mandatory training throughout the hospital. Staff were also given the opportunity to attend training to further their careers.

  • All ward areas were clean, tidy and well maintained. All wards had good access to rooms for activities, visitors, quiet rooms and lounges.

  • Patients had care plans that were detailed, holistic, personalised and recovery focused.

  • The hospital followed National Institute of Health and Care Excellence Guidelines.

  • There was strong multi-disciplinary team working throughout the hospital.

  • The hospital offered patients a good range of psychological therapies.

  • The child and adolescent mental health service had developed a bespoke programme rolling of training for staff.

  • We observed staff interacting with patients in a caring, respectful and responsive manner. All staff we spoke with were passionate and motivated about the service and the patients.

  • Patients told us staff treated them well and were responsive to their needs.

  • Patients were able to provide feedback on the service and were involved in decisions about the service, for example assisting with staff recruitment.

  • Advocacy services were available to patients.

  • There was a wide range of information leaflets available to patients in different formats and languages.

  • The hospital had a complaints policy. Patients were aware of this and were provided information about how to use it. The hospital had a monthly learning and outcome group where incidents and complaints were discussed.

  • The hospital offered a wide range of therapeutic activities to meet the psychological, social, creative and physical needs of patients.

  • The hospital had appropriate governance processes from the hospitals senior management teams.

  • Incidents were reported in line with hospital policy on the child and adolescent and acute wards. The Priory Group share learning from incidents at other hospitals to ensure outcomes are disseminated across the hospital group.

  • There was a wide range of audits taking place throughout the hospital.

  • The CAMHS service were members of the Quality Network for Inpatient CAMHS (QNIC) and were in the process of going for accreditation.

1 August 2013

During a routine inspection

We looked at care records and found that they were person centred and well maintained with systems in place to audit and monitor the quality of care provided. Patients told us that their care and treatment needs were planned and delivered in line with their individual care plan. One patient told us "'I really like it here. The staff are amazing. It's really good.'

We saw evidence to support that prior to receiving care, patients were given appropriate information that enabled them to make informed decisions. We saw that documentation showed that patients were being asked for their consent and that the provider had acted in accordance with their wishes.

The provider had systems in place to protect patients from abuse and to deal appropriately with concerns if they were raised. Staff had received training and were confident about how to recognise signs of abuse. They described the steps they needed to take to keep patients safe.

There were enough qualified, skilled and experienced staff to meet patient's needs in the event of sickness and to allow adequate time to support staff.

We found that there were suitable arrangements in place to support staff with meaningful supervision, appropriate professional development and training, and an inclusive appraisal mechanism.

The provider had systems to deal with and respond to complaints

16 November 2012

During a routine inspection

We used a number of different methods to help us understand the experiences of patients who used the service, because some of the people who used the service had complex mental health needs which meant they were not able to tell us their experiences.

We saw that patients were treated with dignity and respect and that they were supported to retain their independence.

Patients were offered a choice of food which was nutritious and varied. We observed staff interacting positively with the people who used the service. We saw that patients had access to educational and social activities to meet their wishes and needs.

We saw that the provider has effective quality assurance systems in place to identify, assess and manage risks to the health, safety and welfare of the patients who used the service and others.

You can see our judgements on the front page of this report.

22 June 2012

During a routine inspection

During our visit we spoke with patients at the hospital, the registered manager and staff members.

We also took information from other sources to help us understand the views of patients to include surveys and community meetings.

We primarily focussed on Highlands and Upper Grange Court units. However we had discussions with patients from Garden Court and Lower Grange units. We conducted the inspection with a Mental Health Act Commissioner present also from the Care Quality Commission. The Mental Health Act Commissioner completed a separate report on their findings under the Mental Health Act 1983.

The patients we spoke with had mixed views with regard to the care they received at the hospital.

Staff we spoke with knew the people living at the hospital well and had a good understanding of their support needs.

We spoke at length with the registered manager and found that a number of improvements had been made since the last inspection, to address outstanding compliance actions. The registered manager provided transparent feedback on outstanding actions requiring completion.

In addition, we have received regular monthly action plans from the provider advising us of ongoing improvements made in response to the findings from the last inspection in November 2011 and last review in April 2012.

23 November 2011

During an inspection in response to concerns

We were told that 'we get the support we need' ' Sometimes I feel like I am stuck in the middle of nowhere' ' Its great that I can study and I will be able to continue with my education when I leave' ' I have decided to stay voluntarily now as I feel really much better'.

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.