St Mary's Hospital

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained the same. This meant people’s needs were not always met.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

The trust had a responsive frailty team who supported the ED, including a frailty consultant practitioner role who provided specialist clinical leadership, supporting patient flow and enhancing care for patients presenting with frailty however for a trust serving a particularly older population, there were no facilities for frailty SDEC. We spoke with staff who told us they will endeavour to place older patients in a side ED majors cubicle with doors, if there was no inpatient beds and liaise with palliative care if appropriate. Staff we spoke with were not aware of specific end of life prescription packs.

Additionally, the trust also had no designated ED lead for geriatric emergency medicine, frailty and trauma. Leaders explained this was due to lack number of dedicated consultants in post.

Staff made sure patients living with mental health problems, learning disabilities and dementia, received the necessary care to meet all their needs. Patients presenting with mental health needs were appropriately signposted to the liaison team for further assessment. Whilst they waited for this, patients were cared for in the mental health room. However, when this was full, staff told us patients were placed in the general ED waiting area and included patients on Section 136. This did not meet MHA guidelines ‘the ED is only used for S136 patients who have an acute healthcare need. Otherwise, it should be expected that mental health services should provide an assessment suite or alternative place within the mental health unit where a S136 patient can be appropriately assessed’. In response to this, the trust recognised that whilst this did not represent the preferred environment outlined within guidance; this reflected the operational reality where access to dedicated mental health assessment suites was dependent on system availability and not always immediately accessible.

We observed a handover meeting which included a discussion of a patient with learning disability, however there was no evidence that plans were made to assess the individual needs of the patient.

The department had access to interpreters and signers when needed. Staff also had access to communication aids to help patients.

We did not look at Care provision, Integration and continuity during this assessment. The score for this quality statement is based on the previous rating for Responsive.

The evidence showed some shortfalls. The service did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff told us sharing of information with specialties on the mainland was at best via email from clinician to clinician, and via personal messaging services.

Sharing of information via NHS email is considered safe however sharing of information via unsecured personal messaging platform is generally considered unsafe because these platforms often fail to meet the stringent legal and security requirements necessary to protect sensitive health data.

Arrangements did not provide sufficient assurance that patients were kept informed about their care or waiting times. The department had good signposting to support patients in navigating the different clinical areas; however, there was no visible electronic information to inform patients of current waiting times.

In addition, during conversations with patients, we spoke with an individual who was receiving care in a corridor who told us they were unaware of what was happening with their care, as no member of staff had provided them with information or updates. This lack of communication meant the patient was not adequately informed or reassured, and increased the risk of anxiety, distress, and reduced understanding of their care and treatment, particularly for patients waiting in sub‑optimal environments such as corridors.

The department had multiple electronic patient records (EPR)s in place, which was different from inpatient and SDEC, therefore there was no cross viewing of information except via discharge summaries. Staff also reported some observations were completed on paper whilst others electronically. This meant patients could experience delays in care because information did not transfer during a referral or transfer of care.

Staff had access to GDPR policy and equality and diversity policy on the intranet. Staff could also ask for advice from the trust Caldicott Guardian. A Caldicott Guardian is a senior person responsible for protecting the confidentiality of people's health and care information and making sure it is used properly.

The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Patients and families were supported to raise their concerns with the department. In the first instance this was to escalate to staff and leadership team. If they were unable to provide a resolution, patients were signposted to Patient Advice Liaison Service (PALS).

The trust website contained information on how to provide feedback, make a complaint and provide compliments. Patients and relatives were also encouraged to complete the friends and family test if they wanted to leave any feedback.

The trust proactively sought feedback from patients, families, staff, external stakeholders and partner organisations through a range of formal and informal mechanisms. These included national surveys, multidisciplinary team (MDT) meetings, external quality forums and staff engagement mechanisms like staff meetings or daily safety huddles.

Staff understood the policy on complaints and knew how to handle them. Managers investigated complaints and identified themes.

The UEC Division, which encompasses the medical care service groups, received a total of 51 complaints. Of these, 43 (84%) were resolved through the hospital’s early resolution route and 8 progressed to a “closer look” detailed investigation. acute assessment unit received approximately 6 complaints across October 2025 to December 2025.

The department provided us with an example of when changes were made in response to patient complaints. A review of complaints received during quarter 3 2025/2026 identified key themes relating to treatment or medication, patient care including nutrition and hydration and communication. Actions taken in response to the complaints included review of ED handover compliance and strengthening the process for identifying and escalating the needs of vulnerable patients. Following this the trust had received positive patient feedback which recognized the compassionate, professional and person-centred care delivered across the emergency department.

The evidence showed some shortfalls. The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

People could access the service when they needed it, however, they did not always receive care promptly. For example, patients with mental health needs often spent more than 12 hours in the department.

The department was not consistently meeting the national four‑hour performance standard, meaning that patients could not always access treatment within nationally defined timeframes. In response, leaders implemented focused improvement actions aimed at improving patient flow and reducing delays; however, despite these efforts, performance had not improved sufficiently at the time of inspection to consistently achieve the national standard.

The service reported consistently high overall compliance with ambulance handover standards, with the majority of handovers completed within 15 minutes each month.

The trust reported that 12.3% of patients experienced waits exceeding 12 hours following a decision to admit over the previous 12 months. These delays were primarily attributed to inpatient bed shortages, high ward occupancy, and delayed discharges associated with limited community and social care capacity.

Oversight of these patients was included within daily operational escalation processes and site management meetings. However, when compared with national performance, the trust was performing worse than the national average.

We did not look at Equity in experiences and outcomes during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Planning for the future during this assessment. The score for this quality statement is based on the previous rating for Responsive.