All Saints Hospital

On this page

• 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

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

However, handover notes were not always appropriately recorded or reflective of current patient risks that staff may need to be aware of.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

We reviewed 3 patient records during the assessment. Staff had completed a comprehensive mental health assessment of the patient in a timely manner at, or soon after, admission.

Staff assessed patients’ physical health needs in a timely manner after admission.

Staff developed care plans that met the needs identified during assessment. Care plans were generally personalised, holistic and recovery-oriented. Staff had developed care plans for areas identified during their assessment of the patient, including in relation to physical health issues. Physical health care plans for patients were mostly detailed and provided staff with essential information to support with the management of the issues.

Staff updated care plans when necessary.

The service planned and delivered people’s care and treatment 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. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence.

Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. The service had input from a dietician, a speech and language therapist and a physiotherapist who attended on a fortnightly basis.

The service had an agreement with a local GP practice to provide ongoing support in respect of physical health. The GP practice used had recently changed due to the previous practice being out of the local area. Managers reflected that they had been keen to ensure that the offer to patients was not impacted by this decision and were keen to maintain a positive working relationship with the new practice.

Staff monitored patients’ physical health using appropriate monitoring tools. Where patients refused their physical observations, the service had a process in place that staff would follow including the use of no contact physical observations where staff had concerns about a patient.

The dietician had devised a weight management pathway for the service which meant that any patient with a certain body mass index (BMI) would be referred to them. This would also be discussed and reviewed at the patient’s ward round.

The service had a local physical health meeting along with a regional meeting.

Managers provided staff with supervision and appraisal of their work performance.

The percentage of staff that had had an appraisal in the last 12 months was 87% as of September 2025. The service noted there had been challenges with the completion of appraisals prior to April 2025, particularly for the nursing department. The service had implemented an action plan to address this which was resulting in improved completion rates.

The average percentage of permanent staff that had received supervision was 89% for the 12 months prior to the assessment. The average percentage of bank staff that had received supervision was lower at 59.75% for the same period.

The service noted that supervision of bank staff had been a challenge due to some staff members not picking up shifts or making themselves available for supervision where this was required in line with the service policy. The service had identified this as a risk, and this was recorded on the governance risk analysis as an area identified for improvement.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Managers ensured that staff received the necessary specialist training for their roles.

Managers dealt with poor staff performance promptly and effectively. Managers gave examples of how they had oversight of staff performance and actions they would take if issues were identified.

Staff participated in clinical audit, benchmarking and quality improvement initiatives. The service had a local and organisational audit calendar which identified when and how often audits were undertaken within the service.

Mental Health Act

93.1% of staff had received training in the Mental Health Act.

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

The provider had relevant policies and procedures that reflected the most recent guidance. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had easy access to information about independent mental health advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

The service did not always ensure that information being shared across handovers was documented and recorded appropriately. However, the service generally 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 held regular and effective multidisciplinary meetings. We observed patient ward rounds during the assessment. Patients chaired their ward rounds and had advocacy in attendance. Patients were involved in reviewing their risk assessments during these meetings. Staff promoted engagement and the patient’s voice within these meetings.

We observed a senior management team handover. Staff shared essential information about patients and the service during the handover.

We reviewed handover notes during the assessment. Within the handover notes and allocations documentation, there was no recording or identification as to which staff on shift could sign. We observed that this was considered verbally during a senior management team handover that we observed, however, this was not documented or recorded within the notes. There was therefore no clear record as to which staff on each shift could sign.

The teams had effective working relationships with teams outside the organisation. Managers reported positive relationships with external agencies and stakeholders.

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, reduce their future needs for care and support.

Staff supported patients to live healthier lives. The service had an occupational therapy team who could plan patient meals with them and hold cooking sessions. The occupational therapy team also supported patients with walks in the community to promote healthy living and exercise. The organisation had a regional occupational therapy lead that the service could access for additional support and advice.

The service had input from a dietician who provided information about nutrition and exercise.

Managers noted that a longer-term goal for the service was to have a men's health group for patients. Managers had asked the nursing team to lead on the development of this.

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.

Staff used recognised rating scales to assess and record severity and outcomes for example, Health of the Nation Outcome Scales. The service utilised rating scales and outcome measures to monitor patients and their progress within the service. There was evidence that staff were undertaking these and reviewing as necessary.

Staff used technology to support patients effectively. Patients noted that technology was used to enable them to keep in touch with their friends and family, along with attending meetings with organisations.

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

Staff took all practical steps to enable patients to make their own decisions. Patients felt involved in decisions about their care and treatment. Patients stated that staff helped them to understand aspects of their care.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. Managers gave examples of how capacity was considered and the processes that were followed within the service.

Patients were informed of their rights under the Mental Health Act. The service had a video that could support staff in this process to ensure this was being appropriately signed to patients. The service would also use interpreters when informing patients of their rights.