- Independent mental health service
Priory Hospital East Midlands
Report from 16 September 2024 assessment
Contents
On this page
- Overview
- Shared direction and culture
- Capable, compassionate and inclusive leaders
- Freedom to speak up
- Workforce equality, diversity and inclusion
- Governance, management and sustainability
- Partnerships and communities
- Learning, improvement and innovation
Well-led
Managers implemented action plans, strategies and processes which had worked well and improved the overall governance of the service. They had recognised where improvements had been required from the last inspection and put appropriate actions and support in place. The service now had a stable management structure in place. Governance and auditing processes were now embedded. Staff were encouraged and supported to develop. Managers gathered staff views on improvement and service feedback through colleague surveys and through regular staff supervision.
This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.
Staff told us that since our last inspection communication from management had improved. The values of the organisation were around the hospital, on the computers and in offices. Staff told us they attended regular team meetings where information was shared. Management and staff confirmed that the process of the new ward design, name and staffing had been a collaborative approach where staff had been able to have input.
The service had implemented a “Tuesday read” document, which was used as a way to disseminate information to the team. Staff received these via email and they were displayed on staff notice boards. Managers used supervisions as another opportunity to discuss culture and shared direction. At the recent colleague engagement survey ‘purpose and value’ was scored at 82% which was an increase of 27% from last year.
Capable, compassionate and inclusive leaders
Management told us that they had worked very hard over the past 12 months to make sure they had presence on the wards. They meet ward staff whilst on their site induction and attended nurses huddles so that nurses knew they were supportive. Management had recently completed a talent mapping for the whole of the management and staff team to support progression.
The service colleague engagement survey 2024 showed an increase in positive responses from last years in many areas. Management told us that Priory Hospital East Midlands had the highest engagement in all the Priory Hospitals regionally. Within the survey staff are asked if the leaders demonstrated the provider values which was scored 78% which was a 28% increase from last year.
Freedom to speak up
Staff knew about how to speak up. However, they did feel that certain staff would be heard over others. From speaking to staff there was a sense of ‘us and them’ culture with some staff streams. There was also a sense of some bias towards the bank and agency staff from ethnic minorities, where staff told us that they would be treated differently due them not being regular. When this was asked to management, they were aware that there were some individuals that do this and they were doing a wider piece around culture. Staff we spoke to were unable to give exact examples and name the patients they were discussing. Management told us they give staff plenty of opportunities to speak up about any issues or suggest any changes to improve the working environment and the experience for patients. Staff and management told us about the employee of the month, wellbeing forum and groups and you say groups.
Freedom to speak up champions were in place with posters and information was displayed around all staff areas. Supervisions happened and we saw the frequency and quality of these was audited.
Workforce equality, diversity and inclusion
Management told us they are conducting a piece of work to support their staff from ethnic minority colleagues that come from out of area and country to understand the local area so they can engage patients with conservations. Management is made of a diverse range of individuals, and this is celebrated throughout the staff team. On the latest colleague engagement survey diversity and inclusion was scored at 79% which is an increase of 18% from last year.
Managers had processes in place to gather staff feedback including colleague surveys and regular staff supervisions. The service had recently implemented workforce development planning to support staff.
Governance, management and sustainability
Leaders told us that they had implemented new systems over the past 12 months that were now embedded and reflected on how the changes had had a positive impact on the service. They told us about the recent staff survey and how they had feedback from staff to say that the staff recognised the strength in the current management of the service.
Results from the recent colleague engagement survey showed how staff see the management with an improvement rate from last year. The management team had remained the stable for over 18 months giving consistency to staff. Although governance processes had not changed since the last inspection, these are now embedded in the service. Governance was a priority to the continued improvement of the service. Management had been able to secure contracts with the local NHS trust who commission over 70% of the beds in the hospital. This was previously removed due to concerns regarding the quality of care being provided. This showed how stable the governance and management were. During our previous inspection we found the new management team had placed new systems in place, including new auditing procedures and new engagement procedures. These were not fully embedded at that time, but these were now embedded and were working well.
Partnerships and communities
We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.
Learning, improvement and innovation
Management had established new systems in how leaders audited the care provided. They told us how this has been implemented and was now established within the service. They recognised that a change was needed and how there has been a positive impact on how these auditing systems had helped improve the service.
Managers and nurses now completed a new care auditing tool called “confirmation of care” to ensure areas of improvement and learning were identified. This tool enabled a rolling program of auditing patient documents and legal framework documentation allowed any gaps to be identified in a timely manner and appropriate actions to be taken.