Archived: St Mary's Hospital

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We undertook an unannounced focused inspection to review two requirement notices we issued following our last comprehensive inspection in January 2016. We published our inspection report in May 2016. The requirement notices related to the responsive key question, which we rated as requires improvement due to breaches of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014, We found breaches of regulation 9, person centred care and regulation 18, staffing. The provider submitted an action plan to outline how they would meet the required improvements.

We inspected St Mary’s Hospital on 1 November 2016 to see if these improvements had been made. We also asked two key questions within the safe domain in relation to safe and clean environment and managing and assessing risk. We did this after we received some information about the hospital. We visited all five wards at the hospital. We found areas of good practice:

• The wards were clean tidy and there was ongoing maintenance work to ensure the buildings were adequately maintained. The hospital had systems and processes in place to ensure there was ongoing monitoring of the cleanliness of the hospital.

• There were adequate numbers of staff who were trained in basic and immediate life support across the hospital. This meant trained staff could respond and act in a medical emergency. The hospital had a clear policy in place for safe and supportive observations of patients. Staff followed the policy and governance audits took place to monitor staff compliance with the policy.

• The hospital had clear medicines management procedures in place. Staff had received refresher training in the administration of medication, and regular prescription chart audits were taking place.

• Staff were knowledgeable about safeguarding and were able to demonstrate the strategies used to safeguard patients and this was evidenced in care records.

• A weekly referrals meeting took place that assessed the suitability of all referrals and assessments. The hospital ran a permitted earnings scheme, where patients could apply for roles within the hospital and be paid for their services.

• Patients had access to a private pay phone, hot and cold drinks throughout the day and were able to personalise their bedrooms. The wards had streamlined the information displayed making it more accessible for patients.

• There had been a significant improvement in how the deaf patients’ communication needs were considered and met which was clearly documented in their care records. There was an increase in the number of staff trained in and receiving training in British sign language.

• The hospital managed complaints in line with the provider policy and patients knew how to raise a complaint. Staff received feedback on complaints through team meetings.

The provider had met the required improvements within six months from the date of the last report being published. This meant we were able to re-assess the responsive domain of the report to a rating of good.

This did not affect the overall rating as this was already good.

However, we also found some areas for improvement:

• Patients told us there were not many diversionary activities that took place on the ward leaving them feeling bored.

• Patients had mixed views about the quality of the food they received.