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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained the same. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

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.

The evidence showed some shortfalls. The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Arrangements did not provide sufficient assurance that mental health risk information was consistently shared to support safe care within the emergency department. The members of the psychiatric liaison team completed full bio-psychosocial assessments and we found this to be complete for the records we reviewed. However, ED staff did not have access to the liaison psychiatry electronic system which meant risk assessments needed to be placed into a narrative on the ED system. We reviewed a patient record where we could not see a reference to the patient risks in the ED system.

At the time of the inspection, the department did not carry out formal, standalone audits specifically for triage and streaming and were in the process of developing a dedicated ED audits that were tailored specifically to the ED setting.

The department had not undertaken any peer reviews and benchmarking since 2024 which represented a current gap in assurance for leaders. There were plans to discuss this at the next governance meeting where appropriate actions and next steps to be agreed.

Staff followed up-to-date policies to plan and deliver quality care according to evidence-based practice and national guidance. We reviewed a sample of the service’s policies and guidelines and noted that all were in date with a set review date. Staff supported patients to understand their treatment and had good knowledge of the communication resources and options available to them.

The department undertook audits, analysed the trends and shared this with all staff. The service used the National Institute for Health and Care Excellence (NICE) guidelines to ensure that care was evidence based and participated in all relevant Royal College for Emergency Medicine (RCEM) audits.

Staff protected the rights of patients subject to the Mental Health Act 1983. At handover meetings, staff routinely referred to the psychological and emotional needs of patients, their relatives, and carers.

The department had volunteers and health care assistants who supported patients food and drink.

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 ED team worked closely with a wide range of specialist services to provide safe, person-centred care and avoid unnecessary admissions. Staff also collaborated with the dementia team, learning disability service, and mental health liaison to ensure timely, specialist support for patients with cognitive, communication or emotional needs. In addition, ED staff worked with end-of-life care teams to provide rapid assessment, symptom management and personalised planning for patients approaching the end of life, ensuring care aligns with their wishes and be delivered in the most appropriate setting, including at home.

We spoke with staff who fedback that there was good support and working relationships with staff from different specialties.

As part of the data request the trust provided an example of when the ED staff had worked alongside and collaborated with members of different specialties to support an autistic patient ensuring they avoided an unnecessary ED attendance. Staff had proactively liaised with pharmacy to identify suitable treatment options given the patients sensory intolerance to oral medication and skin applied products, and the learning disability team were alerted in case their support was required. On arrival, treatment options were clearly explained to the patient and her mother, and an intravenous infusion (IV) was agreed as the safest and least distressing option, which was delivered successfully in a calm, low stimulus environment, resulting in a very positive patient experience. To support continuity and reduce anxiety, future treatment had been arranged for a day when the same SDEC staff were present.

We observed good collaboration and communication between all grades and professions within the department itself. Staff told us of cooperative, supportive and appreciative relationships across the department and other parts of the hospital.

Staff referred patients for mental health assessments when they showed signs of mental ill health or depression. We reviewed patients records and found this had been completed.

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.

The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The trust was not meeting the NHS standard of 95% of patients seen within four hours. Across the reporting period January 2025 to January 2026, the department reported 13,842 admissions, of which 3,063 (22.1%) were admitted within 4 hours. Monthly performance ranged from 15.4% at its lowest to 36.2% at its highest, with improved performance during July to September 2025 and subsequent variability later in the year.

The trust recognised that performance against the 4‑hour standard for admitted patients remained challenging and had in place a structured 4 and 12‑hour recovery programme which was overseen through the established urgent and emergency care governance arrangements. Recent improvement activity included work to standardise and improve streaming and flow (including an ED‑referrals SDEC flow chart), ongoing audit of medical zoning and IAT, strengthened discharge reporting, ward‑based improvement sessions with pharmacy and therapy, testing of an escalation pathway for long stays, and enhanced quality reporting including corridor care reporting.

Similarly, over the 12‑month period, 21.6% of patients experienced a wait of between 4 and 12 hours following a decision to admit before transfer to an inpatient bed. This performance reflected the trust‑wide and system‑wide patient flow constraints, recognising that workforce pressures, the timeliness of referrals and investigations, and congestion within the ED which contributed to delays in clinical decision‑making.

One example of how the trust monitored people’s care and treatments and their outcomes and improvement over time was through the frequent attenders workstream. The workstream included a integrated care review which took place monthly and through structured management planning for each patient. Where outcomes were not positive or attendance patterns did not improve, care plans were formally reviewed and adjusted. This involved escalation, additional community support, revised crisis planning, or alternative interventions.

The trust carried out an annual programme of repeated audits to check improvement over time. In addition to this, the department took part in multiple national and local clinical audits. There were processes to monitor audit results and make improvements.

The evidence showed some shortfalls. The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

We reviewed 12 patient records and found the majority of these to have clear discussions with patients and their relatives. However, some sections within the records were incomplete. For example, we reviewed the record of a patient with learning disability and found that the consent and capacity section had not been completed. Another patient record detailed the patient may have dementia and confusion, however there was no record of consideration of a mental capacity assessment.

Staff had access to and followed the CAMHS liaison referral pathway when referring young people.

Staff had a good understanding of Deprivation of Liberty Safeguards (DoLS), and could clearly articulate how they would assess patients, and ensure their rights were safeguarded.

Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

Staff had received training in relation to the MCA and understood the importance of giving people choice in the support they received. We observed staff always sought people's consent before providing any support.