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

Priory Hospital Suttons Manor

Overall: Good read more about inspection ratings

London Road, Stapleford Tawney, Romford, Essex, RM4 1BF (01708) 687398

Provided and run by:
Partnerships in Care Limited

All Inspections

31 October 2023 and 1st November 2023

During a routine inspection

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 comprehensive assessments. They provided a range of treatments suitable to the needs of the patients in line with national guidance about best practice. Staff engaged in clinical audits 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 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 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.
  • Staff planned and managed discharge well and consulted with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • Leaders had the skills, knowledge, and experience to perform their roles. The hospital director, the clinical director and the ward managers worked well together to meet the needs of the patients and support their staff. Leaders were accessible, approachable and were spoken highly of by staff and patients.
  • The service was well led, and the governance processes ensured that ward procedures ran smoothly.

19 March, 25 March and 8 April 2019

During a routine inspection

We rated Suttons Manor as good because:

  • Staff protected patients from avoidable harm and abuse, through defined systems, training and processes. Staff took a proactive approach to reporting safeguarding concerns and the designated safeguarding officer wrote detailed and person-centred investigation reports. Staff showed openness and transparency when things went wrong.
  • Senior management shared lessons learned with all staff through bulletins, emails and ‘learning from experience’ monthly meetings.
  • Managers planned staffing in advance to ensure safe staffing as per the needs of the patients. The provider used bank and agency staff familiar with the service to fill all shifts and both bank and agency staff received the same induction and training as regular staff.
  • Staff completed comprehensive needs assessments. Staff assessed, monitored and reviewed risks to patients regularly. Staff completed detailed risk assessments and included positive behaviour support plans for each patient to manage risk in the least restrictive way.
  • The provider reported all low-level incidents and had a low seclusion rate, with only one seclusion taking place in the between December 2018-March 2019. Staff managed incidents well and in the least restrictive way by using de-escalation techniques which resulted in a low number of incidents resulting in harm.
  • Patients found staff to be compassionate and caring. Patients felt able to raise concerns and enjoyed the opportunities available to them such as; recovery college, first aid, metal detecting courses and real work opportunities ranging from shop assistant work to photography. Managers considered patient needs when planning and designing services which included a horticulture project which allowed them to grow and sell their own vegetables.

However:

  • The décor in some areas was in a poor state of repair. Floors were sticky and walls had peeling paint and some bedroom doors had viewing panels that other patients could open.
  • Staff did not always act on patient complaints and concerns raised in community meetings. We saw evidence of patients raising concerns around the bad smell within the hospital which had not been actioned during our inspection. Patients also asked for kitchen staff to attend meetings, but this had not been actioned either
  • The provider supplied data which reported 82% staff compliance with supervision, however the quality of supervision records was poor. Supervisees had not signed 44 out of 48 supervision records. Supervision templates did not provide a standard agenda of topics to discuss and records were therefore inconsistent in the detail they provided.

09 January 2018

During a routine inspection

We rated Suttons Manor as good because:

  • Wards had sufficient numbers of nurses on all shifts. We reviewed the duty rotas for the previous six weeks. These showed that the provider was meeting staffing establishment numbers. Staff had received up-to-date mandatory training. The current mandatory training compliance rate for the service was 80%. The provider had a mandatory training action plan to improve mandatory training to meet the provider’s target of 95%. Staff received supervision and an annual appraisal in line with the provider’s policy. We reviewed the supervision and appraisal records and found that staff compliance was 100%.
  • Staff knew how to use the whistleblowing policy. Staff we spoke to told us that they would feel confident in raising concerns without fear of victimisation. Staff told us they felt that managers would deal with concerns appropriately. Staff are open and transparent and explained to patients when things went wrong. We reviewed the incident reports the saw evidence within care records that staff had discussed with patients when things went wrong.
  • Patients received a comprehensive and timely assessment of their needs. Staff used the information gathered during this assessment period to formulate care plans. Patients had good access to physical healthcare. The provider employed a physical health care nurse who worked at the service three times a week. The provider also had a GP who visited the service once a week. Patients’ were involved in the planning of their care. Care plans had a section where patients could comment. Patients attended care review meetings where they could discuss their care plan and any changes they felt needed to be made. Families and carers were involved in patient care. The provider offered family and carers one-to-one sessions and they also invited them to patients’ care reviews.
  • Patients knew how to complain. Staff provided patients with information on how to make complaints within the admission pack. Staff knew how to handle complaints appropriately. Staff we spoke to were able to explain what action they would take if a patient made a formal complaint to them.
  • The food was of good quality. All the food was prepared on site each day. Patients we spoke to told us that the food was excellent and there was always a choice if patients did not like what was on the daily menu.

However:

  • There were ligature points throughout the wards, including the bedrooms and the bathrooms. The provider had completed a ligature audit and risk assessment. However, this did not include all ligature anchor points and the actions staff would take to mitigate each risk.
  • Staff did not always update risk assessments following incidents. Staff did not always document all identified risks within the risk assessments such as when patients were subject to multiagency public protection arrangements. Staff did not complete seclusion documentation appropriately. Staff had not documented 15 minute checks on a patient in seclusion.

21-22 April 2016

During a routine inspection

We rated Suttons Manor overall as ‘good’ because:

  • Ward environments were clean, safe, and welcoming.
  • The use of restraint was low because staff had the skills to support and de-escalate potential aggressive situations. The seclusion room was spacious and well-equipped. There were observation windows that staff closed to support patient’s privacy and dignity.
  • The provider staffed the wards appropriately and managers were able to increase staffing numbers based on patient need. 24 hour medical cover was available and the provider employed a physical health care nurse to support and monitor patients with physical health conditions.
  • The organisation learnt from incidents. Staff reported incidents and managers investigated thoroughly. Managers communicated lessons learnt to all staff and the wider organisation.
  • Patients had access to psychological therapies and treatments in line with NICE guidelines. The provider used National Institute of Clinical Excellence (NICE) guidelines in prescribing and monitoring the use of medications.
  • Ranges of staff disciplines were available to work with patients to achieve their mental and physical care outcomes. Staff had regular team meetings to share information about how to support individual patients and discuss any issues that they had found.
  • Staff were kind and respectful to patients and always took into account their personal, cultural and religious needs.
  • Managers supervised staff regularly to ensure that they were up to date with mandatory training.
  • The provider had a ‘ward to board’ initiative in place where staff and patients could feed back any concerns that they had. Staff knew the whistleblowing policy and told us that they felt confident that senior staff would manage their concerns appropriately in a sensitive and robust way without fear of victimisation.

However,

  • There were blind spots in the bedroom corridors of the ward. Staff had used mirrors to reduce the risk. However staff would still find it difficult to see all these areas. Staff supervised patients when in the bedroom area to reduce any risks.

10 January 2014

During a routine inspection

When we inspected Suttons Manor on 10 January 2014 we found that people were asked for their consent and the provider acted in accordance with their wishes. One person spoke about their medicines and said, "I told them I didn't need them anymore and so they took me off them."

We found that assessments of people's capacity to consent had been carried out and that appropriate certificates had been completed in relation to their capacity. We noted that Second Opinion Appointed Doctors (SOAD) had been used where this was necessary and in accordance with legal requirements.

People had access to an Independent Mental Health Advocate (IMHA) to help them to participate in decisions.

People's care and treatment was planned and delivered in a way that ensured their safety and welfare. We found that risk assessments were comprehensive and resulted in specific measures being put into place to manage those risks.

People told us they were involved in their assessments through meetings and one-to-one sessions. One person said, 'Sometimes you get to talk a lot. You get to give your point of view.'

We found that medicines were stored securely and safely. We also found that medicines were subject of a robust and accountable ordering, administration and auditing system.

There were enough suitably qualified staff on duty at all times to meet peoples' needs. Staff numbers and skill mix were managed using an effective rota system.

People's records were accurate and completed in detail. Particular risks were prominently displayed in people's records in order to ensure staff were alerted to those risks.

31 July 2012

During a routine inspection

We spoke with ten people as a group, and we had individual discussions with five people who use the service.

People we spoke with told us that they were able to raise any concerns with staff, or through the mental health advocate for the service. Everyone we spoke with said that they had no complaints about their treatment and their experience of the service. One person said,' This is an excellent hospital.' They also said, 'I know my care plan, know why I am here.' Another person showed in discussion that they knew they had a care plan, and they knew a lot about their medication.

Everyone we spoke with said that they felt that they received treatment and support that met their needs, and supported them with the goals of moving into the community. People told us that they were involved in decisions about their treatment, and they understood their care plans, even if they may disagree with the plan. One person said, 'They have really helped me since I have been here.' In our discussion this person was very clear on what had happened to them, why they were there and where they were going on discharge. They said that they had been fully involved in the planning meetings with community mental health services.

Everyone told us that there were a lot of activities available. One person said, 'Who said that there are no activities in this place? There are loads.' One person told us that they did not attend any groups. However we saw evidence that therapy and other activities were scheduled for this person, but they chose not to attend them. This person then told us that they did attend two therapy groups that they enjoyed.

8 December 2011

During a routine inspection

We spoke with two people who use the service. They said that there is an activity programme in place but the activities did not take place. One person said they did not feel safe and had felt threatened by some staff. The second person said he did not feel comfortable in the ward environment and that there is a bullying culture amongst service users. We were told that staff use their own mobile phones when at work and use social networking websites. One person said that they had made complaints about various matters previously but was given no feedback. The second person said he felt unhappy that he had not been able to attend an Islamic centre and was concerned that he was not fulfilling parts of his faith. They were complimentary about the service user meetings and the registered manager. Both people said that they received their Section 17 leave.

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.