Priory Hospital Norwich

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service supported patients to be safe from abuse and neglect. People were always safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination, and their liberty was protected where this was in their best interests and in line with legislation. Patient’s care records and risk management plans were person-centred, proportionate and staff reviewed these regularly, including after any incidents. The provider ensured there were adequate and competent numbers of staff to support patients. The provider used appropriate recruitment procedures to employ suitable staff. Staff completed induction and mandatory training was comprehensive and met the needs of patients and staff.

Safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Where people raised concerns about safety, or ideas to improve it, the primary response was continuous learning and improvement. There was strong awareness of the areas of practice with the greatest safety risks, and solutions were developed collaboratively. Services were planned and organised with people and communities in a way that improved their safety across their care journeys. Patients were supported to make choices that balanced risks of harm with positive choices about their lives. Leaders ensured there were enough skilled people to deliver safe care that promotes choice, control and individual wellbeing.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients and carers understood how to lodge complaints. The provider investigated complaints and incidents, identifying trends, sharing feedback, and implementing improvements.

Patients, families, and carers felt comfortable raising concerns directly with hospital staff and the director. Most patients who filed complaints received responses, though many were unaware of a formal complaint process.

Patients expressed high satisfaction with the service. They noted that ward notice boards provided information on the safeguarding lead, advocacy services, and how to raise concerns with the Care Quality Commission (CQC).

Staff reported that incidents were investigated, and the resulting lessons were shared across teams. Staff were clear on their safeguarding responsibilities for patients.

The provider promoted an open culture, allowing patients, carers, and staff to raise concerns without fear. Staff felt supported to speak up and were confident they would be treated with compassion and understanding. They were knowledgeable about identifying, documenting, and reporting incidents, including near misses, as per policy. Staff were familiar with the whistleblowing policy, the Freedom to Speak Up, and the role of Speak Up Guardians.

Staff understood the duty of candour, staying open with patients and families when issues arose.

The provider had established effective processes and policies that encouraged a positive learning environment. The safeguarding team and managers regularly reviewed incidents, identified actions, and conducted thorough investigations involving patients and their families. Evidence of improvement and change was seen, such as an incident leading to the introduction of in-and-out boards in ward offices to monitor patient activity more effectively. This included a signing-in book with details on patients who are offsite, their risk assessments, descriptions, return times, and mobile numbers

Patients, carers, and families reported understanding discharge plans, though barriers often hindered timely departures from the service. Patients received dedicated time with their nurse or keyworker, fostering continuity of care.

Staff reported effective communication with internal and external colleagues, including GPs and dentists, enhancing patient care. Weekly ward rounds included the multi-disciplinary team, with external advocates invited if requested by the patient.

Leaders highlighted discharge challenges, noting delays often stemmed from coordinating with community mental health teams (CMHTs) in diverse locations and identifying appropriate contacts. Such barriers were regularly reviewed in clinical governance meetings. Delays also arose when finding suitable community mental health support and obtaining GPs’ agreement on shared care.

The hospital served a wide geographic area, including England, the broader UK, and Ireland. Staff screened referrals carefully to ensure the service aligned with each patient’s needs.

The service lacked a psychiatric intensive care unit (PICU) for complex cases, though leaders aimed to establish one. Physical health concerns after hours required patient transport to the nearest hospital's accident and emergency department, as local general practice was distant.

Staff routinely updated risk assessments to reflect evolving needs. Exclusion criteria prevented admission for patients with risks of violence, eating disorders, alcohol detox needs, or specific disabilities.

Patients told us they knew how to reach out to staff if they had any concerns. All patients we spoke to said they felt safe on the ward. Family and carers we spoke to told us that they feel safe when visiting their loved ones in the hospital. They told us that they do not have safety concerns where their loved ones were in the service.

Leaders told us that they have safeguarding meetings. Staff told us that they are trained and knew how to report concerns and raise a safeguarding alert.

We found safeguarding information in the staffing offices on each ward. The service had a separate visiting area for family visiting with children located outside of the ward

Staff reported incidents on an electronic system, which monitored any safeguarding alerts. All staff had completed safeguarding adults and safeguarding children’s training and had access to the service safeguarding policy. Patients' care plans had a section on keeping safe, including a patient’s history section informing staff of how to support them. Staff had a good relationship with the local safeguarding team.

Patients reported being aware of their personal risks, which were discussed during ward rounds.

The management team regularly reviewed safeguarding concerns, discussing these in daily staff and monthly management meetings. Staff confirmed patient involvement in these discussions in ward round. All staff were knowledgeable about observation protocols. Staff demonstrated strong risk management skills and understanding of reducing restrictive interventions.

The service had effective systems, processes, and practices to protect people from abuse and neglect. The provider maintained good oversight of safeguarding issues.

In the nursing offices, an "in and out" log helped staff track patients on leave, noting their mood, clothing, return time, and mobile numbers. We observed that patients occasionally took items like lighters off-site, with the expectation they would return them afterwards. Checks showed logs were correctly completed, matching visual boards.

On all wards, restricted items were securely stored, with a designated security staff member performing daily checks.

Observations were recorded per the organisation’s policies, with records reviewed for accuracy.

During our inspection, we reviewed five patient care records. Care plans were person-centred, offering guidance for supporting patients as they preferred. Risk assessments were individualised, completed upon admission, and reviewed after incidents. We reviewed Section 17 leave forms and saw that a five-point risk assessment was conducted before each patient left the ward. Staff adhered to procedures and policies to minimise risks, conducting searches when necessary to maintain safety.

Patients and carers felt the environment was safe, clean, and comfortable. While the furniture and beds were generally comfortable, some patients found the plastic covers on pillows and duvets made them too warm. Family members appreciated the facility’s design and maintenance.

Staff ensured that general cleaning records were current and that the premises were kept clean.

The ward design, layout, and furnishings were tailored to meet patient needs, with well-maintained facilities, equipment, and technology supporting safe and effective care. Staff consistently upheld patient privacy and dignity.

During the assessment, we toured 3 acute wards, all of which were clean, well-maintained, and appropriately furnished. However, Redwood Ward lacked natural light. All wards featured open-access gardens, though staff supervision was required for high-risk patients.

The ward areas, including clinic rooms, were clean, confirmed by both patients and staff. We saw two cleaners on site and noted that recently cut grass in the gardens created a cared-for appearance, though weeds gave parts of the garden an unkempt look. Seating in the garden included chairs and benches.

Staff could not observe all areas directly, so fitted mirrors were used in communal spaces to enhance monitoring and ensure patient safety. The ward met mixed-sex guidance standards and had no mixed-sex accommodations. Staff were aware of potential ligature points and took measures to reduce risks. Observation boards were clear, indicating each patient's observation level. Safe systems were in place, and areas with safety concerns are kept locked with supervised access. Activity rooms and gardens were consistently accessible to patients unless specific clinical risk identified.

A local risk register was maintained to mitigate risks such as IT failures, environmental incidents, communicable disease outbreaks, e-cigarette fires, and power outages. Restricted patient items were stored in a locked cupboard in the laundry area, and one staff member was responsible for ensuring items were returned by shift’s end.

Enhanced observation policies were in place, with clear records of patient leave and return, including descriptions and contact information. Patient logs and visual boards were consistently accurate, ensuring effective monitoring and safe care.

Patients told us that staff are professional, caring and supportive, and they feel comfortable approaching them with any concerns.

Carers and families told us the standard of care for their loved ones at the service was very high, and the staff kept their loved ones safe.

Staff told us they felt comfortable in challenging poor practice. Leaders told us that the agency usage had dropped significantly which enabled continuity and consistency for patients.

Leaders had recruited enough staff for the ward. However, there was a vacant post for an occupational therapist. Leaders told us post inspection they have appointed a senior occupational therapist and the role commenced on 16th September 2024.

We saw that on each ward there was enough staff to fulfil the needs of the patients. We observed the ward managers on both wards making sure that the night shifts were also fulfilled.

Staffing levels and skill mix were appropriate to ensure patients received consistently safe, high-quality care that met their needs. There was low use of bank and agency staff.

Patients told us the hospital and the ward environments were clean and met their needs.

At the last inspection in 2021, there were concerns around the provision of clear masks for deaf patients. The 2021 inspection was during the pandemic where masks were required to be worn on the wards.

At this onsite inspection, staff and leaders told us they have these masks although it is no longer a requirement for these masks to be worn onsite. Staff felt PPE was available if needed.

Staff ensured that general cleaning records were current and that the premises were kept clean.

We found the wards to be clean and tidy. We saw the cleaning staff actively maintaining the cleanliness of the hospital. All wards were well equipped, maintained, well-furnished and fit for purpose.

We saw the cleaning staff actively maintaining the cleanliness of the hospital.

Cleaning checklists were in place to ensure all areas were cleaned. Ward level environmental risk assessments were conducted and in place for each ward. These were updated and reviewed regularly. The service had a site lead for IPC and an audit programme in place. Themes were highlighted from regular audits and discussed at daily risk meetings and clinical governance meetings. The service had quarterly health and safety meetings.

Patients we spoke with told us that they did not have any concerns regarding their medication. This is an improvement since the last inspection in 2021 where there were concerns around safe prescribing, administering, recording and storing of medicines.

At this onsite assessment we found staff followed systems and processes when safely prescribing, administering, recording and storing medicines. Managers reviewed pharmacy audits monthly, and the pharmacy team were part of the monthly clinical governance meetings.

We reviewed the 3 clinic rooms at the service and found them to be clean and tidy.

We reviewed 5 patient care records and 9 medicine charts and found no concerns with prescribing, administering, recording and storing medicines. Staff reviewed the effects of each patient’s medicine on their physical health according to NICE (National Institute of Clinical Excellence) guidance including monitoring of blood tests and regular checking of their vital observations. The provider had safe systems and processes in place to prescribe and administer medicines safely, all equipment to support treatment were well maintained, calibrated, and stored in a clinical bag and clinical room.

Staff stored medicines and prescribing documents in line with the provider’s policy