St Mary's Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed a total of 7 quality statements in the well led key question and found it to be good. The service had not been previously inspected and this domain had not previously been rated.

There was strong and effective leadership at all levels. Managers created a positive culture that encouraged staff feedback and innovation. Staff were positive about the service, managers and culture. Managers had a good understanding of the service and a clear overview of service performance. They were able to describe risks and challenges the service faced as well as actions to address them. There was a commitment to service improvement and innovation.

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.

Staff we spoke with understood the vision and values of the provider. Senior leaders were able to explain how these were embedded into the service and incorporated into activities such as supervision.

The service had a diverse workforce and managers worked to be inclusive including holding themed days around specific cultures or religious events.

The service had an established vision and values in place. These were discussed as part of the staff induction programme.

The service had completed closed culture assessments and delivered closed culture awareness sessions to staff.

The hospital had also completed wider work around culture through a psychology led service evaluation of the social climate using the Essen climate evaluation schema (EssenCES). This took the form of a short quantitative questionnaire given to staff which measures three aspects of social climate; patient cohesion and mutual support, experienced safety and therapeutic hold. Leo scored ‘clearly above average for patient cohesion and mutual support and therapeutic hold. The ward scored average for experienced safety. Eve ward scored clearly above average for patient cohesion and mutual aid. The ward scored average for experienced safety and therapeutic hold. Identified recommendations and actions had been developed from the survey and were monitored through the governance framework.

Staff spoke positively about managers at ward and hospital level. They told us managers were supportive and led by example. Staff knew the providers values and were able to discuss how they reflected these in their day-to-day work.

Managers we spoke with had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed and were visible in the service and approachable for patients and staff. Managers we spoke to demonstrated a good understanding of the challenges their services faced and were able to describe plans to address them.

The provider company’s Senior Operations Director held monthly staff engagement meetings. These were held on a regional basis and staff from the hospital and the service were able to send representatives. The Senior Operations Director also met with patient forums.

Leaders and managers in the service had access to leadership and development training. The service had completed assessments around closed cultures and staff surveys around wider cultural issues.

Staff we spoke with told us they felt able to raise concerns without fear. Staff knew how to escalate concerns and how to use the whistle blowing process. They understood the role of the Freedom to Speak Up Guardian and described an open and honest culture.

Staff had access to a policy detailing the freedom to speak up and whistleblowing procedures. There was a Freedom to speak up guardian in place and the option of contacting the provider company’s board. A high-level overview of any concerns raised with the Freedom to speak up guardian were presented to the board along with details of actions that were being taken. There had been no whistleblowing concerns in relation to Leo or Eve wards.

Staff we spoke with, including those from ethnic minority groups told us they felt supported and considered the service to have an inclusive culture. Some staff attended the hospital’s diversity, equality and inclusion group. Staff had completed staff surveys to enable them to feedback on leadership and culture.

Senior managers within the hospital had completed cultural intelligence training. Managers were able to discuss the annual Workforce race equality standards audit and the associated action plan.

Staff had access to an Equality, diversity and inclusion forum where they could raise any issues or concerns. Staff survey results were analysed considering protected characteristics to help identify themes or areas that may be impacting staff. The staff group was multi-ethnic, and the wards had held themed days around different cultures and foods. Senior managers completed cultural intelligence training.

Staff we spoke with understood their roles and responsibilities. They were able to describe how different roles and professions within the multidisciplinary team worked together to deliver care and treatment.

Managers we spoke with were able to describe the governance and reporting structure at ward and hospital level as well as the quality and assurance processes in place with commissioning bodies. Staff we spoke with knew how to raise concerns and reported that they received feedback when they submitted incidents. They told us they felt empowered to make suggestion for improvement.

Staff we spoke with had completed information governance training and understood the protocols around privacy and confidentiality.

The service had clear and effective governance, management and accountability arrangements. There were processes to identify, understand, monitor and address current and future risks. There were escalation pathways to enable the service to raise concerns at hospital and provider level. Leaders and senior managers demonstrated a good understanding of the issues and challenges faced by the service.

There were forums and processes to monitor performance. The service submitted performance reports to commissioning bodies and were part of monthly governance and quality contract meetings. Staff undertook or participated in regular clinical audits to ensure quality.

Staff had access to a suite of policies, procedures and operational guidance to support them in the delivery of care. Staff could access further support from hospital and provider level teams and specialists where required.

The hospital completed the Data security and protection toolkit. The toolkit is an on-line self-assessment tool that allows organisations to measure their performance against the National Data Guardian’s 10 data security statement. The service had policies and procedures in place to support data protection and confidentiality.

We did not ask patients specific questions around partnerships and communities. However, none of the patients we spoke with raised concerns in this regard. Patients we spoke with did talk about using leave to access the local community and community facilities.

Managers described positive relationships with key external stakeholders including commissioning bodies. They were able to describe how bed occupancy and patient flow was managed in conjunction with those organisations and the Northwest Bed Bureau. Staff were knowledgeable about local support services.

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

The ward bed stock was managed regionally by the Northwest Bed Bureau and beds were block booked. There were appropriate governance and reporting structures in place to support effective monitoring of quality and performance.

Staff we spoke with had completed quality improvement training. Staff were aware of some quality improvement projects that had been undertaken but we did not speak to any staff who had been directly involved. Staff told us they felt empowered to make suggestions and put forward ideas to support quality improvement.

Staff completed quality improvement training. There was access to a quality improvement mentor within the hospital. The quality improvement mentor and hospital manager attended a monthly quality improvement group held at provider level that considered new initiatives. The service had been involved in quality improvement initiatives, including improving support to staff who had suffered racial or sexual abuse from patients.