St Mary's Hospital

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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We assessed 6 quality statements on leadership and governance. Leaders understood and embodied the culture and values of the workforce and the organisation. They had the skills and knowledge, experience and credibility to lead well. They demonstrated their integrity and honesty which was recognised by their staff. There was a clear system of governance and risk management based around delivering safe and good quality care and treatment. The service worked with stakeholders and partners to drive improvements to care pathways. Leaders promoted an open and transparent culture, encouraging staff to raise concerns and supporting innovation both within the organisation and across system partners. However, leadership oversight was not fully effective in mitigating risks related to staffing shortages, nor in ensuring consistent oversight of appraisals and mandatory training.

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.

We scored the service as 3. The evidence showed a good standard. 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 worked with people and partners to maintain a shared direction and culture and had various clinically led specialty visions in place, that were aligned to a clear trust strategy and a strong understanding of the strategic context of delivering services on an island site.

The Group Chief Medical Officer led the development and alignment of specialty visions with the trust’s overall clinical strategy, with engagement from key stakeholders. These visions had been in development since 2023 alongside the clinical and trust strategy and covered quality frameworks, workforce sharing agreements and programme delivery under the partnership framework.

Trust-wide goals had clear and measurable objectives. For Medicine and Emergency Care, the objectives and strategic initiatives in place were underpinned by the trust’s objectives of having no avoidable delays. In the past 3 months, medicine had achieved a 25% reduction within the endoscopy waiting list.

Equality and diversity were actively promoted at strategic level. The assessment team observed that equality and diversity were actively promoted within the workforce and the causes of any workforce inequality were identified, with action taken to address some impact. This aligned with the Equality Act 2010 and The NHS Workforce Disability Equality standard, WDES and The NHS Workforce Race Equality Standard (WRES). The newly appointed trust chair, appointed in April 2025, brings strategic equality credibility to this agenda having previously served NHS England's Director of Equality and Inclusion.

The trusts joint digital strategy supported long term digital development in medical care. Both trusts had published a joint digital strategy with a current focus on intranet design, digital infrastructure design and a virtual hospital programme.

We scored the service as 3. 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.

The service had capable, compassionate and inclusive leaders at every level, with clear leadership structures, visible day-to-day presence and an open-door culture supporting psychological safety.

The leadership structure for medical wards was clear and effective. The medical wards were led by an acute specialty medicine triumvirate team comprising of a senior head of nursing, a senior general manager and a clinical director. They were supported in each specialty by lead nurses, matrons, service managers, clinical leads and ward managers who provided accessible leadership across professional groups.

Staff described leadership visibility and accessibility as “strong”. They told us leaders had regular day‑to‑day contact with staff across the hospital. Leaders said the island was small enough to allow them to maintain frequent, direct contact with staff and clinical areas, and staff told us they felt able to approach leaders easily. Staff said and we observed that there was an open-door culture across the senior leadership team. Senior staff had protected time between 9am and 10am to attend ward huddles and clinical areas. Nursing leaders held away days and regular direct engagement sessions with ward managers, matrons and wider teams. Managers and staff said teams felt able to raise concerns directly to senior leadership and trusted them to act on these.

Leaders described awareness of the operational and emotional pressures on staff, including those in patient facing roles and active engagement with safe staffing and leadership stability arrangements.

On the Same Day Emergency (SDEC) unit, staff described consultants as very supportive and that they were always willing to review patients promptly and make direct decisions. Staff and managers described consultants as “very visible”.

Inclusive leadership was actively demonstrated, and the causes of workforce inequality were identified, and actions had been developed in order to address the impacts. We spoke to nursing staff recruited from overseas, who described feeling well integrated into their teams. Staff also told us that reasonable adjustments were made to support their cultural and religious needs, including time and space to pray.

We scored the service as 3. 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.

The service had a working Freedom to Speak Up (FTSU) framework contracted to an independent provider, with a 24/7 anonymous reporting tool, a visible open-door culture and operational leadership behaviours consistent with psychological safety broadly aligned with national guidelines. The group‑level FTSU service helped ensure fair access for staff on both the island and the mainland. Island staff could use the same independent speaking‑up support as mainland colleagues, which was especially important given small team sizes that might otherwise make staff hesitant to raise concerns.

Speaking up was reinforced through visible, day‑to‑day leadership behaviours. Leaders told us that staff were able to raise concerns directly with them. Senior leaders were visible on the wards, and accessible leadership at acute specialty medicine, lead nurse, matron, and ward manager levels provided multiple routes for escalation alongside the formal Freedom to Speak Up (FTSU) service. Staff feedback indicated psychological safety in most wards, and staff described ward managers as “very supportive” and make direct decisions.

However, the hospital’s FTSU policy was in the process of being updated to reflect the addition of the guardian service and so had exceeded its intended review date.

Also, evidence of FTSU usage data, themes and learning was not actively triangulated within the documents we reviewed. Without this, we could not confirm whether speaking up concerns are being acted upon at the system level, whether themes are being identified or whether learning is being shared.

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.

We scored the service as 2. The evidence showed some shortfalls. Governance arrangements provided oversight of performance, risk and operation pressures; however, they were not always effective in reducing known risks or imbedding improvement.

Governance, management and sustainability arrangements in medical care provided regular oversight of performance and risk, but they were not always effective in reducing known risks or ensuring improvements were embedded. Leaders had clear divisional ownership arrangements for the service and used regular meetings, performance reporting and escalation routes to monitor quality, safety and operational pressures.

However, concerns we identified in safeguarding training compliance, patient flow, discharge delays, staffing gaps and environmental risks on the stroke ward showed that governance processes had not always led to timely or sustained improvement.

Medical care leaders used an established escalation process to respond to operational pressures. Leaders used operational pressures escalation level arrangements to monitor and respond to pressures, including patient flow, ambulance handovers, occupancy and discharge performance. We observed in operational pressures escalation level (OPEL) meeting where leaders confirmed the current local status and used action cards to trigger responses. Actions included additional ward huddles, review of patients ready for discharge and contact with system partners. Staffing and operational issues were reviewed through the day and into the evening.

However, these escalation processes did not always fully mitigate the risks they identified. Although leaders had oversight of patient flow and discharge pressures, risks relating to patient flow and discharge remained rated as high and the target rating had not yet been achieved. Some elements of the discharge model were described by leaders as “fragile”, with reliance on local relationships and the flexibility of small teams. This meant there was a continued risk that patients could experience delays in admission, transfer or discharge when the hospital was under pressure.

The medical care risk register identified a range of risks, but some risks remained high despite ongoing oversight. We reviewed the February 2026 risk register, which included risks relating to environmental safety, workforce, patient flow, discharge and equipment sustainability. Leaders reviewed risks at divisional and corporate level and some recommendations from the previous assessment had been closed. Including improvements to controlled drugs, records of medicines, expiry labelling. However, the continued high rating of some risks show that governance systems had not yet secured enough improvement to reduce the level of risk. The stroke ward environmental risk was recognised, but action had not yet fully reduced the risk to patients. The risk register included the environmental risk linked to the stroke ward layout. Staff told us the reconfigured bay layout required close oversight to keep patients safe and falls data showed the stroke ward had the highest number of falls in the hospital between August 2025 and January 2026. Leaders had completed a full deep dive and identified that some bays carried higher risk because of the ward infrastructure. However, the level of falls and staff concerns showed that the mitigation's in place had not yet fully addressed the risk.

Safeguarding oversight was in place, but it had not ensured consistently safe practice across medical care. Although the hospital had central safeguarding support and governance routes for oversight, safeguarding training compliance was low across the hospital including medical care. Some ward staff we spoke with also had limited knowledge of the trusts process for responding to undisclosed safeguarding concerns. This created a risk that staff may not consistently recognise, escalate or respond to safeguarding concerns In line with trust processes. Leaders had systems to review incidents and take immediate action, but learning was still being embedded. The trust told us about 2 Information Commissioner’s Office (ICO) incidents in the previous six months where immediate actions had been taken and investigations are ongoing.

Workforce sustainability continued to be a key challenge for the trust. While there was structured oversight of workforce risks and ongoing recruitment efforts, vacancies across critical roles, including pharmacy, microbiology and specialist clinical services highlighted continued pressure. A nurse director vacancy with interim cover was identified within the broader workforce findings. While interim arrangements were in place through the Group Deputy Chief Nurse Officer providing cross-site senior nursing oversight, prolonged interim cover at the director level was recognised as a risk to leadership stability and continuity at the time of assessment, the post was substantively filled, demonstrating a prompt response to this risk.121 staffing-related incident reports between June 2025 and February 2026 indicated that despite supportive leadership and clear escalation procedures, frontline staff continued to experience persistent staffing pressures that had not yet been resolved.

Also, mandatory training compliance gaps suggested some leadership oversight challenges in workforce development. Several mandatory training compliance figures were far below trust targets, which included mandatory training requirement on learning disabilities and autism Tier 2 training at 7%, hypoglycaemia training at 7% and insulin pen training at 3%. Appraisal completion and some staff groups also fell below 60%.

We scored the service as 3. 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.

The service worked collaboratively with partners across the system to support effective delivery of care and timely safeguarding decision-making.

Leaders described a strong and constructive working relationships with the local authority, police and multi-agency partners, which enabled coordinated responses where concerns required a multi-agency review. These relationships supported timely information sharing and decision making, and partners recognised the quality of referrals.

Leaders demonstrated a good strategic understanding of the island context, which included the limits and opportunities of providing services on an island site and the need for partnership working with larger organisations to ensure patients had good access to all the services they needed.

Leaders could define which services could be safely sustained locally, and where partnerships with services on the mainland were required. Leaders described a clear vision for a sustainable clinical model that was tailored to its population, supported by continuous service development and transformation.

Partnership arrangements were supported through established governance structures, including system groups such as the Tactical Discharge Group and Post Transition Executive Partnership Group. These forums provided effective oversight of system pressures, discharge pathways and interdependencies across community, acute and mental health services. Regular meetings with clearly defined membership and representation from key system partners helped to ensure that risks were escalated appropriately and that there was shared accountability for addressing system challenges.

However, some discharge model elements were highly dependent on local relationships within a small team’s flexibility, which leaders themselves acknowledged maybe fragile.

Also, while partnership working was strong and generally effective, it was not yet fully embedded or consistently optimised across all areas. Some processes depended on established relationships rather than standardised pathways. There were opportunities to improve how consistently leaders oversaw and reviewed partnership arrangements.

We scored the service as 3. 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. They actively contribute to safe, effective practice and research.

The service demonstrated a strong and embedded culture of continuous learning, improvement and innovation that consistently translated into measurable outcomes for patients.

Staff at all levels were actively engaged in quality improvement activity, supported by visible leadership and structured programmes that promoted innovation and shared learning.

There was clear evidence of impactful, data-driven improvement work at the ward level. For example, in the stroke service, a falls reduction initiative (Project DECAF) had resulted in a sustained reduction in falls of approximately 50%. This has been achieved through a combination of evidence-based interventions, which included environmental changes, proactive toileting support, the introduction of ultra-low beds where appropriate and patient-centred education to support informed decision making around bed rail use. Improvements were underpinned by the use of research and continuous evaluation, and staff were able to describe the rationale for the changes and the impact of this quality improvement measure on patient safety. However, leaders made no reference to any ward layout concerns regarding this initiative.

Innovation was further demonstrated through targeted clinical improvement projects, such as work to reduce aspiration pneumonia among stroke patients. This included standardising swallow assessments, improving oral care practices, enhancing documentation and introducing safety prompts such as bedside tools and multidisciplinary huddles. These initiatives show a systematic approach to identifying risk, testing solutions, and embedding sustainable change, with clear alignment of patient safety priorities.

The service has invested in developing staff capability for improvement through structured programmes, which included the aspiring Band 6 programme and preceptorship initiatives, where staff are required to undertake and present improvement projects. This has resulted in multiple locally led innovations and the sharing of learning through case studies and organisational events.

We observed improvement champions being developed across the workforce, helping to embed a culture where continuous improvement is seen as part of everyday practice rather than a separate activity.

Leaders actively promoted learning beyond the organisation. Staff engaged with external organisations, including learning from established improvement systems and have contributed to regional and national forums through presentations and shared learning. This outward-facing approach ensured that the service both adopted best practice and contributed to wider system improvement.

We also saw further evidence of innovation and workforce development, where services had responded to operational pressures by redesigning training approaches. For example, the introduction of flexible bite-sized training sessions had enabled staff to maintain clinical competency while balancing service demands. This demonstrated a proactive and creative approach to overcoming barriers to learning.

The hospital operated a Quality Assurance Accreditation Scheme (QAAS). This was a structured ward accreditation framework using Bronze, Silver, Gold and Platinum ratings to benchmark ward level quality, safety, and patient experience against hospital-wide standards. From the data we could see 5 of the medical wards we visited were under the scheme and all were rated silver and gold apart from Coronary Care Unit which was awarded Gold. Wards scoring Bronze were required to submit a quality improvement (QI) action plan (signed off by the matron, and following a third consecutive Bronze, by the Director of Nursing) with a scheduled 2-month revisit. Staff told us that visible improvements had been made on Whippingham ward, which had progressed from Bronze to Silver. As a result of this work, leaders had identified 3 core areas for improvement: infection prevention and control (IPC), documentation, and staff wellbeing.