St Mary's Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We assessed all 7 quality statements in the responsive key question and found it to be good. The service had not been previously inspected and this domain had not previously been rated.

Staff had a solid understanding of equality, diversity, inclusion and human rights. This was reflected in their engagement with patients. Staff were proactive in preventing discrimination. The service was able to make reasonable adjustments and provide equity in access and outcomes.

Patients had access to information about their care and treatment that could be provided in a format suitable to them. Patients were aware of how to complain and told us they would be confident that any complaint they raised would be managed appropriately.

We observed care being provided in a person-centred way. This was visible in the patient and staff interactions we witnessed and the care and treatment we saw being delivered. The multidisciplinary patient reviews we attended were holistic, personalised and included patient involvement. However, we found that the quality and personalisation of care plans did not always reflect this. Managers had identified this and in response had arranged co-production training and were undertaking a review of the number and structure of care plan documents.

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 we spoke with generally felt involved in their care. They told us they were able to have 1:1 named nurse sessions and could attend their multidisciplinary team reviews if they wished. There were processes to contribute to the reviews even if they did not attend in person. However, not every patient we spoke with did this and not every patient felt they were involved or listened to.

Patients we spoke with told us that family members and loved ones were involved in their care where they wanted them to be. Carers and family members were able to attend multidisciplinary team reviews alongside on behalf of the patient.

Staff we spoke with demonstrated a good understanding of individual patients. They were able to give examples of how they delivered personalised care and how they considered patients individual needs, goals and preferences. Staff were able to describe how they encouraged patient and carer involvement in care and treatment, for example in 1:1 sessions or supporting patients to attend multidisciplinary team reviews. They acknowledged that some patients were more involved than others and understood the work that was being done to improve care plan documents.

We attended two multidisciplinary patient review meetings. The meetings were well structured and included patients and family members where they wanted to be involved. The reviews were comprehensive, holistic and personalised. Staff demonstrated a good understanding of individual patients’ history, presentation, strengths and goals. However, we reviewed nine care records and found that care plans did not always reflect the holistic, person-centred conversations held in the multidisciplinary meetings. Some care plans had generic elements within them which were based around NICE guidance. The service had identified this as a concern through their governance and assurance processes. The service had developed an action plan to address this. At the time of our assessment staff had completed co-production training that had been delivered by an individual with lived experience. There was an ongoing project to improve the personalisation of care plans and prompt more service patient involvement and ownership.

Assurance processes had identified that care plans were not as personalised and individual as they could be. Staff had completed co-production training that was delivered by an individual with lived experience. There was a project ongoing alongside the medical director to improve care plan documents and contents.

Policies and procedures were in place to protect and promote equality, diversity, inclusion and human rights.

We did not ask patient specific questions about care provision, integration and continuity. However, no concerns were raised in this regard. Patients had been supported through the referral and admission process into the service. One patient was able to discuss their discharge plans which included potential visits to onward placements.

The service was part of the Northwest Bed Bureau and provided a service to the northwest region. Staff we spoke with understood the diverse needs of patients who were admitted and had received training to help them understand and meet those needs. Staff were able to explain the process and pathways for admissions, transfers of care and discharges. They described good links with the commissioning bodies that booked their beds. Managers were able to describe how services were coordinated and delivered within the Northwest Bed Bureau.

We contacted stakeholders for comment, but they did not raise any issues.

The service had block booked beds and worked closely with the organisations who commissioned and purchased them. There were systems and pathways in place to ensure continuity of care including guidance on planning and facilitating discharge or transfer of care.

Patients we spoke with told us they had access to the information they needed. They told us that if required they would also ask staff. Patients were aware of the different information available on the ward. None of the patients we spoke with had specific communication needs. Patients told us that they were regularly read their rights in line with the requirements of the Mental Health Act.

Staff we spoke with were able to explain how communication needs were identified during the referral and assessment process. They made sure patients had access to relevant information and were able to provide that information in different formats dependent on need and preference. This included documents and leaflets in easy read, braille and large print formats. The service had access to translation services and provided information leaflets in languages spoken by the patient and local communities. Managers made sure staff and patients could access interpreters and signers where required.

Referral and admission documentation captured patient communication needs. The provider had contracts in place with translation service to provide document, phone and face to face translation.

Patients we spoke with felt involved in decisions on the ward. They attended weekly community meetings where they were able to give feedback and make suggestions. Patients told us that staff were receptive to ideas. Patients knew how to complain if they needed to. Patients were able to give feedback on the service in patient surveys.

Staff we spoke with understood the providers complaints policy. They were able to explain the complaints process and how they would support patients who wished to raise a concern. Staff protected patients who raised concerns or complaints from discrimination and harassment.

Managers investigated complaints and identified themes. They shared feedback from complaints with staff and learning was used to improve the service. The service used compliments to learn, celebrate success and improve the quality of care.

We observed that information on how to complain was provided to patients, carers and family members. The complaints process was advertised on posters and leaflets available on the wards and within the hospital.

There was a complaints policy and process in place. We were satisfied that the service dealt with complaints appropriately and complied with their own policy. Managers and senior staff had been trained to complete complaint investigations when this was required. Complaints were monitored at a hospital and provider level to identify themes and trends and monitor responses. In the 12 months prior to our assessment the service had received 9 complaints. Two complaints were upheld, three complaints were partially upheld, and four complaints were not upheld.

Staff completed annual Suggestions, Ideas and Complaints training. At the time of our assessment compliance with training was 97.62%.

We did not ask patients specific questions around equity of access. However, no concerns were raised regarding the referral and admission process or any discriminatory behaviour. We did not speak to any patients who required reasonable adjustments.

Staff we spoke with were up to date with their Diversity, Equity and Inclusion training. Complex referrals were reviewed by a multidisciplinary team to ensure that need could be met. Leaders and staff were alert to discrimination and inequality that could disadvantage different groups of people in accessing care, treatment and support. They were aware of the reasonable adjustments they could make and how to source additional specialist advice or equipment when required.

We contacted stakeholders for comment, but they did not raise any issues.

Beds in the service were either block booked or spot purchased by commissioning organisations. Referrals into the service were made by those organisations and the service was not a frontline service. Referrals and transfers into the service were managed in a timely manner and promoted continuity of care.

Referral, assessment and admission processes considered the needs of people with different protected characteristics and the service made reasonable adjustments to avoid discrimination and meet need.

Staff completed Diversity, Equity and Inclusion training as part of their mandatory training programme. At the time of our assessment compliance with the training was 100%.

We did not ask patients specific questions around equity of experience or outcome. However, none of the patients we spoke with raised concerns about discriminatory behaviour by the staff or the service and we saw no evidence of concerns. Patients we spoke with generally felt involved in their care and treatment.

Staff we spoke with were up to date with their Diversity, Equity and Inclusion training. They were aware of the resources available to them to support patients during their care and treatment including translation services, pastoral support and speech and language therapy services.

Staff were able to give examples of where adjustments had been made or were in place to support patients with mobility concerns. Staff supported patients with religious or spiritual needs including supporting access to places of worship and offering cultural and religious specific foods.

Senior managers were able to describe how patient experience and outcome was considered from the perspective of protected characteristics, for example when reviewing incidents and the use of restraint or seclusion.

Beds in the service were either block booked or spot purchased by commissioning organisations. Referrals into the service were made by those organisations and the service was not a frontline service. Referrals and transfers into the service were managed in a timely manner and promoted continuity of care.

Referral, assessment and admission processes considered the needs of people with different protected characteristics and the service made reasonable adjustments to avoid discrimination and meet need. Patients had access to an interfaith room and cultural and religious specific diets. Leo ward was a ground floor facility and had an assisted bathroom for patients with mobility issues. Staff had access to interpretation services and were able to produce information in different formats, for example easy read.

Incident reviews and particularly the use of restraint and seclusion included consideration of protected characteristics. Patient outcomes were reviewed in line with protected characteristics by both the hospital and commissioning bodies.

Staff completed Diversity, Equity and Inclusion training as part of their mandatory training programme. At the time of our assessment compliance with the training was 100%.

We did not ask patients specific questions in relation to planning for the future. However, patients we spoke with did not raise any concerns in this regard. We did not speak to any patients with an advanced decision or do not resuscitate order in place. We spoke to one patient who was involved in their discharge planning and agreeing on an onward placement.

We did not ask staff specific questions about planning for the future. Staff were able to discuss long term plans for patients in terms of treatment goals and objectives for discharge or the transfer of care to a different service.

There were processes in place to facilitate the planning and delivery of discharge or transfer of care. There were processes in place to support advanced statements where required.