All inspections: The Priory Hospital Middleton St George

The Priory Hospital Middleton St George is a 104-bed hospital that provides 24-hour support 7 days a week for people aged 18 years and over with mental health problems, personality disorders or both.

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

We inspected both of the location’s two core services: the long stay and rehabilitation wards and acute wards and psychiatric intensive care units.
We rated the acute wards and psychiatric intensive care units requires improvement under the Safe and Well Led key questions and the service as requires improvement overall. We rated the long stay and rehabilitation wards as good under each key question and the service good overall.
When the ratings were aggregated, the overall rating for the location is requires improvement.

We rated The Priory Hospital Middleton St George as requires improvement because:

During our inspection visits, system, and resources to enable the provider to monitor the cleanliness and safety of some wards were not fully effective. We found the service was not clean or well maintained in some areas.
We had identified, during our Mental Health Act review in September 2023, that fully effective operating systems, to ensure seclusion processes within the service were in line with the Mental Health Act Code of Practice, were not place. This was because medical reviews had been carried out by advanced practitioner nurses and not responsible clinicians or duty doctors as stated in the Code of Practice. Following internal staff discussions, the provider had agreed they would cease this practice and had plans in place for how this change would be implemented.
Nurses did not always complete nursing reviews in line with the requirements of the Mental Health Act Code of Practice. We reviewed 10 seclusion records, pertaining to 7 patients, and founds shortfalls in record keeping that could indicate poor practice, potential risk and that national guidance was not adhered to.
Some of the nursing staff we spoke with were unable to demonstrate their understanding of the Mental Health Act, Mental Capacity Act and duty of candour.

However:

The rehabilitation wards provided safe care and 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.
The ward environments on Linden and Hazelwood were clean and well maintained.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. 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, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
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.
Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason. Staff delivered a recognised model of mental health rehabilitation.

Our rating of this service improved. 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. 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.
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 and appraisal. The ward staff worked well together as a multidisciplinary 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.
Most patients felt staff treated them with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They involved patients and families and carers in care decisions.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However, we found the following issues that the provider needed to improve:

We found a blanket restriction within the hospital during our inspection. Patients on Chester ward were being made to use plastic cutlery. However, we were informed shortly afterwards that metal cutlery had been ordered so the provider had addressed this.
Managers did not always ensure staff received regular supervision. An action plan was in place for low compliance with supervision on Birch ward.

We have taken enforcement action against the registered provider in relation to our concerns about this location.

Our rating of The Priory Hospital Middleton St George went down because we found a significant deterioration in the quality of care and treatment at this hospital. We rated it as inadequate because:

The service did not have enough nurses and healthcare assistants on the wards. We saw evidence that shifts did not always operate with sufficient numbers of staff to keep patients and staff safe. Staff were often moved between wards to cover other wards. There are other instances where staffing levels fell short of the required numbers for other wards which are included throughout this report.
Staff sickness absence within the long stay and rehabilitation wards was an average of 7.28%. This figure was higher than normal due to absences associated with the COVID-19 pandemic such as staff needing to self-isolate if they or their loved ones had symptoms or to shield because of underlying medical conditions. There were also 16 staff who had been on long term sickness absence for other medical conditions. However, the provider originally reported that the figure was 46%.
The wards relied on agency and bank staff to meet the needs of patients. Agency staff were not able to carry out physical interventions except in emergency situations, which meant there were not always enough staff on the wards to participate in required interventions.
Agency healthcare assistants did not always have the communication skills needed to meet the needs of patients. Patients on Hazelwood, a long stay/rehabilitation ward, told us that language barriers made it difficult for them to build rapport and trust with these staff members. Managers were already aware of this issue but had not addressed it at the time of our inspection.
Agency staff did not receive supervision and were unable to carry out physical interventions except in emergency situations, due to not being trained by the provider in the prevention and management of violence and aggression.
Patient observation charts were not signed in accordance with the provider’s observation and engagement policy. Staff members observed patients for long periods of time without breaks which was not in line with the provider’s observation and engagement policy.
Governance structures within the hospital were not consistent in identifying areas of concern and improvement. For example, they did not highlight that observation charts were not signed in accordance with the provider’s observation and engagement policy or that there was a haphazard approach to ensuring the ward was sufficiently staffed. Poor documentation made it difficult to determine when staff had been on duty.
Not all the staff on the ward felt supported by managers. Although staff spoke highly of ward managers, some staff members said they never saw members of the senior management team and one said the relationship between the senior management team and frontline staff was dependent on the personalities concerned.

However, we found the following area of good practice:

Staff assessed and responded to risk. Risk assessments were comprehensive and risk management plans were updated following incidents on the wards.
Staff managed medicines safely and carried out patient observations within the frequencies prescribed.

We rated The Priory Hospital Middleton St George as outstanding because:

Leaders at all levels demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. Staff felt respected and supported through all management levels. Staff of all grades and professions told us they felt part of a team, their opinion was valued and treated with equal respect. The company recognised the value of their staff and annual awards were given to staff members in recognition of their service and contribution.
There was a demonstrated commitment to best practice performance and risk management systems and processes. The organisation reviewed how they functioned and ensured that staff at all levels had the skills and knowledge to use those systems and processes effectively. Problems were identified and addressed quickly and openly. Staff were proud of the organisation as a place to work and spoke highly of the culture. Staff at all levels were actively encouraged to speak up and raise concerns, and all policies and procedures positively supported this process. Plans were consistently implemented, and had a positive impact on quality and sustainability of services.

The long stay/rehabilitation wards had a bright and homely feel with a calming and relaxing environment. Patients and carers told us that staff treated them well and were invested in the welfare of the patients.

Staff and patients were kept safe and were able to get help when it was needed. Clinic rooms throughout the hospital were clean and tidy with all the necessary equipment. Equipment was well maintained and calibrated. Staffing levels throughout the hospitals were appropriate to the needs of the patients. Managers were able to increase the numbers of staff on the wards if needed. There was a good range of disciplines, knowledge and skills to care for the patients.
Patient risks were identified on admission and updated as needed. Management of risks was dealt with in a way that was individual and least restrictive. Incidents were reported quickly and clearly and were discussed in both the daily multi-disciplinary and hospital operational meetings.
There were a range of care and treatment interventions that were suitable for the patient groups. Multi-disciplinary working was planned and well structured with a clear and collaborative approach to patient care.
Staff completed mandatory training in both the Mental Health Act and Mental Capacity Act. The on-site Mental Health Act administrator demonstrated a clear knowledge of the Act and of patients who were detained under the Mental Health Act. Both the Mental Health Act administrator and other staff working in the hospital reported close working relationships.
Staff supported patients to understand and manage their care, spending time talking to them about their individual needs. Cultural, religious and social needs were discussed on admission and documented in care records. Patients were encouraged to download an application for their mobile telephones which could help them deal with situations they might find challenging. Staff involved patients in their care. Patients were able to attend meetings about their care and if they were not able to attend, could submit questions for staff to respond to. Patients were involved in the formulation of care plans and staff noted records to show which patients had accepted or refused copies of care plans. Staff donated items to ensure patients on the acute ward were provided with a bag of essential personal items on admission.
In the last 12 months, there had been no delayed discharges from the services. Staff planned for patient discharges and established relationships with external stakeholders to ensure patients were appropriately supported. Discharge planning throughout the service helped to ensure patients had a positive experience when leaving the hospital.
Patients were given information on how to make a complaint. There was information on display throughout the hospital on how to make a complaint and how to contact the Care Quality Commission. Staff and patients received feedback on complaints and investigations. Lessons learned were feedback and action points developed which were acted on as a result of these.
The provider had an online career pathway which provided staff with information on career progression and the knowledge and experience required to attain the role. Advertised posts were open to all staff with the right level of knowledge and experience. The provider had ring-fenced upcoming roles within the service to allow existing staff progression opportunities.
There was a clear framework of what was to be discussed during meetings. The hospital director was aware of all the meetings that took place in the hospital and reviewed the minutes of all meetings. Information was shared to teams in the hospital and where appropriate nationally throughout the organisation.
Staff used quality improvement methods and knew how to apply them. The service identified a number of innovative practices to drive quality improvement. This included defensible documentation training which gave staff the knowledge and tools to write clear and concise care notes, using the most appropriate language in line with professional standards, completion of the reducing restrictive practice self-assessment tool and implementation of the local steering group.

We rated the Priory Hospital, Middleton St George as good because:

Following our last inspection in October 2015, the provider was required to make improvements in relation to three regulatory breaches. The breaches related to concerns about staffing levels and how the provider met the requirements of the Mental Health Act code of practice. The report about this inspection was published in March 2016. We carried out a focused inspection within six months of the published report and found the provider had made improvements to the service. We have re-rated the safe and effective domains from requires improvement to good.
The provider was taking proactive steps to address their recruitment and retention issues and had improved vacancy rates for both qualified nurses and health care assistants.
Managers ensured that staffing levels and skill mix were in line with the providers staffing level tool. Ward managers adjusted staffing levels based on patient need. Managers used regular bank and agency staff where possible to maintain continuity of care.
When patients were detained under the Mental Health Act staff explained their rights under section 132 and at appropriate intervals. Staff referred patients who lacked capacity to the independent mental health advocacy service. Patients’ views regarding section 17 leave were recorded. Staff offered patients a copy of their section 17 leave form.
The provider was complying with the guiding principles of the Mental Health Act code of practice.

However:

During the inspection two members of staff and three patients made us aware that some agency staff did not have good English Language skills. This made interaction and communication difficult.
During the inspection we heard concerns about handovers between shifts and agency staff not always being aware of patients’ risks.

We rated The Priory Hospital, Middleton St George as requires improvement because:

The hospital had experienced difficulties in the recruitment and retention of qualified nurses. It filled gaps in staffing with bank and agency nurses or staff working overtime. It could not always secure extra nurses which meant some shifts did not always have the correct number of nurses on duty.
A patient had been secluded in his bedroom for a lengthy period.The records of this seclusion were missing at the time of our visit so we could not review these, but we were concerned whether this was the most appropriate or safe management of the situation.
Patient risk assessments on Thoburn ward did not always fully document historical risk.
Staff did not always explain patients’ rights under the Mental Health Act to patients at appropriate times on Thoburn ward.
Care plans on Thoburn ward did not all include the patients’ views and did not identify strengths and goals.
Staff did not always clearly record patients Section 17 pre-leave risk assessment in the care records.

However:

Systems were in place to monitor and manage patient risk. Staff carried out comprehensive risk assessments in a timely manner and regularly reviewed these.
Assessments of ligature risks (a ligature risk is a place where a patient intent on self-harm might tie something to strangle themselves) were in place, along with policies to support the management of these risks.
The hospital had made safeguarding an integral part of its routine. Staff were aware of their responsibilities to report and raise any incidents and safeguarding issues.
Staff had received mandatory training.
Managers assessed and reviewed staffing levels to keep patients safe.
Feedback from patients and carers was positive. We observed staff treating patients in a respectful manner, and with a caring and compassionate approach. Most patients were involved in their own care planning. Managers evaluated feedback from patients to improve patient care and treatment at the hospital.
Senior managers were visible and actively involved staff in the vision and values of the organisation. Staff felt supported and consulted about their roles.
There were good governance structures with individualised and group audits in place to support and deliver safe care and to monitor the performance of the hospital.

Patients told us that the food quality and choice had 'improved massively' since our last visit to the service in October. Every patient we spoke with told us that the food and access to food had got better.

We saw menus available on the wards with choices for each day and patients told us if something wasn't on the menu that you could request an alternative and it would be sent over from the kitchens.

We saw for patients who had specific nutritional needs that this was recorded in their plan of care and patients' nutritional intake and weights were recorded in a consistent format. We saw appropriate referrals had been made to dieticians were required.

There was plenty of fresh fruit available and kitchens on the three wards we visited were well stocked with food and snacks that were appropriately stored.

At the time of this visit the hospital was going through significant changes which included upgrades to the premises and improved clinical support for the patients. As a result of these planned changes, some wards were closed for refurbishment.

We visited the four wards that were in use at this time. These were Oak (a locked rehabilitation unit for female patients) Hazelwood (a locked rehabilitation unit for female patients with personality disorder), Linden (a locked rehabilitation unit for male patients) and Thorburn ward (acute emergency unit for female and male patients). We spoke with 29 patients, two relatives and a range of management, clinical, nursing and support staff.

Patients and staff told us there were more psychology staff based at the hospital who provided improved therapies for them. There were more opportunities for people to engage in activities. People commented 'staff are very supportive' and 'the service is brilliant'. One person told us, 'Staff have helped me gain my confidence.'

People also had support to go out, but this was dependent on how the wards were staffed, so people on one ward felt they did not often get the chance to go out compared to the other three wards.

People's comments were mainly critical about the quality and quantity of food. They described the food as 'never hot', 'disgusting', 'always bread' and 'not enough food, I'm always hungry'. The care of one person who needed support with their nutritional well-being was inadequate which had placed their health at risk. The provider was already aware of the issues around catering and was drawing up an action plan to address these.

All areas of the premises that had required improvement at our previous inspection had been addressed. All wards had been redecorated so were much brighter and better furnished. Patients on each of the four wards made positive comments about the accommodation. For example, several patients described their room as 'nice' and many patients commented on the 'clean' environment.

The provider had effective ways of checking the safety and quality of the service it provided. We saw that records were accurate, up to date and securely stored.

We carried out this follow up visit to check whether the Priory Hospital had taken action to make sure it was compliant with a Warning Notice we had issued in January 2013 about the recruitment of suitable staff. We talked with human resources staff and looked at personnel records. We saw the hospital had improved the systems for checking the suitability of applicants before they were employed at the hospital.

We also checked whether the Priory Hospital had taken action to make sure it met two compliance actions we made in December 2012 about staff support and accuracy of records.

We visited each of the five units that were in use. We talked to some staff on each unit about their opportunities for training and for supervision sessions with their line manager. Staff told us this had improved and we saw evidence of this in supervision records.

We looked at care records in each of the five units. We saw some new care records were being introduced and some patients were involved in setting their own care goals and risk assessments. We saw care records were being audited to check whether they were accurate and complete.

We also talked to several people who were staying at the hospital but their comments did not relate to the standards we were inspecting on this day.

We carried out this responsive inspection to look at the recruitment and selection of staff who worked at Priory Hospital Middleton St George. The reason for our visit was because we had received concerning information about the recruitment of a care staff member who may not have been suitable to work with vulnerable adults.

We looked at the personnel files for seven members of care and nursing staff. We looked at the recruitment and selection checks of those staff. We spoke with human resources staff at the hospital.

We found there were gaps in the recruitment processes. We found the provider did not always check people's conduct in a previous employment in services relating to children or vulnerable adults before employing them. This meant the provider could not fully demonstrate that some staff were suitable to work in an environment where they had direct contact with vulnerable people.

During this inspection we visited three of the six units at the hospital. These were Hazelwood (a medium secure unit for female patients with borderline personality disorder), Rosewood (a low secure unit for female patients with borderline personality disorder) and Thorburn ward (acute emergency units for female and male patients). We also arranged to carry out this visit at the same time as a mental health act commissioner who visited Linden unit (a low secure unit for male patients).

People told us they felt they were given information about the service and their rights. We saw that people had opportunities to be involved in planning a 'structured day' on each unit. This included morning meetings for the patients to discuss as a group the activities for the day.

People told us they were involved in their care planning meetings. People told us they felt 'safe' and 'supported' by staff.

Some areas of the premises were not well maintained. Although there were plans to address improvements there was no planned timetable of when and how this would be carried out.

There had been gaps in the management of some units. This had led to inconsistent standards of supervision and support for staff across the different units. There were also inconsistencies in the standard of care records.

The provider had systems to check the quality of the service and this had identified a number of areas for improvement that were to be addressed.

We visited one unit at the Priory Hospital to check whether improvements had been made to the two compliance actions and two improvement actions we made in November 2011.

We spent time talking with people and the staff to get their views about whether the service had improved since our last visit.

The people we spoke with were very positive about the change to the model of care provided. The service was now delivering care under the 'star recovery' model instead of the previous 'stages' model. One person told us, 'The star recovery model is great because you can see how far you have progressed.'

One person said, 'I write my own risk assessments and care plans and that's good because I have started to recognise when my own mental health is not so good.'

Another person commented, 'I like being so involved in my care, I write a journal every day about how I feel and I talk through it with the psychiatrist at the ward round. It helps me understand my thoughts and feelings.'

People were positive about the staff on the ward. They said, 'I can talk to anyone if I'm worried' and 'I do have my favourite staff but I think everyone has people they get on better with.'

We saw from records people were supported by staff to go out much more than previously. One person we spoke with said, 'I go out of the ward a lot more than I used to.' Two people said their leave did not always happen. They felt this was because staff were busy because of other patients' behaviour on the ward.

One person said they had found the change in care model more difficult as they felt that some patients got more of the staff time if their behaviour was poor.

On one unit people told us that they were fully consulted every month about being a detained patient. They told us that their rights were fully explained and that they understood these.

One person commented, 'Staff go through my rights every month and I sign them.'

People told us, 'We have morning meetings every day. We have asked for the kitchen staff to come over to talk about the meals.'

People we talked with told us that they had been involved in their review meetings.

But they also commented on the restrictions. People told us:

'Bedrooms are locked during the day.'

'Starting from tonight we have to go to bed at 11.00pm.'

'You get more privileges in prison. It's supposed to be homely but they enforce too many rules.'

The people we spoke with on Linden unit were all were very positive about the care, treatment and support they received. One person said, 'They look after me alright.' Another person said, 'It's very good here, I am well looked after.'

On Thoburn unit people felt that the care was 'ok' and that there was 'enough to do'.

On Jasmine unit there was a different treatment programme (called 'stages process'). People did not feel that this type of treatment supported them to get better. One person said, 'I don't agree with the stages. I have been in loads of hospitals and they don't have stages. I have self harmed here because I feel like I have failed'.

Other people said, 'If I don't do activities during the day I might lose my stages' and 'There are not enough activities for the young ones.'

On two of the three wards we visited people said that they generally felt 'safe'.

One person said he felt nervous being alone in areas where staff were not around. He said that he had never been verbally or physically abused by other patients, but he felt vulnerable at times.

On one ward people commented: 'Staff take you to seclusion to calm you down. Sometimes you are asked to walk in and staff shut the door but they don't lock it.'

'I feel safe sometimes. Staff sometimes help. Sometimes I'm led into seclusion, sometimes I'm asked to go in.'

One person said, 'I don't feel safe because of the young ones.'

One person said, 'I would feel able to talk to (the manager of the ward) if I had to make complaints about the staff attitude.'

On Linden unit people said, 'I think there are enough staff around most of the time'.

People on the Jasmine unit felt that there were not enough staff and that this affected their daily living choices. One person told us, 'Our bedtime has had to be changed from 1.00am to 11.00pm as staff aren't getting home until late.'

One person said, 'I don't feel I get enough support because staff are often restraining other people or observing them in the seclusion room.'

Another person said, 'There are not enough staff. Sometime I don't feel safe.'

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.

The Priory Hospital Middleton St George

All Inspections

11-13 December 2023

During a routine inspection

18-20 May 2021

During a routine inspection

20 and 21 September 2020

During an inspection looking at part of the service

10 - 11 September 2019

During a routine inspection

19-21 September 2018

During a routine inspection

7 and 13 September 2016

During an inspection looking at part of the service

19, 20, 21 October 2015

During a routine inspection

24 February 2014

During an inspection looking at part of the service

29, 30 October 2013

During a routine inspection

28 February and 4 March 2013

During an inspection looking at part of the service

14 January 2013

During an inspection in response to concerns

3, 4 December 2012

During a routine inspection

1 June 2012

During an inspection looking at part of the service

11 November 2011

During a routine inspection

Mental Health Act Commissioner reports