The Mary How Trust

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

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. The service had made improvements and is no longer in breach of regulations. This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

The service was well-led, with effective governance systems, supportive and visible leaders, and a culture focused on delivering high-quality, person-centred care. Staff felt valued, able to speak up, and involved in service improvement. Leaders used audits, performance data and feedback to monitor quality, manage risks and drive continuous improvement, while maintaining strong partnerships with external organisations to support safe and effective care.

We have not awarded this service a score for Well-led.

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

The evidence showed a good standard. The service had a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Leaders communicated the vision and values effectively, and staff understood how their roles contributed to delivering the organisation's objectives.

Staff were aware of and understood the service's vision and objectives, which focused on delivering high-quality health screening services, maintaining best practice standards and ensuring the long-term sustainability of the service. These objectives were regularly monitored by leaders through governance processes and board meetings.

The provider's leadership team had successfully communicated the vision and values to frontline staff, who described a culture centred on patient experience and providing person-centred care. Staff were clear about their roles and responsibilities and were able to explain how their work contributed to delivering safe, effective and high-quality care.

Staff had opportunities to share their views on service developments through team meetings, one-to-one discussions and staff surveys. Although the board and senior managers led the development of the organisation's overall strategy, staff understood the strategic direction of the service and how it related to their day-to-day work.

The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the experience, integrity and knowledge to manage the service and showed a good understanding of the challenges and opportunities facing the organisation. They explained how they maintained quality through staff competency assessments, audit activity, performance monitoring and governance processes. Leaders also understood sustainability risks and had taken action to address these through funding strategies and succession planning.

Leaders were visible and approachable to staff. Although managers were not always physically present on site, staff consistently reported that they were accessible by phone or email and described them as supportive and responsive. Staff felt respected and valued and were able to raise concerns openly.

The service had established arrangements to support leadership development and career progression. These included a leadership strategy, a development programme, and succession planning to prepare staff for more senior roles in the future. Staff also had opportunities for career development as the organisation planned for future service changes and expansion.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff reported good access to senior leaders, who were visible, approachable and receptive to feedback. Opportunities to share views were available through team meetings, and one-to-one discussions. As a small organisation, there were close working relationships between staff and leaders, enabling staff to raise concerns and contribute to discussions about service development and quality improvement.

The service actively encouraged patients to provide feedback about their experience through questionnaires following their screening appointments and through direct contact with the service. Information about how to provide feedback, raise concerns or make a complaint was available in accessible formats, including easy-read versions, ensuring people could share their views in a way that met their individual needs. Feedback received was overwhelmingly positive and demonstrated high levels of satisfaction with the care and support provided.

Leaders and staff reviewed feedback from patients and staff through governance processes, team meetings and one-to-one discussions. Leaders used patient feedback, audit activity and performance monitoring to identify opportunities for improvement and inform service developments. Staff told us they were kept informed of service changes and had opportunities to discuss learning and improvements.

Leaders considered patients’ feedback and suggestions when making service improvements and planning future developments. The service maintained an open culture that welcomed feedback and viewed it as an opportunity to improve the patients’ experience.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service supported flexible and responsive working arrangements where required. Staff reported that managers were proactive and supportive when employees experienced health issues, and opportunities were available to discuss individual circumstances through regular one-to-one meetings. This approach helped ensure staff felt valued and supported in their roles.

Managers demonstrated a commitment to supporting staff wellbeing and making reasonable adjustments where needed. The service promoted an open culture where staff could raise concerns and discuss support requirements without fear of negative consequences.

The service supported workforce development and inclusion through career development opportunities and succession planning. 

While there was no specific evidence of formal workforce equality monitoring or designated equality and diversity champion roles, staff consistently reported feeling treated fairly and equitably, regardless of their individual circumstances.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Staff had regular opportunities through team meetings and one-to-one discussions to share concerns, discuss service developments and receive updates about quality and performance.

Staff participated in clinical audits and quality monitoring activities, and leaders used performance data, audit findings and competency assessments to provide assurance about the quality and safety of the service. Staff understood how to work with external organisations, including GPs and NHS providers, to support patient care. 

Leaders maintained an up-to-date risk register, and staff concerns reflected the risks identified by leaders, including service sustainability. The service had business continuity plans for emergencies, and staff had access to the equipment, IT systems and information needed to perform their roles. 

Leaders maintained information governance arrangements that kept patient records secure and confidential, and provided managers with timely information to monitor performance and identify areas for improvement.

Leaders had effective systems to ensure learning from incidents, complaints and feedback was shared with staff and used to support service improvement. There had also been no complaints during the reporting period.

The registered managers demonstrated a clear understanding of their responsibilities in relation to statutory notifications. They told us they would ensure any notifiable incidents or events were reported in a timely manner and in accordance with regulatory requirements, supporting openness, transparency and regulatory compliance.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders worked with external organisations, including local GP practices to ensure effective referral pathways and continuity of care. The service also engaged with the wider community through fundraising events and outreach activities and provided health screening services to specific groups, including veterans and police personnel.

The service actively encouraged patients to provide feedback through questionnaires following screening appointments, and leaders reviewed comments to identify opportunities for improvement. Staff were also regularly engaged through team meetings, one-to-one discussions and wellbeing surveys, providing opportunities to share views on service developments and raise concerns. 

Leaders maintained effective working relationships with healthcare partners and local stakeholders to support continuity of care and promote awareness of the service within the community.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. 

As a small service, staff worked closely together and were encouraged to contribute ideas to improve how the service operated. Staff described a collaborative culture where new ways of working were welcomed, helping the service remain flexible and responsive to patient needs.

Leaders and staff demonstrated innovative thinking by developing and expanding the service to meet demand, including plans to open a second health screening clinic. The service's preventative screening model was aligned with wider NHS priorities around health improvement, early detection and illness prevention, supporting local communities to take a proactive approach to their health.

The service used patient feedback, audit activity and performance monitoring to identify opportunities for improvement and inform service development. Staff contributed to discussions about service improvements and developments, supporting a dynamic approach focused on maintaining quality while expanding access to screening services. While there was no evidence of formal research activity, the service demonstrated a clear commitment to learning, innovation and continuous improvement.