At the comprehensive inspection of The Priory Hospital Bristol on the 18 – 21 April 2016 we rated the service as ‘good’ overall. During comprehensive inspections we always ask the following key questions; are services safe, effective, caring, responsive and well-led. We rated the key questions, are services effective, caring, responsive and well led as good.

However, we rated ‘safe’ as ‘requires improvement’, because of the poor management of ligature point (a ligature point is anything that a person could use to attach a cord, rope or other material for the purpose of hanging or strangulation) risks on Lower court and Upper Court wards; the fire doors on Lower Court weren’t alarmed so could be used by patients to easily abscond and there was inadequate cleaning in bathrooms and of mats used to cushion patient falls from bed in Garden View ward.

Following the inspection we served a warning notice against Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014 – safe care and treatment which required the hospital to:

• Ensure the appropriate management of ligature risks, including having adequate governance processes and systems in place that identify ligature points and risks.
• Ensure that fire doors were adequately controlled to manage patients absconding from the ward.

We also served a requirement notice that required the hospital to:

• Ensure all areas of the ward follow appropriate infection control procedures.

On the 16 May 2016 the hospital sent us an action plan that detailed how it would meet the warning notice and requirement notice. This action plan included reviewing the ligature audits of the wards to ensure that all ligature points were noted and risks mitigated. It identified the changes the hospital would make to the environment to reduce the ligature risks, and it identified that it would introduce an audit tool to look at any blind spots on the wards (places that could not easily be observed by staff where patients may harm themselves or others). The plan also included stated that the hospital would review the systems around the fire doors to ensure they opened when the fire alarm was triggered, to help reduce the risk of people who were detained under the Mental Health Act from leaving the ward without an escort. The hospital also said it would review the facilities on Garden View and make changes to allow proper cleaning.

On 4 May 2017 we undertook an unannounced, focussed inspection to check that the hospital had addressed all of the concerns identified in the warning notice and requirement notice. Since our last inspection (April 2016) we have received no information that would cause us to re-inspect other aspects of the key question, are services safe.

We found that multiple changes to the environment had been made, including the removal of ligature points and changes to reduce the likelihood of patients tying a ligature. For example, they had mitigated the risks by putting boxes around items such as extractor fans and fire alarms. The hospital had re-furbished the rooms on Upper Court to provide purpose built furniture to reduce the chance of a patient tying a ligature; it had replaced the doors of ensuite bathroom across Brunel, Redcliffe and Upper Court to reduce the risk of ligatures. In addition, bedroom doors on these wards had been replaced to ensure that patients could not barricade themselves in their room. Mirrors had also been installed to reduce blind spots (places on the ward not easily visible by staff on the ward).

The hospital had taken steps to address the poor infection control procedures on Garden view. The mats used to minimise injury to patients who were at risk of falling out of bed were clean and well maintained. Night staff had responsibility for cleaning these and the cleaning rotas recorded staff had cleaned the mats. The hoists in the communal bathroom had been repaired and the damaged area near the sink in the communal bathroom had been repaired, allowing it to be easily cleaned.

As a result of the improvements made by the hospital, we judged that it had met the requirements of both the warning notice and requirement notice. As such we lifted the warning notice and requirement notice and rated the safe as ’good’.

When we carried out a visit to the Priory Hospital Bristol during December 2011 and January 2012 we found improvements were needed. We visited the Hospital on 28 and 29 June and 9 July 2012 to see if improvements had been made in respecting and involving people with their care, welfare and safety. We also looked at how improvements had been made in offering people different activities, supporting staff with their training. and in record keeping.

We found that improvements had been made with people being listened to and involved with their care in a respectful way. People were supported more safely through improved management of risk; there was a more consistent approach in providing staff with appropriate and updated information to support people with their needs. Staff training had been updated with more staff receiving suitable training.

External managers from within the organisation had been involved in working with staff and an interim hospital director had overseen improvements. We saw that this had helped in making positive changes that impacted in the management and leadership of the wards. This had resulted in better outcomes for people using the service. A new hospital director is now in place.

We had been sent copies of a compliance monitoring visit by the Priory Group in April 2012 and a quality improvement action following our previous inspection. We saw a robust approach in the monitoring of practices in the hospital with activities undertaken to address shortfalls with compliance.

We visited the area of Lower Court ward that provides treatment for people with eating disorders, and three wards on the Grange unit, Garden View, Oaklodge and Rosewood. Both Garden View and Oaklodge wards provided treatment to people who have a mental disorder and people with degenerative disorders such as Huntington's disease and early onset dementia. Rosewood ward is a rehabilitation ward for slow stream rehabilitation and provides palliative and physical healthcare for some people.

On all the wards there may be those people using these services who may also be liable to be detained under the Mental Health Act (1983).

We spoke with a total of four people using the service. Some people told us they were well supported by staff and happy with their care and treatment; that they felt safe and that they had no complaints. Some other people told us about their future plans and that they were now able to leave the Priory.

Other people spoke to us about their concerns which included food and the medication they were given. We followed these concerns up by speaking with the ward managers and staff. We looked at records to show us how people had been supported to make decisions about their choice of food and treatment. We found staff had supported people appropriately with their care and treatment.

Some people were unable to tell us how they were cared for due to their dementia or mental health needs. For these people we carried out observations of their care and interaction with staff in the communal areas of wards.

We spoke with staff in differing roles. These included the director of the Priory Hospital, the medical director/consultant, the clinical services manager of Lower Court, and the manager of the Grange. We also spoke with four ward managers, five registered nurses, three healthcare assistants, and an occupational therapist.

We carried out visits to the Priory Hospital on 9 December 2011 and 4 and 5 January 2012. This was due to concerns raised with us on several occasions through an anonymous whistleblower alleging wards were unsafe and patients were being neglected due to short staffing.

A further whistleblower then raised a number of serious allegations using the provider’s whistleblowing procedure. This resulted in ongoing police and safeguarding investigations.

We visited all the wards at the hospital.

The three wards on the Grange unit are Garden View, Hillside and Oaklodge. They provide treatment to people who have a mental disorder and people with degenerative disorders such as Huntington's disease and early onset dementia.

Lower Court ward provides treatment for people with eating disorders, psychiatric assessment and treatment including substance abuse.

Rosewood ward is a rehabilitation ward for slow stream rehabilitation and provides palliative and physical healthcare for some people.

On all the wards there may be those people using these services who may also be liable to be detained under the Mental Health Act (1983).

During our visits we spoke with people on the majority of the wards.

Some people told us that they were independent and made their own drinks and that they were helped by staff with things like checking their bath water.

They said they went out to Bristol for a half day every week which they enjoyed and said they would like to go out more.

They told us they spent their time watching television, writing poetry and sometimes did some cookery. They also expressed their view that there was not enough occupational therapy (OT) support on the ward to help people to be involved with other activities.

Some people told us they were well supported by staff and happy with their care and treatment.

Some people were unable to tell us how they were cared for due to their dementia or mental health needs. For these people we carried out observations of their care and interaction with staff in the communal areas of wards.

We spoke to staff on the wards in differing roles. These included ward managers, registered nurses, healthcare assistants, an occupational therapist, a speech and language therapist, agency nurses and a domestic.

The provider has recently engaged external managers who have been involved in working with staff on some of the wards to assist with improving outcomes for people and the management and leadership of the wards.

We carried out a visit following some concerns that were raised by an earlier inspection by our inspectors who check that people detained under the Mental Health Act 1983 at the hospital are being cared for in accordance with the Act. Some concerns had been identified at this earlier visit and we were concerned that the provider had not responded to let us know how they intended to address the issues we had raised. This was a joint visit to the service by a Mental Health Act Commissioner, two Compliance Inspectors and a Pharmacist Inspector under the respective legislative frameworks.

The areas we visited at the Priory Hospital were Lower Court and the Grange.

Lower Court provides treatment for people with eating disorders and addiction problems.

The Grange provides treatment to people who have a mental disorder and people with degenerative disorders such as Huntington’s disease and early onset dementia. People using these services may also be liable to be detained under the Mental Health Act (1983).

We spoke with five people who told us they were happy with their care and accommodation, and that they liked the staff. We saw people had activity timetables that included activities such as walks, trips to the local hairdresser, shopping and having refreshments away from the ward. We were told people had been to the recent Bristol balloon fiesta and to Horseworld. Whilst we were carrying out our visit we saw people were involved in a cookery activity, which was supported by occupational therapists.

We saw 'patient forum’ records showing that people were involved in making choices about their meals.

We were told by people they were listened to by staff.

Some people said they did not know who to complain to and said they had not been given information about how to make a complaint.

People said that if they wanted information about their medicines they could ask their consultant or staff on the unit. This information was not always offered if they did not ask. They were happy with how they were given their medicines. They told us that they could go to the clinic room to collect their medicines at the appropriate time but, if they did not, staff would come and find them.

At the time of our visit to the Priory, we identified major concerns under Outcome 7 Safeguarding people who use services from abuse. However since our visit a meeting was held with Bristol City Council Safeguarding Lead on 12 October 2011. The Priory submitted an action plan framework setting out proposed action and we will be monitoring this.

We rated the Priory Hospital Bristol as good overall. This was the same rating as the previous inspection in April 2016. We rated the key questions, are services safe, effective, caring, responsive and well-led as good.

The reason for the rating of good overall was as follows:

• The provider managed risks well. The hospital had an up-to-date risk register that highlighted key concerns and had plans in place to manage these. Staff completed regular environmental and patient risk assessments.Managers adjusted staffing levels to meet changing needs, bringing in extra bank and agency staff who were familiar with the wards to cover any shortfall. The hospital ensured all agency and bank staff used were familiar with the wards and had access to the same induction, support and training as permanent staff.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• The provider had clear processes for monitoring and investigating incidents and complaints. The provider also undertook a variety of audits to monitor and improve the quality and safety of the service. Systems were in place to learn from these and improve practice as a result.
• Staff provided a range of care and treatment interventions suitable for patient groups in line with guidance from the National Institute for Health and Care Excellence (NICE). Robust arrangements were in place to meet patients’ physical and mental health needs.
• Staff were discreet, compassionate, respectful and responsive, providing patients with help, emotional support and advice at the time they needed it.
• The ward managers and senior leadership team provided strong and effective leadership and staff members had confidence in them. Managers within the service promoted an open and honest culture. Staff felt able to raise concerns, report incidents and make suggestions for improvements without fear of consequences. Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.
• Staff felt respected, supported and valued by senior managers and leaders. They were proud to work at the hospital and felt positive about their work and the support they gave patients. The provider recognised staff success within the service through star awards, nominated by other staff members or by patients.

However:

• On the acute wards for adults of working age, care plans were not personalised or collaborative and used generic statements for goals and interventions. Care plans and risk management plans were not updated to reflect progress or change in needs. However, on the long stay/ rehabilitation, child and adolescent mental health and eating disorders wards, patient records were person centred, detailed and up to date. They included comprehensive mental and physical health assessments, with detailed and holistic care plans that included the patients’ voice.
• The acute wards for adults of working age were not in a suitable environment for the service, as they did not have adequate space to support treatment and care. The communal room in each of the acute wards did not have anti-barricade doors and were a safety risk due to the limited space and the lack of alternative access to the rooms.
• On the child and adolescent mental health wards, multi-disciplinary working needed to improve to ensure good communication between the different staff meeting the complex needs of the young people using the service. Some staff experienced significant levels of violence and racial abuse from patients in the child and adolescent mental health service. Staff felt the aftercare and support available following these incidents could be improved.
• Staff did not always record that patients were being told of their rights under the Mental Health Act (1983). Not all informal patients were aware of their rights. Some staff were also not clear about their responsibilities under the Mental Capacity Act 2005 and did not see this as part of their role.
• On the acute wards, staff were not aware of the results of clinical audits and where improvements were needed.