The Priory Hospital Roehampton

Updated 1 June 2023

The Priory Hospital Roehampton is an independent hospital that provides support and treatment for people with mental health problems and substance misuse problems. There are seven inpatient wards at the hospital:

• Garden Wing (private acute ward for adults of working age)
• Upper court (private acute ward for adults of working age)
• West wing (private acute and addictions ward for adults of working age)
• East wing (specialist adult eating disorder ward)
• Priory court (specialist child and adolescent eating disorder ward)
• Lower court (child and adolescent mental health ward)
• Richmond court (private child and adolescent mental health ward)

This was a comprehensive and unannounced inspection of Lower Court and Richmond Court, the two child and adolescent mental health wards, and Upper Court and Garden Wing, the two acute wards for adults of working age. This included an out-of-hours unannounced inspection of Lower Court on 6 February 2023. We completed further telephone interviews with staff and families and carers following our on-site inspection. Our final telephone interview was on 14 February 2023.

We inspected these four wards due to an increase in the number of serious incidents reported to the CQC, which indicated there were risks to patient safety, and to check improvements made since our last inspection in February 2022.

The last inspection of this hospital was in February 2022, where we completed a focused inspection of Lower Court, one of the child and adolescent mental health wards, and looked at the domains safe, effective, caring, responsive and well-led. We found one breach of regulation. This was in relation to regulation 12 (safe care and treatment). The service did not ensure that persons providing care and treatment to young people had the competence, skills and experience to do so safely.

This location is registered to carry out the following regulated activities:

• Treatment of disease, disorder or injury
• Assessment or medical treatment for persons detained under the Mental Health Act 1983

There was a registered manager in post at the time of the inspection.

What people who use the service say

Feedback from young people using the service was mixed across Lower Court and Richmond Court, the two child and adolescent mental health wards. Some young people we spoke with on Lower Court said that agency staff were often rude, did not make an effort with personal pronouns, and did not listen or have regard to personal space. Patients on both wards said the permanent staff were great. Young people told us that they enjoyed their therapy sessions and that there were enough staff on the wards.

Carers feedback from Lower Court was mixed. Some said that staff did not always keep them informed about their relative’s care and treatment, and communication was inconsistent. They said some of the permanent staff were very helpful, but sometimes there were too many different agency staff. One carer told us that there had been an improvement since the Director of Clinical Service for Operations had provided specialist support to Lower Court.

Patients feedback across Garden Wing and Upper Court was mostly positive. They were mostly very complimentary about their stay in hospital and the staff team. Patients told us staff were kind, helpful and professional. Patients told us they felt safe within these wards. Patients told us staff were eager to get to know them and were helpful when needing support. However, some patients said nursing staff were often overworked, which impacted on the amount of time they got to spend with them. One patient felt staff were sometimes patronising in the way they spoke to them.

Updated 1 June 2023

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.

Updated 3 May 2019

Updated 1 June 2023

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

• We rated the service as requires improvement for safe, caring and well-led. We rated the service as good for effective and responsive.
• The service had made some changes since our last focused and unrated 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 ward.
• The child and adolescent wards were not always clean. Although the hospital kept cleaning records for the ward areas, these were not always effective 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.
• The service 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.
• We observed a poor-quality handover on Lower Court. This meant that staff may not know about risks on ward.
• 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.
• Staff did not always record details about how physical restraint had been used. On Lower Court, staff did not always complete food and fluid charts for young people who had been identified as needing them.
• Some carers we spoke with on Lower Court said that staff did not always keep them informed about their relatives’ care and treatment, and generally communication was inconsistent.
• Some patients told us that the food quality was poor which had also been an issue at the inspection in 2021. One carer told us they brought in food for their relative to ensure their dietary requirements were met. The catering manager had been invited to a community meeting on Lower Court but did not attend. The provider was due to outsource to new catering company to improve food quality.
• 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. Whilst the provider was aware of this and the associated risks the work to address this was ongoing.
• Our findings from other key questions demonstrated that governance processes did not always operate effectively on the child and adolescent mental health wards. For example, the provider’s housekeeping procedures did not ensure all ward areas were effectively cleaned and there were no systems in place to ensure patient food had not expired in patient kitchens. There were lapses in recording of restraint, and food and fluid chart documentation.

However:

• Changes had been made since our last inspection in February 2022 on Lower Court. Agency staff now had access to patient records and supervision, staff had access to regular staff meetings and debriefs following incidents, there was a clear care pathway in place to support admissions, and there were robust systems in place to learn from incidents.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment.
• The ward teams had access to the full range of specialists required to meet the needs of patients on the wards. There was good access to therapies. We received positive feedback about the therapy staff.
• Most staff treated patients with compassion and kindness We observed caring and jovial interactions between staff and patients on Lower Court and Richmond Court. The environments were calm.
• Young people were able to feedback on the service they received via ward rounds and community meetings. In these meetings, staff and patients were able to give compliments to each other in the form of ‘big ups’.
• At the last inspection in February 2022, the care pathway on Lower Court was not clear. At this inspection improvements had been made and there was a clear pathway to support patient admissions and how it was tailored to meet individual needs.
• The provider’s governance processes highlighted that the Lower Court required significant improvement and senior management put an immediate action plan in place to support the performance of the ward. However, this was in its infancy at the time of our inspection, and time was required to ensure improvements were consistently embedded.
• Staff said they felt supported by their colleagues, including senior management. They felt able to raise concerns with senior managers without fear of retribution.

Updated 30 December 2020

Updated 1 June 2023

Our rating of the acute wards for adults of working age and psychiatric intensive care units went down. We rated it as requires improvement because:

• We rated safe, effective, caring and well-led as requires improvement. We rated responsive as good.
• 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 available in areas of the ward and garden to observe and mitigate risk. Some staff were not aware of what a ligature points 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 clinic room on Upper Court was small and cluttered which might make it harder for staff to locate equipment when needed.
• 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.
• 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.
• The ward multi-disciplinary teams were not always well connected with each other although team members felt this was starting to improve.
• Staff did not always complete physical health checks. 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.
• There were food items in the fridge which had expired. There were no plans in place to manage and dispose of the food from patients who were no longer on the ward.
• There was an overly restrictive blanket restriction in regard to leave for patients on the acute wards. Patients, including informal patients, 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.
• Upper Court did not have information on advocacy services available to patients. Signs explaining informal patient rights were not visible on either ward.
• 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.
• Some staff on Garden Wing felt some staff were unprofessional. Some staff felt it was sometimes difficult to work on the ward due to the difference in cultures. 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.
• The governance processes had not identified the areas for improvement needed on the wards.

However:

• The ward environments were well equipped, well furnished and well maintained. The wards had enough nurses and doctors.
• The rooms and furnishings of the hospital supported patients’ treatment, privacy and dignity. Each patient had their own bedroom with an en-suite bathroom and could keep their personal belongings safe. There were quiet areas for privacy. Patients could make hot drinks and snacks at any time.
• Staff assessed 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.
• 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.
• 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 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.
• 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.
• Most staff felt respected, supported and valued. All staff could raise concerns without fear. However, some staff felt that issues relating to staff cultures which were causing issues in people working together were not being addressed.