St Mary's Hospital

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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

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.

We assessed 4 quality statements. At our last assessment we rated this key question good. At this assessment the rating has remained good. We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

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.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We scored the service as 3. The evidence showed a good standard. 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.

The trust's intranet contained a comprehensive range of policies and standard operating procedures which reflected best practice. It provided guidance for staff around working with multi-agency teams and for the delegation of clinical tasks to ensure the right people delivered evidence-based care and treatment.

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. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance.

Wards had inclusion and exclusion criteria that were appropriate to the specialty. For example, Colwell ward cared for older patients aged 75 and over who had an assessed frailty score above 5 and dementia, and ward staff had identified dementia and distressed patients as part of the ward profile. A doctor was allocated to the ward with formal feedback meetings and protected clinical time between 9am and 10am, supporting continuity and evidence-based frailty care consistent with National Institute for Health and Care Excellence (NICE) guidance. On the chemotherapy unit, a clinical nurse specialist (CNS) was aligned to each tumour group, and we observed new patients on their first cycle of treatment being supported in line with NICE cancer service guidance.

Appley ward patients reported staff had “gone above and beyond for my respiratory care” with clinical notes showing physiotherapy involvement and communication with mainland specialists regarding pulmonary fibrosis management that was consistent with NICE guidance. On SDEC unit, staff reported patients received an immediate consultant review when they identified there were signs of a clinical deterioration, which supported evidence based acute ambulatory care models under the NHS same day emergency care operational guidance.

Visual Infusion Phlebitis(VIP) scores and PVAD (Peripheral Venous Access Device) checks are essential in the Coronary Care Unit (CCU) to monitor for complications such as phlebitis, infiltration, or extravasation, which can occur with frequent medication administration In line with NICE guidance and local clinical policy, we saw that Coronary Care Unit (CCU) staff completed VIP/PVAD checks clearly and accurately, supporting early identification of complications and safe patient care.

In most wards we observed fluid balance charts were completed to a high standard, were accurate, and were consistent with patients’ individual care needs.

The trust was awarded full accreditation by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) in October 2025.

The trusts current Sepsis 6 compliance stands at 93%. While sepsis data is collated at trust level by the Critical Care Outreach team, it is not broken down by department. The trust recognises that departmental‑level data would enhance oversight, enable more effective analysis, and inform targeted improvement actions

We scored the service as 3. 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.

The service demonstrated multidisciplinary and cross-team work, with collaboration embedded as a cultural norm rather than a process. We observed communication and coordination between staff of all roles and grades, with patient information shared promptly and effectively to ensure continuity of care.

Managers held regular, structured multidisciplinary team (MDT) meetings that promoted cohesive working, shared learning, and collaborative decision making. All relevant staff were invited to MDT meetings. Effective and compassionate board rounds were observed across medical wards with staff from multidisciplinary teams reviewing and discussing patients to ensure they receive the correct treatment, care and discharge planning.

Cross team working extended beyond the wards. On the chemotherapy unit, staff worked closely with the Wessex Cancer Alliance supporting access to specialist pathways and regional expertise consistent with NHS England's Cancer Alliance model for coordinated cancer care. On the SDEC unit, staff confirmed that GPs could phone consultants directly, enabling rapid senior decision making and avoiding unnecessary emergency department admissions. The trust’s resuscitation team supported wards with training and emergency response, strengthening compliance with the Resuscitation Council UK 2021 guidelines and ensuring staff across the medical care group had immediate access to expert life support guidance.

Also, the therapy team on Appley ward held a daily midday meeting with therapies to escalate concerns. Therapy staff described how discharge issues were discussed directly with nursing staff in the ward and progressed through ward meetings, supporting a coordinated discharge planning approach. The therapy team had newly created a referral system which the ward staff described as having “massively benefited” patient flow and rehabilitation access. The team was based in the emergency department but worked across all wards under the medical care division, except for Compton ward.

Dementia and mental health liaison arrangements were a particular strength on the stroke unit. Staff told us about The Older People’s Mental Health (OPMH) referral process, who reported that the dementia liaison team were “very good to work with”.

However, staff on 2 wards had noted that recent reduced involvement from mental health team since recent service changes meant that the consultant team was less involved in care. This was evident in 4 patient records reviewed, where documentation was limited or awaiting consultant review. Leaders were aware of the changes in the mental health service model at the trust, and its impact was being actively monitored.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We scored the service as 3. 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.

The service routinely delivered care and treatment in line with the guidelines and participated in 27 national audits logged across Unplanned Care, Planned Care, Corporate, and Trust-wide programmes during 2025-2026. These included cancer audits, the Sentinel Stroke National Audit programme (SSNAP), the National Cardiac Arrest Audit (ICNARC, NCEPOD reports, FFFAP National Hip Fracture Database, UK Renal registry, BAUS urology audits, the National Ophthalmology Database, the National Joint Registry, and the National Audit of Inpatient Falls (NAIF). Most submissions were submitted on time with compliance ratings that were rated as either “green” or “yellow”, which meant performance was on track and demonstrated a sustained commitment to national benchmarking.

The Stroke Sentinel National Audit Programme (SNAPP) is the national audit benchmarking acute and post-acute stroke care against evidence-based standards. Results between July and September showed the hospital retained and overall grade of ‘C’, which was one of the highest scoring trusts in most domains, within Wessex.

The service performed well in the National Lung cancer Audit (NLCA). Compared with the NLCA 2026 benchmarks, the service achieved full performance in key areas. The service made sure that all lung cancer patients (100%) were seen by a lung cancer nurse specialist, which is higher than the national target of 90% in England. This is also much higher than the England average of 64%, showing strong and consistent patient support. One patient who fit this demographic on Appley ward told us they had experienced a definite improvement in their condition since admission. They said their oxygen requirements had reduced, and they had regained some mobility as a result of the care provided.

Getting It Right First Time (GIRFT) data showed sustained operational improvement. The number of patients who did not attend their appointments fell from 8.6% in January 2023 to 5.7% in September 2025. The 52-week waiting position moved from 0.69% to 0%.

Stroke performance was mostly supported by the trusts Sentinel Stroke National Audit Programme (SSNAP) data, but there were delays in patients accessing definitive stroke care. SSNAP data showed areas of positive performance, however during the audit period, reperfusion performance dropped to a D rating. This was linked to delays between patients arriving at the hospital and leaving for definitive stroke care. Staff told us, and data supported, that delays in the receiving mainland hospital accepting patients for transfer also contributed to this. This meant that although the service monitored stroke performance, some patients experienced delays in accessing time-critical specialist stroke treatment.

We scored the service as 3. 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.

Staff had access to a clearly communicated consent policy and understood the principles of informed consent. Patients told us staff explained care and treatment options and gained verbal consent before undertaking physical assessments, and we observed staff taking the time to explain the treatments and options that were available to them. We also reviewed files during the assessment that showed staff gained and documented consent from patients for their care and treatment appropriately.

We spoke with staff who understood the relevant consent and decision-making requirements of the Mental Health Act 1983 (as amended 2007), their responsibilities as part of the Mental Capacity Act 2005 and knew who to contact for advice when decisions were complex. Staff could describe how to access the trust’s consent policy and obtain accurate guidance on the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

We reviewed 4 patient records and saw that best interest and consent forms were completed for patients who lacked capacity. Staff explained that MCA and DoLs training was mandatory at the service and those spoken with were able to describe the MCA and its practical application on the ward. The service provided evidence that mandatory Mental Capacity Act training compliance was 90% for most staff groups; however, compliance for medical and dental, it was significantly lower at 56%.

The service monitored consent and mental capacity practice, but audit results showed compliance was not yet consistently high enough to provide full assurance that records were always completed in line with expected standards. Local audit activity demonstrated active monitoring of consent and capacity related practice. The trust’s Ceiling of Treatment and Resuscitation Decision Record audits achieved 76% compliance with 76 submissions in January 2026 and the Nursing Record Keeping audit reached 72% compliance with 129 submissions. The Nursing Documentation Standards and Care Planning audit achieved 67% compliance with 74 submissions in the same month.