Priory Healthcare Quality Account

Priory Healthcare Quality Account2020-2021

| Quality Account 2020-2021 | 2

ContentsIntroduction from the Priory Group Chief Executive Officer 3

Quality statement from the Executive Lead for Quality and the Group Medical Director 5

Quality Account – COVID-19 7

Priorities for improvement 9

Our statements of assurance 17

Additional information on Quality Performance 20

Service user stories 21

Outcome measures 26

Learning from complaints and incidents 27

Regulatory compliance 31

Appendices 35


Introduction from the Priory Group Chief Executive Officer (CEO)


At the beginning of the COVID-19 pandemic, we established an Incident Control Team (ICT), led by the Group Director of Nursing. The team monitored guidance from the NHS and Public Health England (PHE), informing business continuity planning in line with our Infection Control and Pandemic policies.

Priory has remained committed to the continued delivery of effective safeguarding and protection processes. We do not believe that the pandemic allows for any deviation from the established requirements of our policies and procedures. Safeguarding children and adults at risk is ‘business as usual’ and continues to be ‘everybody’s business’.

With traditional face-to-face training largely suspended, we quickly developed bespoke materials for ‘virtual classrooms’, which ensured participatory, interactive training opportunities. A new team of dedicated internal safeguarding trainers are facilitating safeguarding training, which has resulted in an increase in safeguarding training compliance across the group to 87.6%.

Over the past year, we have rolled out a number of other initiatives, to improve the quality and safety of our services. An enhanced process was introduced for the bi-annual ‘Ligature Point and Blind Spot audit’, supporting sites to complete a robust audit, and receive appropriate training and support. Each site is also part of a buddying system to provide ‘fresh eyes’, in which a team from another site completes some of the audits.

A review of the ‘deliberate self-harm and suicide risk assessment and risk management’ system was undertaken. Improvement of the delivery of meaningful activities to meet service user needs, obtaining a clear risk profile of a suicidal service user, learnings from incidents and updating of care records were some of the findings in ensuring the effective and safe risk-management of service users with a risk of suicide.

We always focus on learning and improving in response to incidents, and have established systems to ensure a prompt and thorough response when things go wrong. As a result, we have continued to build on improvements in respect of how we equip our colleagues, to provide high quality care and treatment, also the way we assess and interact

with our service users, and enhance the safety of our environments in general.

We continue to implement our Digital Strategy, focused on new business systems, to improve service user pathways. We now have over 2,500 private service user reviews on our ‘Doctify’ review system, with average scores ranging from 4.5 to 5 out of 5. We have also launched a new automated service user registration system that can be completed online.

Following a successful pilot, we have now fully launched a new digital platform for our ‘Priory Connect’ service, enabling service users to choose their therapist and book appointments at their convenience. This service will improve the digital offering to service users wishing to receive online therapy. We have also launched ‘My Possible Self’, a cognitive behavioural therapy (CBT) based mental health app that provides support and tools for anxiety, depression, sleep disorders, stress, gambling and alcohol addiction.

Overall, we are aiming to achieve a positive, transparent and person-centred culture, ensuring dignity and respect for all service users. We want all colleagues, at all levels, to demonstrate a commitment to service users recovery, with strong site leadership and good governance. We align focus with our regulators to improve service user safety and the quality of outcomes. As a result, 84.2% of our 76 Care Quality Commission (CQC)-registered healthcare sites in England are ‘Good’ or ‘Outstanding’. This compares with other NHS mental healthcare sites (81%), and compared to the independent mental health sector as a whole (75%). However, we remain very clear that there is no room for complacency and we want to see all of our hospitals to be rated as ‘Good’ or ‘Outstanding’, and the equivalents in the other constituent parts of the UK.

We will continue to ensure all Priory employees are supported and equipped to deliver the best standard of care and treatment, demonstrating our core values every day, to our service users, their families, our partners and each other.

I am delighted to present the Priory Healthcare Quality Account for 2020/21.The past 12 months have been hugely challenging for all of those working across the healthcare sector, yet we still strived to provide the best possible support to those in our care, whilst taking the required measures to reduce the risk of transmission of COVID-19. We adapted our healthcare services, ensuring we were able to continue helping those in need, and support often vulnerable and confused individuals through a period of such uncertainty.

Trevor TorringtonPriory Group, CEOJune 2021


Our specialist inspection teams comprise health, safety, regulatory compliance experts, and experienced financial auditors.

Despite the challenges of the pandemic, we have continued to progress our quality objectives for 2020-21. This includes sexual safety, learning from deaths, suicide prevention, our Digital Strategy, Physical Health Strategy, our service user and carer Participation and Engagement Strategy, and enhancing our core meaningful week activities programme for inpatients. Progress has included the embedding of our Group-wide Suicide and Self-Harm Strategy for 2020-23, centred on service user safety planning, improved involvement and support of carers, colleagues and other service users affected by suicide, improved support and planning around transition points in a service user’s journey, and training for colleagues to allow them to better engage and support service users.

We continue to improve the full functionality of our electronic service user record system, working with our IT experts and clinical leaders to create the most effective system. Our aim is to create a system that not only provides an effective care record but one that supports the continual quality improvement and learning process, through the extraction of effective outcome data.

Following on from the publication of our Group Participation and Engagement Strategy, the Healthcare Division has set up a Participation and Engagement committee with service user and ‘experts with experience’ involvement.

Commitment to safe and effective services remains our priority and we have received some positive inspection feedback from the CQC. At the end of the accounting period between 1st April 2020 and 31st March 2021, we have had 75 inspections of which 58 were carried out remotely, given the challenges of the COVID-19 pandemic. Our current standing with CQC has 52 of our sites rated as ‘Good’ or higher and five sites rated as ‘Outstanding’ overall. Seven sites were rated as ‘Requiring Improvement’ overall and each of these sites were then required to develop a comprehensive individual improvement plan, with support and monitoring from senior management and members of the Quality team. Five sites were rated as ‘Inadequate’ overall and as a result, they are all subject to intensive improvement plans, with very close working with the CQC and local and national systems.

During the reporting period, there were no inspections of our services in Scotland and so all ratings remain in place.

Healthcare Inspectorate Wales (HIW) inspected two sites during the reporting period, with requirements noted at one site with immediate rectification undertaken.

In addition to the external inspections run by regulatory bodies, we have our own internal monitoring with the Corporate Assurance team. The aim is to continually assist and support our services on a journey of quality improvement. Our activities for this reporting period included 130 internal regulatory compliance visits, 38 fire risk assessments and 94 health and safety internal audits. These internal reviews feed into robust Quality Performance Indicator reviews, intelligence monitoring and risk profiling.

Quality statement from the Executive Lead for Quality, and the Group Medical Director

As the leading provider of behavioural care in the UK, Priory Healthcare continues to place its primary focus on delivering the highest quality service user-centred care for the people we support. This year saw the continuation of the COVID-19 pandemic and with it the resultant challenges for all healthcare providers, service users, colleagues and the wider society. This has pushed all services to think differently about how they work, about how they ensure the basics of care are embedded, and how systems operate collectively to deliver quality during challenging times. Despite these challenges, we have strived to ensure that we keep delivering high quality care, reflect on and learn from experiences, and that we rapidly respond to support services when they need the collective support of the organisation.


During the pandemic, we have conducted COVID-19 mortality reviews of all COVID-19 related service user deaths and we have reviewed all outbreaks. This body of knowledge and learning has helped ensure that we are as prepared as possible for future outbreaks and that our clinical practice is appropriate and proportionate to the services that we deliver.

Our 10 service lines have continued to evolve, keeping involved in national projects and developments. Increased use of online systems has acted as a major enabler to being more rapid and effective in linking and networking across and outside of the organisation. Each service line is now informed by their own individually tailored dashboards, allowing them to take on an increasing governance and quality improvement role.

Dr Adrian CreeGroup Medical Director

Colin QuickGroup Director of Nursing, Professional Development and Service Improvement


Quality Account: COVID-19We are satisfied that our high standards of service user care has been maintained throughout the COVID-19 pandemic.

Given the unprecedented nature of the challenges created by COVID-19, we enhanced our already robust governance structure. This structure helped ensure that the safety and wellbeing of our service users and colleagues remained the focus of all that we do.


Our COVID-19 governance structure comprised of a Gold/Silver/Bronze chain of command. This enabled us to maintain a focus on, and oversight of, the issues arising from the pandemic and the UK Government’s response to it (including responses by government agencies such as PHE, the Health and Safety Executive (HSE) and other regulatory bodies such as the Care Quality Commission (CQC)).

As part of the COVID-19 governance arrangements, sites upwardly reported any developments and concerns through the management structure, culminating in a daily ‘Gold’ call comprising all board members and heads of function (the SMT). The call served to ensure the SMT were sighted on key risks at particular hospitals and homes and provided the forum through which updates were provided on new COVID-19 guidance (or changes to existing guidance). It also provided the operational steps needed to address them including the distribution of key information to relevant colleagues.

A dedicated email helpline was also established in February 2020 ([email protected]). The email address was overseen seven days a week by our Director of Nursing, Deputy Director of Nursing and the Director of Risk Management. The email address enabled colleagues to raise queries and ask for advice on a real-time basis and proved invaluable in providing support and assurance to colleagues in a period of great uncertainty and anxiety.

Throughout the pandemic, we have followed the guidance issued by PHE, HSE, the CQC and other agencies in England, Scotland, Wales and Northern Ireland. We have assimilated the guidance into standard operating procedures (SOPs) and safety bulletins, which were circulated to colleagues by email and placed onto the Priory intranet COVID-19 ‘hub’ to facilitate access.

Additionally, we have communicated with our colleagues via platforms such as a weekly group-wide conference call where key updates and information were delivered and we invested in a COVID-19 app, which colleagues could and can load on to their mobile phones, to facilitate and expedite the communication process still further.

Our compliance teams continued to operate during the pandemic and gave us a valuable insight into the response by our hospitals and homes, to the challenges that were faced. Audit report templates were adjusted to take into account the increased focus on infection prevention and control, for example with scrutiny of handwashing arrangements and the appropriate use of personal protective equipment. Similarly, our wide-ranging training function continued to operate during the pandemic with adjustments made to help ensure that training compliance rates were maintained, despite the various restrictions that were in place.

Quality Account: COVID-19


Summary of progress against 2020-21 Quality Performance Indicators

The Quality Account published in 2020 identified seven priorities to improve the quality of our services across the three domains

of service user safety, clinical effectiveness and service user experience. The information below provides a summary of our

performance against these objectives in the last 12 months:

Priority 1

(carried forward to 2020-21)

Sexual safety: To fully implement and embed a new policy on sexual safety on our inpatient wards, in line with the CQC report published in September 2018

Rationale: People whose mental ill health is so severe that they require care on a mental health ward are often at the most vulnerable point in their lives. Many will not have consented to being treated in hospital and will have been admitted against their will. Given this, mental health services have a heightened responsibility to protect people using inpatient care, from harm

What we will focus on: We will fully implement and embed a new policy on sexual safety and ensure that all new admissions to our inpatient units have a sexual safety risk assessment

Progress in 2020-21: Sexual safety has seen the launch of an online training module for all sta� across the divisions. There has also been the launch of sexual safety cards in standard, easy-to-read formats for service users, the gathering and monitoring of sexual safety incidents data, guidance on the forming of safe sexual relationships, monitoring and management of any same sex accommodation breaches, and using our learning to inform future retooling or new service developments

Priority 2

(new for 2020-21)

Safewards: To reduce the number of incidents of violence and aggression in high acuity inpatient wards/units

Rationale: The Safewards model and associated interventions has been highly e�ective in reducing conflict and containment, and in increasing a sense of safety and mutual support for sta� and service users alike

What we will focus on: We will identify five wards/units in each of our three operational regions and undertake a baseline data collection in each unit, to capture data on the numbers of sta� assaults, violence and aggression incidents, seclusion and long-term segregation, and complaints. Units will identify ‘Safewards Champions’ and there will be a phased approach to implementing the interventions. There will be a final data collection at the end of the project, which will also include service user and sta� evaluation surveys

Progress in 2020-21: Five wards from each of the three regions in existence in September 2020, were selected to take part in the project. They had high acuity, incidents, self-harm, restrain and assaults. One service closed during this project:

— A steering group met monthly

— Unit champions were identified for each unit

— A zoom launch event was held in September 2020 with presentations from Geo� Brennan and Priory sites who had successfully implemented safe wards

— The project commenced in October 2020

— Benchmarking data collection was undertaken for each of the 14 units and monthly data collections thereafter. Data comprised ward profile, admissions and discharges, observations (special duty nursing SDN), service user age range, primary diagnosis, total incidents, self-harm, violence and aggression, sta� assaults, restraint, seclusion and long term segregation

— Monthly champions calls held where the data is reviewed, progress is discussed, achievements and challenges shared

Service user safety

Priorities for improvement


Priority 2

(new for 2020-21)(continued)

— Safewards folder set up on the Priory intranet

— Review of data there has been a mixed impact and this has often varied from month to month. Noteworthy is that particularly challenging service users can skew the data

— A closing event is being planned, where data will be presented and units will present their successes and challenges

Priority 3


Suicide prevention: To develop and implement a Suicide Prevention Strategy

Rationale: The first UK Minister for Suicide Prevention, Jackie Doyle-Price, was introduced in October 2018, followed by the launch of a Cross-Government Suicide Prevention Work Plan in January 2019. The Mental Health Five-Year Forward View and the NHS Long-Term Plan set out a commitment to make suicide prevention a priority over the next decade

What we will focus on: We will launch and implement our Suicide Prevention Strategy. This will be supplemented by an audit of our risk management plans to better understand the assessment of suicidality in the context of history and current mental state. This will help to determine if risk plans highlight adequate mitigations/clear safety plans and assign appropriate levels of risk. This audit will make recommendations, which will feed into the implementation of our Suicide Prevention Strategy

Progress in 2020-21: The strategy has launched for the Group and the committee has now been formed, to oversee implementation. There has been some work on improving the data sets for the Committee to review, and the first steps in developing the safety planning form has been completed with a draft out for comments from the service networks. Implementation of the form is targeted for Q3 2021

Service user safety

Painting by client at

Priory Arthur House

Autumn Leaves 2018,

Priory Wellbeing Centre Canterbury


Priority 4

(new for2020-21)

Reducing incidents of absconding from inpatient services: To reduce the overall number of unauthorised absences, more commonly referred to as ‘absent without leave’ (AWOLs) by learning from other AWOL incidents and ensuring robust clinical assessment and governance

Rationale: Going AWOL from a psychiatric hospital has potentially serious negative consequences for service users including suicide, homicide, self-harm and physical health problems. Bowers et al (1999) estimated that in the region of 3.6% of AWOLs result in harm to the service user or to others

What we will focus on: We will undertake thematic reviews and share learning from these. We will also carry out a review of our site security arrangements and understand our approach to relational security better.

We will review our processes, particularly for informal service users, and ensure that informal service users are adequately risk assessed for leave. We will also undertake a full review of our policy to ensure they are streamlined and our governance is strengthened

Progress in 2020-21: An AWOL subgroup was convened and met monthly via Zoom. 15 reviews have been undertaken and the themes and learning communicated across the division. Oversight continues to target any hotspots and deep dives undertaken as required. A need for relational security for all sites was identified.

Amendments have been made to Datix classifications to ensure the correct reporting of `true' AWOLS. Five-point risk assessment forms and guidance have been revised and issued; anti-absconding workbooks circulated to all sites; AWOL policy has been revised and the final version will be agreed shortly; informal leave form (similar to section 17 leave form) has been built for CareNotes and is currently being piloted; environment AWOL audit tool has been developed and is due to be issued

Service user safety


Priority 5

(new for2020-21)

Supportive observation and engagement: All clinical sta� to have the skills and competencies to undertake observation and engagement as per the divisional policy, to improve clinical e�ectiveness

Rationale: The primary aim of supportive observation and therapeutic engagement should be to engage positively with service users to reduce risk and prevent harm. Supportive observations should be seen as a therapeutic plan and not custodial care

What we will focus on: Three key areas of work:

— Sta� induction, training and competencies

— Recording and documentation

— Reducing the overall number of incidents that are directly attributable to poor observation and engagement of service users

Progress in 2020-21: A gap analysis was completed, mapping the current reality compared to preferred practice, which included a review of data linked to observations (self-harm and sta� sleeping) and a sta� sleep survey aimed at focusing on reasons for sta� sleeping and strategies to support and assist sta� undertaking observations, to remain alert. A review of the policy was undertaken as well as further development to the sta� induction and related academy module and competencies. There were also observation and engagement webinars (filmed for future use) developed

Clinical e�ectiveness

Priority 6


Physical health: We will continue to implement our Physical Health Strategy

Rationale: Premature mortality is higher for people with severe mental illness (SMI). Latest information from PHE confirms that compared to the general population, people with SMI experience a greater burden of physical health conditions. It is estimated that for people with SMI, two in three deaths are caused by physical illnesses, such as cardiovascular disease (CVD) and can be prevented. Recent analysis by PHE also found that younger adults with SMI are five times more likely to have three or more physical health conditions, compared to younger adults overall

What we will focus on: During the next year, we will be focusing on competency development and broader engagement with the wider national screening programmes

Progress in 2020-21: To support the response to the COVID-19 pandemic, the work related to this priority was refocused onto specific pieces of work which included:

— Review and support of the ‘clinically extremely vulnerable’

— Further embedding of NEWS2 within services to excellent e�ect

— Support to the mass vaccination programme

Fairy garden by colleagues and patients at Priory Hospital Nottingham


Priority 7


Service user and carer engagement: Develop and implement a new service user and carer Participation and Engagement Strategy

Rationale: Divisions aim to deliver improved service user experience by consistently engaging and involving service users, carers and other stakeholders in delivering its services

What we will focus on: Building on the implementation of the strategy in 2020, we will focus on the development of our divisional committee and structures, to establish a network of ‘Participation and Engagement Champions’ and work in partnership with ‘Your Say Forums’ to identify a range of initiatives which we will report on next year. We will also review the training requirements of our sta� in relation to the delivery of this strategy. In 2021, we will create a new Priory Award for Excellence in Participation and Engagement

Progress in 2019-20: The Healthcare Participation and Engagement committee is well established, with site champions and ‘expert by lived experience’ involvement. A Participation and Engagement Hub is now in place, accessible to all sta� to share best practice. An annual plan of events is agreed to foster cross-site and cross-service participation and engagement. The first Priory Award for Excellence in Participation and Engagement took place at the Priory Annual Awards ceremony.

The service networks have recruited ‘experts by lived experience’ to join their quarterly network committee meetings.

The foundations of service user co-production in care planning, bi-annual and discharge satisfaction surveys, consistent community ‘You Said, We Did’ meetings, involvement in recruitment, training and service planning, are well embedded.

During COVID-19, virtual carers meetings were facilitated

Service user experience

Wall mural at Priory Ty Catrin

Handsewn decoration at

Priory Hospital Cheadle Royal


Priorities for improvement 2021-22

Following consideration by the Healthcare Executive team and Clinical Governance committee, the healthcare division has

agreed the following priorities for improvement for 2021-22. A number of the 2020-21 priorities are carried forward for a

second year, in order to fully complete and embed the developments. The priorities are again categorised under the quality

domains of service user safety, clinical effectiveness and service user experience.

Priority 1 Closed culture review: Develop and undertake a closed culture review of all healthcare sites

Rationale: Protecting people’s basic human rights is at the heart of good care. Everyone involved in the care of people has a duty to act where there is a risk that a person’s human rights are being breached

What we will focus on in 2021-22: Through the development of a robust ‘closed culture assessment review’ tool, aligned to the current government and regulatory guidance, we will gain a better understanding of all Priory services cultures. By understanding the service needs, supporting and striving for the right model of care, right sta� and the right culture, we can provide the highest quality care to all service users. Following benchmarking culture indicators, will be monitored through a bespoke indicator set within the performance framework

Priority 3 Ligature point audit: Strengthen and embed a robust process for ligature point audits and completing environmental actions to ensure safer environments

Rationale: It is recognised that the environments we provide care and treatment in to individuals, whether purpose built or not, provide challenges to remove all fixtures and fittings to which a ligature could be attached by a service user who intended to strangle themselves. Therefore, in order to ensure a safe environment as possible, e�ective and robust assessment, mitigation and management is required to protect and ensure the safety of those service users we care for

What we will focus on in 2021-22: Through a structured and joined up approach of assessing environmental risks, mitigating and taking actions required will allow us to be in a better position to complete and close actions in a timely manner to ensure the safest environment possible for the delivery of care for our service users. Quality assurance checks built into audit rounds will be vital to the successful delivery of safer environments across the division

Priority 2 Supervision: Develop and embed a consistent and quality approach to undertaking supervision

Rationale: E�ective supervision is a key element of ensuring high quality care is delivered. The opportunity to review performance, reflect on the personal impact of providing care, and plan future personal development needs, is essential for all colleagues. A good supervision culture is at the core of any positive care setting

What we will focus on in 2021-22: Improve supervision quality; review policy to reflect the needs of the services/workforce; review reporting mechanisms to ensure accurate monitoring and oversight

Priority 4 Learned Lessons framework: Develop a robust divisional integrated Learned Lessons framework to increase the sharing of lessons learned within the division and beyond

Rationale: In an e�ort to provide the safest and highest quality care and treatment, it is imperative that we share good practice and learn when things haven’t gone well. This requires an integrated framework to capture all aspects of service provision across service lines, teams and services

What we will focus on in 2021-22: Through the development of an integrated Learned Lessons framework, we will enable e�ective sharing of good practice and learning across sites and service lines to promote the safest and highest quality of care and treatment for our service users. Through the development of communication structures, forums and virtual learned lessons teams, reflective practice and real time implementation will occur

Service user safety


Priority 5 Reduction in self-harm: Explore strategies to reduce incidents of self-harm, specifically ingestion/head banging

Rationale: Self-harm is prevalent in most of our services. Head banging and ingestion of foreign objects are hard to prevent and to manage. The can result in serious harm to service users. Focusing on these two methods of self-harm and building on the guidance that we have already developed, we aim to work with ‘experts by experience’ and service users to identify interventions to prevent these behaviours and to support sta and service users to manage them

What we will focus on in 2021-22: Two special interest groups of clinicians working in services, and ‘experts by experience’, will review the data we hold, the current literature and best practice and Priory Guidance. Revised guidance will be produced and interventions to prevent and manage these behaviours will be agreed.

We will also focus on how the Keeping Safe care plan is developed with service users, to agree and document self-harm reduction plans and the evaluation of these plans. This will include development of the primary nurse sessions where this work is undertaken with service users.

We will monitor the number of incidents, their severity, and in which service they occur

Priority 6 COVID-19 as business as usual

Rationale: The expectation is that COVID-19 will become endemic within the population in the same way that seasonal influenza has. This means that we have to move from our crisis response, to managing it by embedding high quality infection control practice into our routine work

What we will focus on in 2021-22: Embedding COVID-19 required practices into sites as everyday processes and practice

Service user safety

Priority 7 Therapeutic engagement: Increase therapeutic engagement over a seven-day period, to aid service user recovery

Rationale: A lack of therapeutic engagement and participation in a diverse range of meaningful activity leads to withdrawal, boredom and frustration. This can increase incidents of self-harm and conflict with others. By ensuring every service user has an individualised activity programme covering each seven-day week, and monitoring their engagement/attendance incidents, will decrease occurrences and aid recovery

What we will focus on in 2021-22: Scope the current therapeutic activity and engagement levels and highlight areas where improvement is required. Develop data and reporting metrics to audit and monitor performance and improvement. Revisit workforce needs in line with service network requirements to meet service user need

Clinical e ectiveness

Priority 8 Care plans: Promote the service user voice in developing individualised and holistic care plans

Rationale: To embed the service user at the centre of the care planning process in a consistent manner, across all the service networks

What we will focus on in 2021-22: Care plans are individualised to meet service user need, including robust consideration of physical health needs. We will develop ways to enable a holistic/full multidisciplinary view, including service users at the heart of care planning; run a trial of DIALOG+ as a framework for improving the consistency of the service user experience in care planning as well as providing a useful outcome measure to monitor service user experience and improvement


Priority 9 Clinical Governance: Review the current Clinical Governance structures and refine/develop to ensure they are fit for purpose

Rationale: Structured, systematic and integrated Clinical Governance is central to any e�ective and well-led healthcare organisation. Any such system is always at risk of becoming stagnant and less responsive to the complexity of the organisational need. Therefore, a review and restructure will be undertaken within the reporting year, with engagement across the division at all levels

What we will focus on in 2021-22: Resetting the basics, creating divisional learning systems, linking in all relevant interfaces. Focus on data and its value and role in creating and sustaining robust Clinical Governance

Priority 10 Data intelligence: Review and strengthen data quality and create shared knowledge and intelligence of systems to enable an intelligent organisation

Rationale: To create reliable, robust and consistent data quality to ensure accurate metrics for dashboards in governance, quality reviews, management and external groups such as NHSE and Provider Collaboratives (PCs)

What we will focus on in 2021-22: Review of current data reporting and requirements and identification of need. Ensure all sta� are trained and supported to fully use data systems to inform practice. Explore and implement new systems as deemed appropriate to build an intelligent division. Improve communication between CareNotes and Datix and other data sources. Aim for paperless systems and automated collection of data where possible

Clinical e�ectiveness

Priority Service user and carer engagement

Rationale: The division will aim to deliver improved service user experience by consistently engaging and involving service users, carers and other stakeholders in delivering its services

What we will focus on in 2021-22: We will continue to progress the objectives set out in the Priory Participation and Engagement Strategy. These are set out below:

— Establish working group to lead on the Always Events Project

— Divisional committee to agree 12 month co-produced plan of events

— Deliver focus groups for colleagues and service users to discuss participation and engagement

— Open the groups to all colleagues and service users

— Test the strategy with them to ensure we are focusing on the right areas and establish what the focus for future developments should be

— Review e�ectiveness of divisional satisfaction surveys

— Establish process for service user stories at Board meetings

— Grow the network of EBLEs workers to support sites and division

— Pilot Peer Support Workers in specific sites

— Promote Priory Award for Excellence in Participation and Engagement

Service user engagement

Quality Account 2018-19 16

How these priorities will be delivered in 2021-22

Each of the priorities will have a delivery plan and they will be

monitored by each clinical network and at the divisional Clinical

Governance committee. Each priority will have an implementation

lead assigned. This will ensure accountability for oversight

throughout the year.

Art at Priory Hospital Cheadle Royal


Our statements of assuranceTo assure the public that we are performing to required standards, providing high quality care, measuring clinical effectiveness and are involved in initiatives to improve quality, we offer the following statements:

Internal assurance statement from our Group Commercial Director

I have been asked by Priory Healthcare Senior Management to undertake an internal assurance audit in respect

of the company’s quality report for the year ended 31st March 2021 (the ‘Quality Report’).

The company has voluntarily applied certain principles of the guidance provided by NHS England and Improvement

(‘NHSE/I’) to NHS Foundation Trusts in its guidance: ‘Detailed Requirements for Quality Reports 2019/20’ published

in January 2020 and its subsequently-published ‘Quality Accounts Requirements 2020/21’ (together ‘the NHSE/I

Guidance’). These principles have been selected based on those deemed most applicable to the company.

I have conducted this internal assurance audit to include:

Reviewing the content of the Quality Report, having regard to the requirements of the NHSI Guidance

that are relevant to the company

Reviewing the Quality Report for consistency against the NHSI Guidance

Checking the reported statistics back to the underlying data, including undertaking sample spot checks

Making enquiries of relevant management

Having regard for reports submitted to NHS commissioners during the year

Based on the results of my review, nothing has come to my attention that causes me to believe that the

Quality Report does not:

Present a balanced picture of the company’s performance over the period covered

Contain reliable and accurate performance information

Reflect the application of proper internal controls over the collection and reporting of the

measures of performance

Mark WilsonGroup Commercial DirectorChartered Accountant


Participation in clinical research

There has been continued progress in our commitment to research, driving quality improvement and the ongoing development of our colleagues. We are participating in one national study looking at rehabilitation outcomes in the NHS and independent sector and have a number of smaller internal studies that are driven by individuals, usually as part of their professional and academic development. To support the ongoing research, we have been looking to increase availability of statistical packages for analysis and Athens accounts for literature reviews. The Research committee oversees the quality and appropriateness of the research, which is chaired and staffed by experienced researchers that meet monthly to review the progress of current research projects, and all new research applications.

Goals agreed with commissioners – use of the CQUIN payment framework

Due to the COVID-19 pandemic, 2020-2021 CQUINs

were suspended.

Quality domainAudit type Purpose

Ligature point audits x 2 Safety To review the environment for risks of ligatures being attached to a ligature point as a means of ensuring that risks are understood, acknowledged and removed/managed, as appropriate (including audits of blind spots and external areas)

Infection prevention & control audit

Safety and Clinical E�ectiveness To measure compliance against the IPC Code of Practice

COVID-19 outbreak preparedness audit

Safety and Clinical E�ectiveness To assess compliance against national IPC guidance specifically related to COVID-19

Safeguarding audit Safety and Clinical E�ectiveness To ensure compliance against national standards and Safeguarding Policies

Mental Health Act audit

Safety, Clinical E�ectiveness and Patient Experience

To explore issues and gain lessons to be learnt around record keeping, Section 17 leave, medication errors, cancelled leave and AWOLs from leave

Restrictive practice audit

Safety, Clinical E�ectiveness and Patient Experience

To review current restrictive practices that are in place and whether these can be reduced without a�ecting the safety of our service users

Participation in clinical audits

During 2020-2021, Priory Healthcare participated in the following audits:


Statements from the CQC

The relevant operating subsidiary companies within

Priory Healthcare are required to register with the

CQC and their current registration statuses are ‘fully

registered’.

At the end of the reporting period, Priory Hospitals

Norwich, Arnold, Hayes Grove, St Johns, Bristol, and

Middleton St George, had conditions of registration

placed on them. Priory Hospital Arnold had a warning

notice and an imposed suspension on admissions, and

the other facilities had no conditions of registration

placed on them.

The CQC issued warning notices to two facilities

between April 2020 and March 2021. Middleton St

George in September 2020 and Newcombe Lodge in

March 2021. Priory Healthcare has not participated in

any special reviews or investigations by the CQC during

the reporting period.

Data security and protection toolkit

The data security and protection toolkit is a performance

assessment tool, produced by the Department of Health,

which is a set of standards that organisations who provide

NHS care must complete and submit annually. The toolkit

enables organisations to measure their compliance with a

range of information handling requirements, thus ensuring

that confidentiality and security of personal information is

managed safely and effectively.

Priory has provided all mandatory evidence for

assessment and has been deemed to have met the

required standards..

Clinical coding

Priory Healthcare was not subject to the audit

commission’s ‘payment by results’ clinical coding

audit during 2020-21.Data quality

Priory Healthcare did not submit records during

2020-21 to the Secondary Users Service (SUS), nor

for inclusion in the Hospital Episodes Statistics (HES).

This is included in the latest published data.

Art at Priory Hospital

Woodbourne

Components - painting by

patient at Priory Hospital

Ticehurst House


Additional information on Quality Performance

Service user satisfaction and experience

As a leading provider of mental health services, we recognise the value of learning from service user satisfaction and experience. Information from service user satisfaction surveys is important for understanding what service users think about their care and treatment, and to improve the quality of the services provided by Priory Healthcare.

Overall satisfaction with the quality of care by service (of service users who participated)

Acute and addictions

2019-20 2020-21

96% 95%

Child and adolescent mental health

89% 71%

Rehabilitation and recovery

91% 89%

Secure

81% 86%

Eating disorders

96% 94%2019-20 2020-21

2019-20 2020-21

2019-20 2020-21

2019-20 2020-21

The Friends and Family Test (FFT) gives service users the opportunity to submit feedback to providers of NHS funded care or treatment, using a simple question which asks how likely, on a scale ranging from extremely unlikely to extremely likely, they are to recommend the service to their friends and family if they needed similar care or treatment.

During 2021-2022, we will be relaunching our surveys (service users, friends and family, and colleague feedback) with the aim to encourage sites to promote take-up on all three surveys, and continue to promote the surveys and results moving forward.

Friends and Family Test

0%

10%

Negative Neither/Don’t know

Positive

20%

30%

40%

50%

60%

70%

80%


Service user stories

A former patient of Priory Hospital Altrincham

shares their story of living in the depths of

addiction, going through treatment at Priory and

regaining hope and happiness in their life. Now,

after leaving Priory, they are living a life where

they can see a positive future for themselves.

Priory Hospital Altrincham

Before

I began drinking alcohol heavily at around the age

of 21. My behaviour over the next 12 years became

progressively more destructive, dangerous and out of

control as my addiction took hold. I can say addiction

now, but at the time, I was in complete denial, with no

understanding of my illness and a total disregard for

the chaos that I created. Through my actions, I hurt

the people that I loved most in the world, I lost friends

as I isolated myself and I struggled to hold down the

job that I had worked so hard to achieve.

My life slowly crumbled, but I continued to abuse

alcohol as it was the only way I knew how to live. I

believed that it was my support, my friend and my

coping mechanism. I know now how wrong I was. With

each drink, my pain grew and I drank more to survive

in the life that I felt like I didn’t belong in.

My recovery journey – Mary’s* story

During

Looking back on my time as an inpatient, my first feeling

is one of safety. I was welcomed into a place surrounded

by addiction specialists that wanted to help me and those

like me. I felt absolute relief to be somewhere safe, where

I could finally speak about my thoughts and feelings,

without the fear of judgement.

The message was simple: there was a solution and if I

worked hard and did what was suggested by those with

more experience than me, I had the chance to rebuild my

life. My family were given support too and whilst it was

difficult for me to face up to the impact that my drinking

had upon them, Priory guided them to work through my

recovery in parallel to me.

Through daily therapy sessions, I began to understand

that I wasn’t a bad person, but that I was a very poorly

one. With the support and guidance of Priory, I began


to believe that I had a future and it was one worth

fighting for.

I made a promise to myself that I would give the

28-day programme 100% and I can honestly say that

I did. I embraced each day and worked through the

pain that I had carried in secret for so many years.

Priory, I believe, was the very best place for me to

do this as they introduced me to external addiction

support meetings, mindfulness, meditation and a

programme of recovery.

Upon discharge, I had a plan in place and knew how I

could use what I had been taught at Priory back in my

daily life.

AfterI left Priory nearly six months ago, and now I

return twice a week for aftercare. Aftercare,

which is provided for 12 months, has been key to

maintaining my sobriety. Without a doubt, I am

sober today because of the treatment programme

and the support that I have from the team.

The care provided doesn’t end after the 28 days

and returning to Priory Hospital Altrincham

always feels like going home. I continue to work

through a plan of recovery, the foundation of

which was created during my time at Priory.

By taking life one day at a time, I am rebuilding

relationships with my family, forging new

friendships and can now look ahead with hope.

I will always be grateful to the Priory team. When

I believed I was utterly lost and broken, they

guided me into recovery and towards the future

that I now believe I deserve.


I have struggled with anorexia since I was 16, on

top of self-harm, depression and anxiety. They all

made me feel isolated and trapped from everyone

I knew, and I felt like my whole life revolved

around my eating disorder. I avoided my friends

and family, my schoolwork suffered and things as

simple as standing up became a huge struggle.

Priory Arthur House

Megan’s* eating disorder recovery

I thought no-one could notice me and that I did not

matter, but the truth was that everyone else around me

was noticing the change and how far from myself I was

becoming. Despite this, I was too scared to tell anyone

and unable to get the help I needed so desperately.

After a few years, my parents found out about my eating

disorder and contacted Life Works for me.

Life Works gave me a huge amount of support and

helped create a safe and supportive environment,

where I felt able to both open up about and challenge

my eating disorder. Inevitably it took some time, but

eventually I realised no-one was there to judge me;

instead they were there to understand and support me

as best as they could. The environment was controlled,

which hugely contributed to me being able to progress

from eating nothing to eating three meals and three

snacks a day – and eventually feeling strong enough to

do this at home without the support of Life Works.

All the support and help I have had

and still receive is invaluable to me and

has saved my life.


Life Works and Arthur House are part of Priory’s

specialist eating disorder care pathway. Life

Works provides intensive residential support,

combining dietetic techniques, tried and tested

therapies, as well as a highly experienced

multidisciplinary team, offering bespoke

programmes for people with an eating disorder.

Arthur House supports people once they have

left more intensive inpatient treatment, such as

Life Works, or can provide earlier intervention

support. One of the key therapeutic goals is to

provide a safe space for individuals to maintain

a healthy relationship with food, including full

nutritional and dietetic support.

Staff are always available and willing to help when needed, but I also have the opportunity to go out in my free time if I feel safe enough to do so. This has helped me to reintroduce normality into my life and create a life for myself away from my eating disorder.

At Arthur House, there is more exposure work, for example clothes shopping, and caf and restaurant outings, which has been a crucial part of my recovery as it re-develops ‘normal’ eating and helps me create the life I want to be able to live once discharged. I am proud to say that I am slowly re-building my life through applying for jobs, rebuilding friendships and family relationships and exercising in a safe and non-obsessive way – all whilst receiving a huge amount of support, encouragement and help from staff and other clients. I can say with confidence that Arthur House is the right place for me, and would encourage anybody in need of secondary treatment for their eating disorder to consider admitting here.

Looking back on my experience so far, I can confidently say that there is nothing I would change in regards to the treatment I have received. All the support and help I have had and still receive is invaluable to me and has saved my life. I feel like a completely different person compared to who I was just a few months ago.

I immediately started treatment at Arthur House, where I remain six months later.

The difference between Life Works and Arthur House is the increase in freedom

and control I have over my food (for example choosing and preparing my own

meals), whilst also receiving the right amount of support and therapy.

Arthur House

Life Works

Life Works


A successful treatment journey from Secure to independent rehabilitation – Tony’s* story Tony was originally admitted to Mattingley Ward, our Low Secure unit, under the Mental Health Act in 2019. He was diagnosed with a mild learning disability, mild autism and attention deficit hyperactivity disorder (ADHD). He also had a long history of concerning behaviours, which included physical assaults on others, violent outbursts, theft, substance abuse and inappropriate sexual behaviours.

The team at Mildmay Oaks got to know Tony, and could soon recognise the early signs of his troubling behaviours. This would include being repetitive in conversation, and complaining about fellow patients and certain staff members. He was treatment resistent and would make phone calls to the police and other professional bodies to make allegations.

These incidents were frequent to start with but with support from our team, he gradually settled and evidence of progress was noted. He engaged in therapeutic activities, he would take his medication and the level and intensity of incidents decreased. Activities he became compliant with included:

Occupational therapy

Completing functional assessments and participating in the leisure pathway

Real work opportunities (RWO) including shop assistant and librarian

Supervision in setting SMART goals for his worker role

Cooking, kitchen and safety skills

Learning to use public transport, shopping and completing road safety assessments

Shopping and budget setting

This progress prompted him to be considered for Heckfield Ward, our rehabilitation unit, much sooner than average (less than a year). Upon this transition, it was identified that Tony had a good baseline for his activities of daily living (ADL) and was supported by ward staff to upkeep this.

He has settled very well on this ward, despite having fluctuations in his mental state, which we manage positively. Our team have taken the time to get to know him well and know how to reinforce boundaries, reminding Tony what behaviours are acceptable. We put a care plan in place to support Tony in how to best interact with his peers and we know it is important to reduce Tony’s boredom, which can trigger his inappropriate behaviours. We have also noticed that high consumption of sugar products will increase his hyperactivity and restlessness, so we support Tony with his dietary needs.

Tony now enjoys free access to the kitchen and the least restrictive practice on the ward. His level of incidents have reduced and Tony is very independent in attending to his daily living skills. He can maintain his own personal care with very little support needed. He enjoys cooking and housework with minimal support. He has a great sense of humour and shows kindness towards others. Tony was soon granted shadowed leave around the hospital grounds, which progressed to unescorted ground leave.

Tony is very close to his family and he has expressed that he would like to move back home. There is hope he could move back in the community soon and a place has already been identified for him.

*Service user’s name has been changed to protect their identity.

Priory Mildmay Oaks – specialist learning disability services


Outcome measures – continuous quality improvement

We believe in tailoring quality and outcome measures so they are relevant to service

users and clinicians, and that they are clinically relevant in order to add value to clinicians,

as a routine part of their clinical practice and continuous quality improvement.

For young people in child and adolescent mental health services (CAMHS), we use

the Health of the Nation Outcomes Scales for Children and Adolescents (HoNOSCA).

All of the HoNOS outcomes quoted that relate to improvements in overall mental

wellbeing, refer to service user outcomes at the point of discharge. Across the

Healthcare division, additional outcome tools may also be used, according to the

nature of each service.

Acute mental health

2019-20

84% Showed improvement in their overall mental wellbeing

Eating disorders

2019-20

87% Showed improvement in attitude to diet, shape and weight

96% Gained weight

85% Showed improvement in their overall mental wellbeing

Child and adolescent mental health

2019-20

79%

2020-21

88%

2020-2021

71%Showed improvement in their overall mental wellbeing

Addiction

2019-20

92%

2020-2021

88%Showed improvement in their overall mental wellbeing

2020-21

71%

97%

79%


We are a learning organisation and we aim to ensure that we capitalise on every possible opportunity to identify and embed improvements. We do this as a means of providing the safest possible care for our service users and the safest possible work environment for our colleagues.

During 2020-21, our focus turned to ensuring a robust response to the risks presented by COVID-19, however we did not lose sight of all other aspects of service user and colleague safety. Despite the pandemic, we were able to maintain and enhance our already robust systems and our year-on-year service user safety improvements continued.

During 2020-21, our use of the Datix incident-reporting tool continued to result in improvements in the timeliness and detail of our incident reports. Additionally, the system has given our hospitals and homes improved opportunities to analyse and understand incident themes and trends and put in place any necessary improvements. During 2020-21, we were able to employ Datix to good effect in helping us monitor and respond to the impact of the pandemic in respect of overseeing colleague and service user self-isolations and outbreak status, at our hospitals and homes.

We continue to complete a rapid review in response to serious incidents. This ensures that immediate improvements are introduced, to enhance the safety of all involved. Safety bulletins continue to be promptly circulated in response to new and emerging risks. Our Compliance team check for evidence that these are discussed at team meetings and that they result in changes to practice. We always commission a proportionate investigation into serious incidents and near misses, and put in place clear and achievable actions in response to the findings of the investigation. We monitor the action plans that arise and ensure that the identified improvements are achieved in a complete and timely way. Additionally we share the lessons that we learn with our colleagues and enhance policies, the content of training modules, audits and monitoring processes to ensure that the improvements are embedded and become part of everyday custom and practice.

Our monthly ’Safety 1st’ initiative continues to be well received and during the year this focused on infection prevention and control, fire safety and swallowing and choking risk. Likewise, our training programme has continued, with new subjects being added during the year, for example ‘Ligature Point Audit’, ‘NEWS2’ and ‘Sepsis Awareness’. We were able to enhance our webinar training systems at relatively short notice, meaning that our training compliance rates have held up well despite the pressures and limitations that resulted from the pandemic.

We continue to embrace the duty of candour and have further incorporated the recently updated CQC guidance into policy, the incident reporting system and all relevant training modules.

During 2020-21, we introduced the Datix feedback module. This has resulted in improvements in the reporting and response to complaints and concerns. The module also enables colleagues to report compliments and this has helped us to

further recognise and reward the high quality care and support delivered to our service users. Our webinar-based complaints handling training continues to be very well received. We continue to see year-on-year improvements in the timeliness and quality of complaint investigations and responses. The improvements made in response to the lessons learnt from our complaint investigations included enhancing ‘on-line’ new service user assessments and improving the ‘welcome pack’ provided to newly admitted service users.

Year

2017-18 1.35

2018-19 1.24

1.19

2019-20 1.30

Complaints per 1,000 bed days

2020-21

Complaints at stage 2 and 3

2018-19 16 8Stage 2 cases

Stage 3 cases


Stage 3 cases


Stage 3cases


Stage 3cases

Learning from complaints and incidents


Improving safety for our service users

Priory Healthcare compares well with similar providers in terms of incident reporting rates. We encourage and facilitate our

colleagues to report incidents. During 2020-21, we continued to encourage our colleagues to understand the benefits of reporting

any near misses, incidents or serious incidents, as a means of identifying themes and trends and to facilitate improvements to

be made.

We have monitoring systems in place to ensure that an acknowledgement, apology, or explanation, is given to those

affected by incidents. We are satisfied that we have a culture of transparency and candour.

Reported incidents (April 2020 – March 2021)

8000

6000

4000

2000

0

Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

Art by a patient at

Priory Hospital

Norwich


Colleague engagement and recognition

In 2020, we launched a new Annual Colleague survey. In a

change to previous years, all sites were surveyed at the same

time (November 2020). The survey was completely anonymous

and allowed colleagues to provide free text comments and

suggestions for the company to consider. The survey was

administered by our new third party partner – Workbuzz.

In the Healthcare division, our overall engagement score was 65,

with a response rate of 43%. As this was a new roll out, it has

been difficult to compare scores and response rates to previous

years. However, as a division we were pleased with our results,

which now gives us a baseline to improve on for the next survey,

along with some key learnings from the feedback provided.

2020 was an exceptional year with the onset of a global

pandemic, which challenged us to look at different ways of

working and delivering training across our sites virtually, to

ensure our compliance and quality of trained colleagues was

maintained.

During 2020, we launched our new colleague communications

portal called ‘My Priory’, which has given us a new and fresh

way to communicate to all our colleagues across the division.

The most popular content areas for Healthcare colleagues are

‘recognition, news, and our wellbeing hub’, which provides

resources split into the three main areas of our Group

Wellbeing strategy: mental, physical and financial wellbeing.

Alongside the new Colleague Engagement survey, to help

us better understand what our colleagues think and feel, we

have introduced a new role of Regional Engagement Lead.

The sole purpose of their role within Healthcare is to go out

and understand what we are doing well and also not so well,

in regards to colleague retention and wellbeing. From this,

they will work with site SMTs to create and build a robust

retention and wellbeing plan bespoke for each site.

The teams continue to focus on retention as a key part of our

Workforce Strategy. This includes getting colleague opinions

on what they would like to see happen at their site. This is in

conjunction with our ‘Your Say Forum’, which holds regional

meetings with senior teams and has a focus of sharing

information, ideas and solutions.

We continue to provide a wellbeing budget to each of

our sites, to encourage our leaders to focus on wellbeing

amongst colleagues. In addition, we have site ‘working

well’ groups who arrange colleague events. Examples of

what has been taking place include bake off challenges

for charity, onsite car washes, Easter egg hunts, relaxation

days, treatments and sessions for everyone, summer BBQs

open to the local community, and healthy breakfasts. In our

annual Priory Awards recognition event, Priory introduced a

‘colleague wellbeing’ category to recognise an individual or

team who has made a significant impact, and the winner was

one of the Healthcare site-based wellbeing teams.

We are now in our second year of providing colleagues with

our recognition, discounts and rewards platform, ‘Priory Perks’,

which has seen over 6000 of our colleagues sign up to use the

platform with a total saving across the division of over £25,000

We continue to recognise our Healthcare colleagues and sites

through nominations and long-service awards. We will continue

to hold our annual Priory Awards, which in April 2021, saw us

hold the event virtually, to ensure colleagues could receive

recognition despite the restrictions caused by COVID-19.


Investing in the future of our colleagues

We continue to utilise Priory Career Pathways, which is

our online interactive tool that identifies all the various

roles available for colleagues across Priory Group. This

tool helps identify aspirational career goals and details the

progressive roles that are required to achieve this goal.

Following feedback from colleagues, we have updated

our annual PDR document to support a more values-led

discussion of a colleague’s progress and allow for future

planning of their ongoing career within Priory.

Due to the continued national shortage of nurses, we

continue to grow our own through sponsoring students

during their training. We currently have 116 students who

are being sponsored by Priory, with an additional 45

starting their studies in September 2021. We have also

continued to collaborate with a third party to explore the

opportunities of bringing overseas nurses to work within

Priory. To date we have 33 overseas Nurses working across

Priory with more expected during 2021.

We continue to invest in continuing professional

development (CPD) and now hold weekly panels to approve

all requests for CPD. This enables us to expedite the training

approvals process significantly. Last year we approved

411 CPD requests ranging from NVQ Level 2 food hygiene

courses to MSc in Family and Systemic Psychotherapy.

Finally, we continue to work with Care First, our Employee

Assistance Programme provider, who have a revolutionary

application that helps individuals understand their mental

wellbeing by carrying out a series of exercises including

breathing and meditation. It highlights areas where

the individual needs to focus to improve their mental

wellbeing but also offers interventions should this be

required. We have also invested in mental health first

aiders to support colleagues and we currently have 95

trained within the Group and continue to invest in having

more trainers throughout 2021.


Regulatory inspections

The Healthcare division operates across England,

Scotland and Wales, and is therefore required to work

under the standards set out by regulators within each

respective area. During the reporting period and because

of the COVID-19 pandemic, the number of onsite

regulatory inspections was reduced in comparison with

previous years. The regulators carried out 77 inspections.

Regulators break this down, as follows:

CQC – 75

Health Improvement Scotland – 0

Health Inspectorate Wales – 2

Care Inspectorate Wales – 0

Ofsted – 0

Mental Welfare Commission Scotland – 0

Internal corporate assurance and quality monitoring to ensure good regulatory outcomes and high standards of care

All Priory Group sites are thoroughly monitored at an

arm’s length by the Corporate Assurance team. The aim

is to assist our services in striving to, and achieving,

regulatory ratings of ‘Good’ or better, and to ensure

continual quality improvement. At the end of March

2020, all regulators suspended routine inspections due

to the COVID-19 pandemic. In the preceding year, every

Healthcare division site had a full internal benchmark

inspection against the relevant outcomes and standards

for all relevant regulators.

Internal corporate assurance activities are prioritised based

on a robust process of Quality Performance Indicator

reviews, intelligence monitoring and risk profiling. The

specialist inspection teams comprise health and safety and

regulatory compliance experts, and experienced financial

auditors. During the period, onsite and remote inspections

took place across Priory Healthcare when safe to do so in

line with statutory guidance related to COVID-19. Inspection

activity was as follows:

130 internal regulatory compliance inspection visits

38 fire risk assessments

94 health and safety internal audits and 20 support visits

Regulatory compliance


The CQC

During the period, the CQC carried out 75 inspections. 58 of these inspections were remote, using CQC’s emergency support

framework or transient monitoring approach. There were 17 inspections that were on site, of which 10 were rated and 7 had no ratings.

CQC adapted their inspection methodologies during the period but the overarching framework remained in place, with the five

key questions considered:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive to people’s needs?

Is the service well led?

At the end of the accounting period on the 31st March, the ratings for services registered with CQC were as follows:

O G O O G G

G O G G G G

G G G G G RI

O O O O O O

G RI G G G G

G RI G G G G

G RI G G G G

G G G G G G

G G G G G G

RI RI G G G RI

G RI G O G G

O G G O O O

G G G G G G

IN IN G O G IN

G G G G G G

G G G G G G

G RI G G G G

Site Overallrating Safe CaringE�ective Responsive

InspectiondateWell led

Key: IN = Inadequate RI = Requires Improvement G = Good O = Outstanding NR = No Rating Given

G G G G G G

G G G G G G

G G G G O G

G G G G G G

O G G G O O

RI RI G G G RI

G RI G G G G

G G G O G G

G G G G G G

G G G G G G

G G G G G G

G G G G G G

G RI G G G G

IN IN NR NR NR IN

G G G G G

G RI G G G G

G G G RI

RI RI RI G RI RI

G G G G G G

G G G G G G

G RI G G G G

G

G RI G G G G

G G G G G G

G

G G G G G G

O G G O O O

G G G G G

G G G G G

G G G G G O

G G G G G G

RI RI RI G G G

IN IN G IN IN IN

G G G G G G

G G G G O G

G G G G G G

G G G G G G

G G G G G G

G G G G G G

G G G G G G

RI RI G G G RI

G RI G G G G

G G G G G G

G IN G G G IN

G G G G G G

G G G G G G

G G G G O G

G RI G O G G

RI RI RI RI RI RI

G

O G O O G G

G G G G G G

G RI G G G G

IN IN RI RI RI IN

RI G G G G

Lichfield Road

51 The Drive

Althea Park

Altrincham

Arthur House

Ashleigh House

Avesbury House

Beverley House

Birmingham WBC

Bisley Lodge

Bristol

Bristol WBC

Burston House

Burton Park

Canterbury WBC

Cheadle Royal

Chelmsford

Dewsbury

Elm Cottage

Elm House

Elm Park

Fenchurch Street WBC

Grafton House

Grafton Manor

Harley Street WBC

Hayes Grove

Hazelwood House

Heathfield

Hemel

Highbank (Elton)

Highbank (Walmersley)

Kemple View

Kent House

Kneesworth House

Lakeside View

Lifeworks

Lombard House

Manchester WBC

Manor Clinic

Market Weighton

Mayfield House

Middleton St George

Mildmay Oaks

Mill Garth

Nelson House

Newcombe Lodge

North London

Nottingham

Oxford WBC

Preston

Priory Hospital Arnold

Priory Hospital Burgess Hill

Priory Hospital Dorking

Priory Hospital East Midlands

Priory Hospital Enfield

Priory Hospital Malvern

Priory Hospital Marlow

Priory Hospital Norwich

Priory Lincolnshire

Richmond House

Roehampton

Romiley

Southampton

Southampton WBC

St Johns House

Station Road

Stockton Hall

Suttons Manor

The Cloisters

The Elphis

Ticehurst House

Westfield View

Woking

Woodbourne

Woodland View

25/09/2017

05/06/2019

10/07/2019

12/11/2018

04/04/2017

NI

22/04/2017

07/11/2017

02/08/2018

06/11/2018

07/01/2019

NI

19/02/2019

21/03/2021

18/06/2018

15/08/2017

23/04/2019

03/03/2020

16/04/2018

21/05/2018

26/06/2018

01/06/2016

30/05/2019

24/04/2019

30/10/2018

24/10/2018

06/11/2018

02/12/2020

16/07/2018

21/05/2018

05/12/2018

21/05/2019

15/07/2019

06/10/2020

24/09/2019

26/09/2018

07/03/2017

NI

06/12/2018

06/02/2018

15/10/2020

20/09/2020

29/01/2020

12/07/2017

17/07/2018

06/08/2019

07/10/2019

21/01/2019

09/07/2019

21/11/2017

09/03/2021

11/08/2020

30/10/2018

20/12/2017

17/04/2018

11/06/2019

NI

04/09/2019

15/01/2019

04/07/2018

15/09/2020

02/05/2018

06/10/2020

27/06/2019

15/12/2020

02/10/2017

21/01/2020

20/03/2019

25/04/2017

10/12/2019

09/09/2019

27/06/2019

17/04/2018

20/02/2018

06/11/2018

RI

RI RI

G G G G G G

RI G RI G RI RI

Awaiting Initial Inspection




G G G G G RI

IN IN NR NR NR IN

RI RI RI G G RI

G RI G G G G

Continued...


O G O O G G

G O G G G G

G G G G G RI

O O O O O O

G RI G G G G

G RI G G G G

G RI G G G G

G G G G G G

G G G G G G

RI RI G G G RI

G RI G O G G

O G G O O O

G G G G G G

IN IN G O G IN

G G G G G G

G G G G G G

G RI G G G G



Key: IN = Inadequate RI = Requires Improvement G = Good O = Outstanding NR = No Rating Given

G G G G G G

G G G G G G

G G G G O G

G G G G G G

O G G G O O

RI RI G G G RI

G RI G G G G

G G G O G G

G G G G G G

G G G G G G

G G G G G G

G G G G G G

G RI G G G G

IN IN NR NR NR IN

G G G G G

G RI G G G G

G G G RI

RI RI RI G RI RI

G G G G G G

G G G G G G

G RI G G G G

G

G RI G G G G

G G G G G G

G

G G G G G G

O G G O O O

G G G G G

G G G G G

G G G G G O

G G G G G G

RI RI RI G G G

IN IN G IN IN IN

G G G G G G

G G G G O G

G G G G G G

G G G G G G

G G G G G G

G G G G G G

G G G G G G

RI RI G G G RI

G RI G G G G

G G G G G G

G IN G G G IN

G G G G G G

G G G G G G

G G G G O G

G RI G O G G

RI RI RI RI RI RI

G

O G O O G G

G G G G G G

G RI G G G G

IN IN RI RI RI IN

RI G G G G

Lichfield Road

51 The Drive

Althea Park

Altrincham

Arthur House

Ashleigh House

Avesbury House

Beverley House

Birmingham WBC

Bisley Lodge

Bristol

Bristol WBC

Burston House

Burton Park

Canterbury WBC

Cheadle Royal

Chelmsford

Dewsbury

Elm Cottage

Elm House

Elm Park


Grafton House

Grafton Manor

Harley Street WBC

Hayes Grove

Hazelwood House

Heathfield

Hemel

Highbank (Elton)


Kemple View

Kent House

Kneesworth House

Lakeside View

Lifeworks

Lombard House

Manchester WBC

Manor Clinic

Market Weighton

Mayfield House

Middleton St George

Mildmay Oaks

Mill Garth

Nelson House

Newcombe Lodge

North London

Nottingham

Oxford WBC

Preston


Priory Hospital Burgess Hill

Priory Hospital Dorking

Priory Hospital East Midlands

Priory Hospital Enfield

Priory Hospital Malvern



Priory Lincolnshire

Richmond House

Roehampton

Romiley

Southampton

Southampton WBC

St Johns House

Station Road

Stockton Hall

Suttons Manor

The Cloisters

The Elphis

Ticehurst House

Westfield View

Woking

Woodbourne

Woodland View

25/09/2017

05/06/2019

10/07/2019

12/11/2018

04/04/2017

NI

22/04/2017

07/11/2017

02/08/2018

06/11/2018

07/01/2019

NI

19/02/2019

21/03/2021

18/06/2018

15/08/2017

23/04/2019

03/03/2020

16/04/2018

21/05/2018

26/06/2018

01/06/2016

30/05/2019

24/04/2019

30/10/2018

24/10/2018

06/11/2018

02/12/2020

16/07/2018

21/05/2018

05/12/2018

21/05/2019

15/07/2019

06/10/2020

24/09/2019

26/09/2018

07/03/2017

NI

06/12/2018

06/02/2018

15/10/2020

20/09/2020

29/01/2020

12/07/2017

17/07/2018

06/08/2019

07/10/2019

21/01/2019

09/07/2019

21/11/2017

09/03/2021

11/08/2020

30/10/2018

20/12/2017

17/04/2018

11/06/2019

NI

04/09/2019

15/01/2019

04/07/2018

15/09/2020

02/05/2018

06/10/2020

27/06/2019

15/12/2020

02/10/2017

21/01/2020

20/03/2019

25/04/2017

10/12/2019

09/09/2019

27/06/2019

17/04/2018

20/02/2018

06/11/2018

RI

RI RI

G G G G G G

RI G RI G RI RI





G G G G G RI

IN IN NR NR NR IN

RI RI RI G G RI

G RI G G G G

The CQC (continued)

O G O O G G

G O G G G G

G G G G G RI

O O O O O O

G RI G G G G

RI IN RI G G RI

G RI G G G G

G G G G G G

G G G G G G

RI RI G G G RI

G RI G O G G

O G G O O O

G G G G G G

O G G O G O

G G G G G G

G G G G G G

G RI G G G G



Key: IN = Inadequate RI = Requires Improvement G = Good O = Outstanding NR = No Rating Given1Priory Hospital Blandford is now closed – 24th April 2020

2 Ellingham is now called Priory Hospital Norwich; Calverton Hill is now called Priory Hospital Arnold

G G G G G G

G G G G G G

RI RI RI G G G

G G G G O G

G G G G G G

O G G G O O

RI RI G G G RI

G RI G G G G

G G G O G G

G G G G G G

G G G G G G

IN IN IN IN RI IN

G G G G G G

G G G G G G

G RI G G G G

RI RI G G G RI

RI IN RI RI RI RI

G G G G G

G RI G G G G

G G G RI

RI RI RI G RI RI

IN IN G IN IN IN

G G G G G G

G G G G G G

G RI G G G G

G

G RI G O G G

G G G G G G

G

G G G G G G

O G G O O O

G G G G G G

G G G G G

G G G G G

RI RI RI O G RI

G G G G G G

G G G G G RI

G G G G G G

G G G G G G

G G G G G G

G G G G O G

G G G G G G

G G G G G G

G G G G G G

RI RI G G G RI

G RI G G G G

G G G G G G

G G G G G G

G G G G G G

G G G G G G

G G G G O G

RI RI RI RI RI RI

G

O G O O G G

G G G G G G

G

G RI G G G G

G G G G G G

G G G G G G

RI G G G G

G G G G O

Lichfield Road

51 The Drive

Abbey House

Althea Park

Altrincham

Arthur House

Ashleigh House

Avesbury House

Beverley House

Birmingham WBC

Bisley Lodge

Blandford1

Bristol

Bristol WBC

Burston House

Burton Park

Calverton Hill2

Canterbury WBC

Cheadle Royal

Chelmsford

Dewsbury

Ellingham2

Elm Cottage

Elm House

Elm Park


Grafton House

Grafton Manor

Harley Street WBC

Hayes Grove

Hazelwood House

Heathfield

Hemel

Highbank (Elton)


Kemple View

Kent House

Kneesworth House

Lakeside View

Lifeworks

Lombard House

Manchester WBC

Manor Clinic

Market Weighton

Mayfield House

Middleton St George

Mildmay Oaks

Mill Garth

Nelson House

Newcombe Lodge

North London

Nottingham

Oxford WBC

Pelham Woods

Preston

Burgess Hill

East Midlands

Enfield

Priory Lincolnshire

Rhodes Recovery

Richmond House

Roehampton

Romiley

Southampton

Southampton WBC

St Johns House

Station Road (HC)

Stockton Hall

Suttons Manor

The Cloisters (HC)

Ticehurst House

Westfield View

Woking

Woodland View

25/09/2017

05/06/2019

11/06/2019

10/07/2019

12/11/2018

04/04/2017

NI

22/04/2017

07/11/2017

02/08/2018

06/11/2018

14/05/2019

07/01/2019

NI

19/02/2019

18/12/2018

04/02/2020

18/06/2018

15/08/2017

23/04/2019

03/03/2020

04/09/2019

16/04/2018

21/05/2018

26/06/2018

01/06/2016

30/05/2019

24/04/2019

30/10/2018

24/10/2018

06/11/2018

25/06/2018

16/07/2018

21/05/2018

05/12/2018

21/05/2019

15/07/2019

07/01/2020

24/09/2019

26/09/2018

07/03/2017

NI

06/12/2018

06/02/2018

13/03/2018

19/09/2018

29/01/2020

12/07/2017

17/07/2018

06/08/2019

07/10/2019

21/01/2019

09/07/2019

30/10/2018

21/11/2017

24/04/2019

20/12/2017

17/04/2018

15/01/2019

10/12/2019

04/07/2018

05/03/2019

02/05/2018

25/06/2019

27/06/2019

03/07/2018

02/10/2017

21/01/2020

20/03/2019

25/04/2017

09/09/2019

27/06/2019

17/04/2018

06/11/2018




RI

RI RI

G G G G G G

Where an overall judgement that does not meet the ‘Good’ or better threshold exists, the site works to a comprehensive individual improvement plan with close monitoring from the operational and central teams.

Painting by a client at

Priory Hospital

Roehampton

Sensory felt animals

made by patients at



Healthcare Improvement Scotland (HIS)

Priory Healthcare has two registered hospitals, and

additional satellite services in Scotland. During the reporting

period between 1st April 2020 and 31st March 2021, ratings

for these services and 100% of the standards inspected, are

currently judged to have been met.

Healthcare Inspectorate Wales (HIW)1

Two Priory hospitals were inspected by HIW between 1st April 2020 and 31st March 2021 – Ty Cwm Rhonda and

Llanarth Court. Llanarth Court had some requirements and

action plans were immediately implemented. Regular liaison

with the regulator regarding progress, also took place.

Care Inspectorate Wales (CIW)

During the period, CIW didn’t inspect any sites and there

were no ongoing regulatory issues.

Sites with regulatory compliance/warning notices

Warning notices Comments

Received in September 2020 (lifted in September in 2020)

Received in October 2019 (still in place)

Received June 2019 (lifted in April 2020)

Kneesworth House

Received September 2019 (still in place)


Received June 2020 (lifted October 2020)

Heathfield

Received September 2020Priory Hospital Bristol

Received in October 2020Middleton St George

Received in December 2020St John’s

Received in March 2021Priory Hospital Arnold

Received January 2020Hayes Grove’s Keston Unit (closed)

Middleton St George


NoP / NoD

Mosaic collage

‘woman and nature’ -

Priory Beverley House


Appendices

Statement of assurance from our lead commissioner

As lead on the contracts for Specialised Mental Health

Services from Priory Healthcare for the two contracts

with Priory Healthcare Limited and Partnerships

in Care Limited, NHS England can confirm that

the organisation has a good understanding of the

reporting requirements as set out in the 2020-21

contract. This includes a collaborative approach to

identifying areas for ongoing improvement in support

of continually improving quality and safety of services

for service users. The organisation responds in a timely

manner to address any concerns or improvements,

including those identified by the service users

themselves, their carers, the CQC or the commissioner.

Whilst recruitment continues to be a challenge, the

organisation has demonstrated that they continue to

respond to this challenge by actively recruiting and

training colleagues as a continuous cycle.

Priory Healthcare has shown that they understand the

value of and continue with CQUIN schemes in order

to improve the service user and carer experience.

Commissioner and case manager meetings with

service users are supported by the organisation

and these enable NHS England to receive first hand

feedback from service users about their experience

whilst in hospital.

Yvonne SrinivasanSenior Mental Health Commissioner Regional Specialised Commissioning NHS England and NHS Improvement – East of England

May 2021

Accountability statement

Directors of organisations providing hospital

services have an obligation under the 2009 Health

Act, National Health Service (Quality Accounts)

Regulations 2010 and the National Health Service

(Quality Accounts) Amendment Regulation (2011),

to prepare a Quality Account for each financial year.

This report has been prepared based on the guidance

issued by the Department of Health setting out these

legal requirements.

To the best of my knowledge, as requested by

the regulations governing the publication of this

document, the information in this report is accurate.

By order of the Operating Board

Trevor TorringtonChief ExecutiveThe Priory GroupJune 2021

Quality Account 2018-19 35

Documents

Priory Healthcare Quality Account