St Martha's

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

Leaders and staff had a shared vision and culture based on listening, learning and trust.

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 service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had clear vision and values based on a strategy, that staff demonstrated they understood. In all wards, staff members said they were moving towards a shared direction and culture. Staff members, spoken to at our focus groups and on site, said that the culture on wards was positive with good staff morale. The Chief Executive Officer (CEO) said it was a positive culture designed to improve the quality of life for patients.

The service ensured good communication with staff via emails and staff meetings. They ensured this was in an accessible format for staff for whom English was not their first language.

Senior staff listened to patients. For example, in 2024, the staff changed the Multi Disciplinary team (MDT) format so they involved the patient in the meeting at a time the patient was comfortable with. Patients told us this put them at ease.

Senior staff were very visible with the CEO on site three days a week. Senior staff offered an open door to staff. Staff members said they found this useful.

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 with responsibility for the mental health wards had the right knowledge and skills to ensure the wards provided high quality care to the patients. Ward leaders and senior managers had worked in similar services for many years and understood the challenges that front line staff address on a daily basis.

The leadership team demonstrated they were capable leaders because they had a wide variety of knowledge and experience. The hospital director had worked in mental health for 24 years as a mental health nurse. They had managerial roles across their career in Mental Health wards. The CEO had a comprehensive background of 30 years working in a variety of roles including nursing units.

St Martha's was a member of the Quality Network for Older Adults Mental Health Service (QNOAMHS) and participated in the peer review process. They were also accredited with local universities to teach and were part of an associate nursing course.

The leadership team demonstrated they were inclusive leaders. Inclusion and diversity training was provided for staff three yearly. They also provided Oliver McGowen training (training on learning disability and Autism) designed to improve their skills and understanding in supporting autistic patients and those with learning disabilities through NHS training sites.

Staff members and patients spoken with, described the managers as compassionate and they had confidence in their decisions. Staff members welcomed the no tolerance approach around racial abuse in the service. They said it made them feel valued.

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

The service created a positive culture where patients felt that they could speak up and that their voice would be heard. Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

The freedom to speak up guardian was the head of education. They reported to the clinical governance meeting. They met all new staff and displayed posters around the site to ensure staff knew who they were. The guardian was involved in incidents across the wards. For example, they were involved in a recent concern about medication. This was investigated and resolved with staff members. This included a lessons learnt analysis sent to staff about communicating patients’ legal status to ensure staff learning and safe patient care and treatment.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Staff were happy and confident with raising concerns and speaking up. They said they would raise any concerns they had about patient care and treatment. They felt they would be listened to and action would be taking to address their concerns. For example, the support workers were concerned they did not have access to IT communication. The service then provided printed handouts for information accessibility. These were available in formats for staff for whom English was not their first language. Staff members welcomed these changes.

Staff were happy and confident with raising concerns and speaking up. They told us they would raise any concerns they had about patient care and treatment.

Patients and carers were involved in decision-making about changes to the service. For example, on Shamrock Ward, patients asked for more access to nature, which resulted in the ward acquiring chickens, which the patients looked after.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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

There were systems in place for oversight of risks in the service to ensure staff were working safely and patients’ needs were met. These included regular oversight meetings that looked at, for example policies like the visiting policy, Inquest updates, the corporate risk register, serious incidents and duty of candour.

The service had oversight of complaints. They looked for themes and investigated appropriately communicating to the relatives.

Staff met regularly with patients and their relatives to establish if they felt safe or not. The manager ensured staff asked the patients what changes would make them feel safer and how they could improve the ward. Recent changes included changes to the environment, introduction of cars to take patients out and keeping chickens on the grounds. Patients told us they understood the complaints procedure and would make a complaint if they were unhappy with an aspect of their care.

Staff members told us they were confident in the systems of governance in place. The Director managed the managers of the ward and he in turn was managed by the CEO. There were regular clinical meetings and staff one to ones in place to ensure effective lines of communication.

However, oversight of the systems in place to ensure patients were safe from the risk of ligatures needed to be further developed to ensure patient safety.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.