The Priory Hospital Roehampton

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

The provider had adequate governance processes. Managers and leaders had access to information they required to complete their roles and had a good understanding of the service. They were visible in the service and approachable for staff and patients. The service had development opportunities for staff and staff were aware of these. The service had an incident reporting system which was not always completed properly by staff. Staff felt able to raise concerns without retribution, however, they felt they weren’t always listened to. Staff we spoke to didn’t understand the provider’s visions and values or talk about how they were applied within the service and their teams.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke to 12 staff across both wards. Staff we spoke to stated that there was a diverse culture and there was the opportunity to get involved. Most staff had no concerns about the culture on the wards. Staff felt supported by both ward managers. However, 2 staff stated that culture on the ward was a problem. For example, staff raising their concerns and not being listened to. The majority of staff stated that they felt able to share their opinions and felt respected, supported, and valued. They said the provider promoted equality and diversity in daily work and provided opportunities for development and career progression. They could raise any concerns without fear. All staff we spoke to stated that they have supervision every month both internally and externally. During these meetings they could speak openly about issues they were facing such as career progression. Staff we spoke to were aware of development opportunities within the service. Staff knew how to develop their skills and roles through training and career progression. The service offered a nursing apprenticeship programme and currently had staff members on the programme.

Teams had access to information they needed to provide safe and effective care to children and young people. The service had a quality improvement lead who visited the ward. Staff turnover across Priory healthcare was 3.6%. The turnover rate for Roehampton was 3.2% which meant the service was below average on staff turnover. Managers believed this was due to the services induction and training programme.

Feedback from staff about leadership was mixed. Some staff stated that leaders were inclusive and that they represented the culture. However, 2 staff members told us they were not consulted, and their opinion was not always counted. Staff completed a staff survey however they were not sure on how the results were used. Staff also reported that they did not feel confident in raising concerns with senior leaders directly. Managers told us staff survey results were reported on staff bulletins. Bulletins for staff were sent out monthly which included information on training, recruitment and updates about the service.

Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed and were visible in the service. Managers told us they spent time on the wards and supported staff when they were short staffed. The hospital director had ‘walk in’ meeting held weekly for staff. This meant staff did not have to arrange a time to specifically meet with senior leaders and had the opportunity to drop in to raise concerns directly with the hospital director.

Staff we spoke to stated that they felt able to raise concerns but didn’t always feel they were listened to. Staff were aware of the whistle blowing procedure and could tell us how to raise a whistleblowing if necessary.

The service displayed posters on freedom to speak up guardians. Staff we spoke to were aware of who their freedom to speak up champion for the service was.

Staff, patients and carers had access to up-to-date information about the work of the provider and the services they used, for example, through the intranet, bulletins, newsletters. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Staff reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression, for example, staff knew about the nurse career progression.

Patients and carers had opportunities to give feedback on the service they received. Patients and carers were involved in decision-making about changes to the service. For example, patients were invited to be part of the interview panel for the new Occupational Therapist. Patients and staff could meet with members of the provider’s senior leadership team and attend Clinical Governance meetings to give feedback. The provider sent out monthly bulletins which recognised individual staff members success as well as improvement and development opportunities within the service. Information about new training programmes and recruitment updates were also included in the bulletin. Managers told us they recognised individual staff success through the bulletins as well as through certificates and vouchers. The provider had a well-being programme which included all staff. The provider acknowledged and made a note of religious occasions as well as landmark days. For example, Ramadan, neurodiversity awareness, International Women’s Day, pride, international stress awareness week. Leaders maintained a well-being calendar to acknowledge occasions every month and sent out emails in relation to the topics. The provider had an appraisal programme available for all staff. At the time of our inspection the appraisal rate was 95%.

Managers told us they had access to information to support them in their role. This included information on the performance of the service, staffing and patient care. Managers had access to a range of policies and procedures as well as staff meetings, including governance meetings and multidisciplinary meetings. There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Staff concerns matched those on the risk register. Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. Staff undertook or participated in local clinical audits. The results from these audits were acted on when needed. Staff knew how to report incidents. Incidents were reported on an internal system. When an incident occurred, a 24-hour incident report would be completed and escalated to senior team. Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Referrals were made if necessary and incidents were raised to CQC. The service held regular clinical governance meetings which included discussions on incidents and learning from incidents. The service had team incident review meetings 24 – 72 hours after incidents where a senior member of staff would attend. Sick pay was discretionary and some staff told us this meant that they still reported for work when they were unwell.

Our findings from the other key questions demonstrated that governance processes operated effectively at team level and that performance and risk were managed well. The service had plans for emergencies for example, adverse weather or a flu outbreak. Where cost improvements were taking place, they did not compromise patient care. For example, the service was making improvements around the management for Lower Court and Richmond Court due to the reduced beds on Lower Court ward. The new ward structure meant there was a combined ward manager for both wards. Each ward would had a deputy manager and lead nurse with the support of charge nurses, consultants, nurses and healthcare assistants. There was 16 beds across both wards and each ward had a consultant. Staff had access to the equipment and information technology needed to do their work. The information technology worked well. We reviewed 10 incidents across both Lower Court and Richmond Court and found 4 inconsistencies around staff debriefs and updating patient risk assessments. Senior management supported staff when acuity was high on the wards and moved staff to other wards to support when wards had high acuity. Managers told us staff also had daily debriefs after each shift. The provider completed yearly ligature audits. Any issues identified were put on an action plan managed by the clinical team. Managers told us all staff received training on ligatures including example scenarios. All staff were expected to complete competencies before going on the wards.

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.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.