The Mary How Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked at whether people’s needs were assessed effectively, whether care was coordinated, and how the service supported positive health outcomes.

The service provided effective care through comprehensive health assessments, screening tests and personalised health advice. Staff worked collaboratively within the service and with GPs to support continuity of care. Staff used screening results and audits to monitor outcomes and drive service improvements. Staff supported patients to make informed decisions about their health and wellbeing and demonstrated a good understanding of consent and the Mental Capacity Act. Overall, the service helped people better understand and manage their health and wellbeing through early detection, health promotion and coordinated care.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff completed a comprehensive health assessment and discussed a range of lifestyle and wellbeing topics with patients. We reviewed 10 care records and found staff consistently assessed and recorded relevant information to support effective care and treatment. These included family medical history, diet, alcohol consumption, smoking, exercise, sleep, stress and wellbeing, osteoporosis, skin health, and gender-specific health concerns. Staff used this information to identify potential health risks. Where appropriate, nursing staff completed diabetes risk assessments and provided personalised advice to help patients understand their health risks and improve their health and wellbeing.

Staff carried out a wide range of screening tests and health measurements. Staff recorded patients’ height, weight, waist measurement, body mass index (BMI), body fat percentage, visceral fat level (fat stored around internal organs), basal metabolic rate and total body water. Staff also checked blood pressure, resting pulse and carried out an electrocardiogram (ECG) to assess heart health. Staff carried out bowel screening using a Faecal Immunochemical Test (FIT), a urine dip test, and blood tests to assess cholesterol levels, blood count, kidney function, liver function and other key indicators of health. Depending on age and gender, staff also carried out a cardiovascular risk assessment and prostate-specific antigen (PSA) testing where appropriate.

Staff arranged ultrasound screening appointments as part of the assessment process. These included abdominal ultrasound examinations of the liver, gallbladder, kidneys, pancreas, spleen, bladder and abdominal aorta. Women also received a pelvic ultrasound to assess the uterus and ovaries, while men received an ultrasound examination of the prostate. Clinicians discussed screening results with patients and signposted them to their GP or other healthcare services when further assessment or investigation was needed.

The evidence showed a good standard. The service planned and delivered people’s care with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The service delivered care in line with evidence-based practice by using recognised screening tests, diagnostic assessments and health risk assessment tools. The service delivered care and screening in line with recognised national guidance and professional standards, including guidance from the National Institute for Health and Care Excellence, the British Medical Ultrasound Society, and national Infection Prevention and Control guidance. Staff told us these frameworks informed their clinical practice, decision-making, and the delivery of screening procedures. This was important because it helped ensure care was evidence-based, safe, effective, and consistent with current best practice. Adherence to nationally recognised standards also supported the early identification of health risks, maintained the quality and accuracy of diagnostic screening processes, and reduced the risk of avoidable harm to people using the service

Staff used the results of diagnostic tests and health screening assessments to support people to better understand their current health status and any potential risks identified during the screening process. Results were discussed with patients in a clear and accessible way, enabling them to make informed decisions about their health and wellbeing. Where concerns or abnormalities were identified, staff provided advice and guidance and, when appropriate, recommended further assessment, investigation, or treatment through the person's general practitioner or other healthcare services. This personalised approach helped ensure people were empowered to take an active role in managing their health, while facilitating timely access to additional support and intervention when required.

The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff worked closely together to review screening results and provide joined-up care. They regularly discussed patients to ensure advice reflected all available information from screening tests. Sonographers used a ‘red flag’ system to highlight potentially concerning findings identified during an ultrasound scan. Nurses reviewed these findings and included appropriate advice and recommendations in the patients’ results letters.

The service coordinated nurse-led screening appointments and ultrasound screening appointments to take place on the same day where possible. This one-stop approach helped provide coordinated care and improved the patient experience.

Staff worked with GPs when follow-up care was needed. With the patient's consent, the service shared screening results with their GP. Staff also responded to GP queries and provided additional information to support ongoing care where required.

The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Nursing staff assessed each patient’s health during their screening appointment and provided personalised advice to support healthier lifestyle choices. Before attending, patients completed a health questionnaire, which helped staff identify any risk factors and guided discussions about health and wellbeing. For example, if a patient reported drinking more alcohol than the recommended weekly amount, the nurse discussed ways to reduce their intake and improve their overall health.

Staff supported national health priorities by offering advice and signposting patients to services that could help them stop smoking, manage their weight and reduce their risk of cancer and other long-term conditions.

The service displayed information in patient areas to promote healthy lifestyles and wellbeing. Posters were available in waiting and clinical areas, and patients received information tailored to their screening results. Where results identified areas for improvement, nurses included relevant information and guidance in patients’ results letters to help them manage their health and wellbeing.

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Clinical staff used information from screening results and service performance to improve patient outcomes and the quality of care provided. The service routinely monitored the outcomes of screening appointments, including the number of patients referred to their GP for further investigation or follow-up. Leaders reviewed this information to identify trends and opportunities for improvement. For example, analysis of referral data showed that bowel screening results were the most common reason for GP referral. In response, managers considered changes to the bowel screening process and how they could provide patients with additional information and support.

The service also monitored the quality of clinical practice. Sonographers completed monthly peer reviews of ultrasound image reports against British Medical Ultrasound Society (BMUS) guidance. They recorded the findings of these reviews and identified actions where improvements were needed. Managers monitored the outcomes of peer reviews to make sure actions were completed and learning was shared across the team. Staff received feedback through team meetings and email updates, which helped promote continuous learning and maintain the quality of the service.

The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

The service gained consent from patients for screening in line with legislation and guidance. Staff provided patients with information about the screening programme, including what to expect and the tests involved, before their appointment. The service obtained consent electronically before patients completed the health questionnaire and recorded consent within the patient's electronic record. Staff ensured patients made informed decisions based on the information available to them. 

The service had an up-to-date, version-controlled Mental Capacity Act and Deprivation of Liberty Safeguards policy. Staff understood the requirements of the Mental Capacity Act 2005 and consent legislation and knew who to contact for advice if needed. Staff explained how they gained informed consent and checked that patients understood, retained and could weigh up information about screening tests. Staff told us they would not proceed with screening if they had concerns about a patient's capacity and would seek support from managers when required.

Clinical staff completed training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff demonstrated a good understanding of the principles of the Mental Capacity Act and explained how they applied these in their day-to-day practice. They understood the importance of supporting people to make their own decisions, gaining valid consent, and providing information in a way people could understand.

Staff described how they would identify when a patient might lack capacity and the action they would take to assess capacity and act in the person's best interests where necessary. They also understood the need to make reasonable adjustments and offer additional support to help people make informed choices about their care. Staff gave examples of how they used this knowledge in practice, including adapting their communication, checking patients understood the information provided, and ensuring consent was obtained before carrying out screening procedures.