St Mary's Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained the same. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of the legal regulation relating to safe care and treatment and environment.

We have not awarded this service a score for Safe.

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

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service managed patient safety incidents in accordance with the Patient Safety Incident Response Framework (PSIRF), applying a proportionate and learning-focused approach based on the level of harm, complexity, and system impact.

Minor incidents were reviewed locally using a structured lessons learned template. Immediate contributory factors were identified, and learning was shared promptly with staff through safety huddles, team meetings and targeted communication where relevant. This ensured rapid dissemination of learning and supports early system improvement.

Moderate incidents were subject to a proportionate review in line with PSIRF methodology. The level of response was determined based on complexity, patient impact, and whether there were cross-service contributory factors. Where there was extended multi-disciplinary involvement, an After-Action Review (AAR) was undertaken. This structured, facilitated discussion enabled the exploration of what happened and why, identification of human and system factors, review of communication and escalation processes and agreement of practical, system-level improvements. Actions were documented, allocated to named leads, and monitored through governance processes to ensure implementation and measurable improvement.

Incidents meeting the threshold for significant harm or system learning were formally reviewed under PSIRF governance arrangements. The response was conducted proportionately, with involvement of relevant stakeholders, and focused on identifying underlying system factors rather than individual blame. Findings, recommendations and improvement actions are tracked through governance forums to ensure completion and sustainability of learning.

We reviewed the three most recent investigation reports. These were comprehensive and demonstrated a clear focus on learning, with identified recommendations, areas for improvement, and system‑wide improvement plans aimed at preventing recurrence and strengthening practice.

Staff recorded all patient safety incidents (PSI) or near misses on the trust’s local risk management system. Staff told us they received learning from incidents via emails and handover meetings.

The trust reported a total of 534 incidents over the past six months. Of these, 386 related to patient safety and 8 were recorded as near misses. A near miss incident is an unplanned event that did not result in injury, illness, or damage, but had the potential to do so.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Emergency department (ED) staff were able to view summary records and test results for admitted patients via the trust electronic patient record (EPR) system; however, they could not access ongoing inpatient clinical notes, which were paper‑based and later scanned into the system. Similarly, inpatient teams did not have access to the ED electronic record, other than discharge documentation uploaded to the EPR.

Arrangements were in place to support the initial reception, triage and allocation of patients presenting to the department. Self-presenting patients arrived at the main emergency entrance where they were triaged and directed to the correct area of the department. Patients who arrived via the ambulance were triaged at the initial assessment and treatment (IAT). Following this, patients were transferred to the resuscitation area, majors cubicles, the majors fit‑to‑sit area, minors, or the waiting room.

The trust also undertook system-wide work to improve patient flow, including a review of discharge and admission processes. Immediate actions included a comprehensive review of all patients awaiting a package of care or onward placement, the establishment of an Emergency Discharge Task Force, and enhanced medical support to NHS 111 to reduce ambulance conveyance.

The trust had established formal pathways to support the delivery of urgent and emergency care. The trust had developed a number of emergency care pathways which included the main adult ED pathway, main paediatric pathway and Medical Assessment Unit (MAU)/Same Day Emergency Care (SDEC) medical pathway. The trust was in the process of developing a pathway for surgical SDEC.

The SDEC service was supported by a multidisciplinary team (MDT), including medical, general surgery, urology, trauma and orthopaedics (T&O), and gynaecology. While the service was open from 8.00am to 8.00pm, consultant presence and a dedicated resident doctor were only in place between 8.00am and 5.00pm. Medical patients were routinely accepted into SDEC up until 4.00pm.

Since the previous CQC inspection in 2020, the trust had undertaken continuous improvement of the SDEC pathway, including structured transformation work through initiatives such as the SDEC “Perfect Week” programme which had demonstrated increased utilisation, improved same‑day discharge rates, enhanced multidisciplinary working, and strengthened patient streaming directly from ED.

The trust had a standard operating procedure (SOP) for SDEC access and medical SDEC criteria which defined clear clinical inclusion and exclusion criteria to support safe, timely redirection of patients to the most appropriate care pathway. However, not all staff were aware of this. We spoke with some staff who provided inconsistent information regarding whether patients could be directly accepted from the ED into SDEC. Based on multiple staff interviews, we concluded that patients were only transferred to SDEC following full ED clinical clerking, including initial investigations and treatment. This approach supported effective patient assessment but limited the service’s ability to streamline pathways and maximise the benefits of same‑day emergency care.

Patients identified as requiring mental health input were referred directly to the mental health liaison team who provided a timely response and undertook a clinical assessment within the required timeframe. For children and young people, referrals were made to the child and adolescent mental health service (CAMHS). CAMHS clinicians attended the ED to conduct a face-to-face assessment and subsequently lead on planning and coordinating any ongoing support, safety planning, or referral to appropriate community or inpatient services.

The department had a qualified mental health practitioner who was employed by another local trust assigned to support the mental health pathway. All additional assessments including risk assessment would be completed by the liaison psychiatry services (LPS) mental health team and uploaded onto the patient’s record. Patients presenting under section 136 of the mental health act were managed in the dedicated mental health room in the adult ED or needed to wait in the general reception area of the ED with police escorts. The distinction between a dedicated mental health suite and a general emergency department (ED) waiting area for individuals under Section 136 (s136) of the Mental Health Act is critical because it directly affects patient safety, dignity, and the timeliness of care. A dedicated mental health room provides a therapeutic, secure environment, whereas a general ED can exacerbate distress and increase the risk of harm to the patient and staff.

Although the service had implemented measures to mitigate these risks, including enhanced observation and police support where required, patients subject to Section 136 could still experience delays and prolonged periods in an unsuitable environment. This created an ongoing risk to patient safety, wellbeing and dignity, particularly for those presenting in acute mental distress.

During the assessment, we observed nursing and medical handovers attended by members of the multidisciplinary team (MDT). The handovers were structured and supported safe systems and pathways, with clear discussion of patients of concern, outstanding actions, discharge planning, and the transfer of relevant clinical information. This helped to support continuity of care and safe transitions between teams and services.

The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

At the time of the inspection not all staff had received role-specific training to recognise and report abuse. Data provided indicated that compliance exceeded the 90% target for safeguarding adults and safeguarding children Levels 1 and 2; however, compliance for Level 3 training was notably lower at 39%.

The trust had a safeguarding adults and safeguarding children and young people policy which aligned with statutory safeguarding requirements. These policies ensured a comprehensive, organisation-wide approach to safeguarding and clearly set out expectations for recognising, responding to, and reporting abuse and neglect. At the time of the inspection, an updated group safeguarding policy was currently progressing through the formal governance route with a deadline of March 2026 for committees members to return comments. Following this the policy would be submitted to the joint policy steering group for ratification following the completion of the review process.

As part of the single corporate services group model with the neighboring NHS trusts, the safeguarding service operated as a unified corporate function which supported shared learning across, improved consistency, reduced duplication, alignment of policies and quality standards and stronger multidisciplinary collaboration.

Staff knew how to recognise, and report safeguarding issues and knew who to escalate their safeguarding concerns to. The trust had a safeguarding team who staff could access for advice and support. The team was also actively engaged in the process of aligning the adult and children safeguarding policies across the trusts, ensuring a unified, robust, and evidence-based approach.

The department regularly submitted safeguarding referrals in line with their trust safeguarding policy to the local authority and the integrated care board (ICB). Data submitted by the trust showed that the adult ED had made a total of 224 safeguarding referrals from December 2025 to February 2026. This was 286 for the paediatric ED.

There were policies to support trust requirements for the safe assessment, observation and management of all mental health and section 136 patients arriving via the ED.

Additionally, the trust had a search policy in place which covered patients with mental health presentations and was a combined policy covering inpatient, ambulance and community. Within the policy there was a statement saying that a new policy was being developed but no ratification date was noted. The current policy was last updated in 2022.

Staff followed safe procedures for children visiting the department. Access to the paediatric waiting room was provided by staff at the reception after a brief assessment of the patient. Access to ED was via a door buzzer system and staff carried electronic passes to gain entry.

The trust had two security staff who were contracted by another provider and completed the appropriate restraint and restrictive practice training as part of their role. We spoke with a security staff who told us they provided training on Maybo and conflict resolution to staff. Maybo training focuses on reducing, managing, and preventing behaviours of concern and workplace violence through, de-escalation, conflict management, and safe physical intervention skills.

The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was a lack of effective clinical oversight within the waiting room, which did not provide sufficient assurance that patients were being appropriately monitored while awaiting further assessment. Although two triage nurses were allocated to this area, they were not consistently present to provide continuous clinical supervision. During the inspection, we observed patients in visible distress, and inspectors had to request staff assistance for at least two individuals. This demonstrated that patient need was not always being actively identified or responded to in a timely way.

The absence of consistent clinical presence meant that changes in patients’ condition, including signs of deterioration, pain, or increased clinical risk, may not have been promptly recognised or escalated. In a busy emergency department environment, this increased the risk that patients could deteriorate without timely reassessment, clinical intervention, or prioritisation for onward care, potentially resulting in avoidable harm or delays to treatment.

Systems were in place to support the electronic recording of patients’ vital signs and the calculation of National Early Warning Score 2 (NEWS2) scores; however, these systems were not used consistently. An audit of 12 patient records reviewed during the inspection identified inconsistent recording of observations. Four of the 12 records were incomplete with no observations recorded, and only three records contained a calculated NEWS2 score.

We also identified inconsistencies in how patient observations and clinical records were documented. Nursing staff were recording observations for the same patient across both electronic and paper records. This resulted in fragmented documentation and increased the risk of incomplete or inconsistent clinical records.

Such duplication increased the likelihood that key clinical information, including physiological observations and escalation scores, could be overlooked or not reviewed in a timely way. This risk was particularly significant for patients with additional needs. For example, we reviewed the record of a patient with a learning disability and found the National Early Warning Score 2 (NEWS2) was recorded on a paper chart, while nursing and medical notes were documented on the electronic system. This separation of records meant there was no single, contemporaneous record to support effective clinical oversight. As a result, there was an increased risk that deterioration may not be promptly recognised or responded to, potentially delaying escalation and intervention.

Staff were unclear and unaware of any other observations that would have been recorded about the person’s mental health, distress or any risks that might be present while they were in the department. Staff we spoke with were not aware of setting observation levels such as constant or intermittent observations due to an individual’s risk caused by their mental health state/condition.

Staff in the adult ED used an escalation form to record any expected activity for the patient, which was delayed, for example: access to a mental health assessment (MHA ) assessment or a mental health bed.

Although patients had risk assessments to ascertain their risk level but there was no set policy for how frequently they should be observed. This reflected on staff’s lack of responses when questioned about observation levels for mental health patients.

The trust reported an average compliance of 93% in sepsis 6 in the last 12 months. The sepsis 6 is a bundle of medical interventions designed to be delivered within one hour of recognizing red-flag sepsis to reduce mortality.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The design of the department largely reflected national guidance. However, not all areas were consistently used in a way that supported a safe and effective environment. We observed patients being cared for on beds placed in the corridor, positioned across the entrances to patient cubicles. This arrangement meant that staff were required to move corridor‑based patients in order to access other patients within cubicles. This increased the risk of delayed access in the event of an emergency or clinical deterioration and did not support safe patient flow or timely intervention.

The department shared the main entrance for both adult and paediatric area with two doors separating both areas. Each area had its own waiting room with a glass divider, which supported age‑appropriate care and separation from adult services. However, both the adult and paediatric waiting areas were large, open‑plan spaces with a shared reception area located between them. As a result, children and families in the paediatric waiting area were exposed to adult patients, including those experiencing mental health crises.

The department had only one designated mental health room, and staff told us that when more than one mental health patient was present, additional patients were required to wait in the general ED waiting area. This at times included patients detained under Section 136 of the Mental Health Act. This arrangement did not meet Mental Health Act guidance and posed a risk to maintaining a safe and appropriate environment for children, vulnerable patients, and others using the department.

The mental health room had two doors and met the standards as per Psychiatric Liaison Accreditation Network (PLAN) requirements. The PLAN standards, developed by the Royal College of Psychiatrists provides evidence-based best practices for liaison psychiatry services in the UK. However, one of the doors opened into an area leading to the exit to the waiting area, which meant patients could leave the department easily via this route. For paediatric ED this was a windowless room without CCTV and no ligature free toilet. These environmental limitations significantly reduced staff visibility and their ability to maintain appropriate levels of observation, particularly for children who were distressed, required close supervision, or were at increased risk of self‑harm.

Following the inspection, immediate actions were taken to address this which included the exit route being fitted with a lock controlled from the nursing station, ensuring patient egress was managed safely and proportionately while maintaining appropriate clinical access.

During the inspection, we also identified a number of environmental risks within a triage room located adjacent to the main waiting area. Several potential ligature points were present, including unsecured wiring and plastic tubing stored in unlocked drawers, making these items easily accessible to patients. This presents an increased risk to individuals who may be distressed or vulnerable while awaiting assessment.

Staff we spoke with did not demonstrate sufficient awareness of ligature risks. This was further compounded by the confusion and length of time it took staff to locate ligature cutters when this was requested.

The environment did not consistently meet ligature risk reduction standards, as ligature-free toilet facilities were not available within the adult and paediatric emergency department areas. Although the trust provided a ligature risk assessment in response to the data request, this did not include these areas, resulting in unassessed environmental risks. However, the trust had implemented a “ligature-light” approach in line with recognised urgent and emergency care practice, including environmental risk reduction, individual patient risk assessment, and observation and escalation processes to mitigate identified risks.

The adult ED comprised an 8‑bedded majors area, including two side rooms, 2 initial assessment treatment (IAT) cubicles used for ambulance off‑loading, a 3‑bedded resuscitation area, and 2 merit rooms which were being used as an escalation area. In addition, a cohort room containing two cubicles was also being used as an escalation area. Staff described this room as a cupboard room which was ordinarily used for storage, and its use for patient care had resulted in equipment being redistributed across the department. Several staff reported that this made essential equipment more difficult to locate promptly, citing delays in accessing items such as knee braces. This posed a potential risk to maintaining a safe, organised, and fit‑for‑purpose clinical environment, particularly during periods of increased demand.

The department was easy to find and well signposted. We found the entrance to be visibly clean and tidy. The reception staff also sat at the main entrance and signposted patients to where they needed to be.

Within the waiting areas, patients had access to drinking water and plenty of chairs to sit on. All equipment was well maintained, and safety checked.

There were systems which ensured clinical waste, including sharps, was appropriately segregated, and disposed of. During our inspection we observed sharps bins that were correctly assembled and labelled in line with national guidelines.

Resuscitation equipment was readily available and easily accessible. The department had systems to ensure it was checked regularly, fully stocked, and ready for use.

Rostering and workforce management were among the department’s highest operational risks across both medical and clerical staffing. The trust reported a total of 48 incident reports which raised concerns about number and skill mix of staff within the department in the last 6 months.

There was no on‑site medical decision‑maker within the initial assessment treatment (IAT) area. Timely medical decision‑making at the point of arrival is essential to identify and manage risks and to support patient safety. Staff told us they escalated each case to an available clinician in the department. The clinical lead confirmed they were aware of this arrangement and explained it was due to insufficient medical staffing, which limited the department’s ability to consistently provide immediate medical oversight at the point of admission. The trust had an operational and non-clinical workforce recommendations with an action plan to address staffing challenges and this included the restructuring of the clinical team structure, job planning and recruitments into ongoing gaps.

At the time of the inspection, three specialist doctors were being supported through the Certificate of Eligibility for Specialist Registration (CESR) portfolio pathway. This formed part of a workforce development initiative aimed at increasing the number of substantive consultants on the full rota and strengthening senior clinical cover.

The SDEC consultant reported a high proportion of low‑risk patients, with an admission conversion rate of approximately 5%, and attributed this to limitations in nursing and medical staffing.

The psychiatric liaison service was provided by another healthcare trust and this was provided 24/7 for both adult and children’s ED. However the psychiatric liaison team currently only had access to 1.5 days of consultant psychiatry per week. Leaders were aware of this and this deficit was recorded on the team’s risk register.

Nursing establishments within the department were reviewed using the emergency department safer nursing care tool (EDSNCT), which was completed every six months in line with national methodology. The outcomes of the EDSNCT informed the required whole time equivalent (WTE) nursing establishment based on patient acuity, dependency, attendance profiles, and activity levels. 

The trust reported an overall appraisal compliance of 90.3% for urgent and emergency care. Employee appraisals are an important element of performance management to improve organisational efficiency by ensuring that individuals perform to the best of their ability, develop their potential and identify any potential areas for improvement.

Staff were trained for their roles. We spoke with a range of staff who described mandatory training and qualifications they had undertaken which supported their role and development. The trust reported an overall mandatory training compliance of 82% for all staff as part of the data request.

Additionally, nurses working within the department were required to complete the UK resuscitation council paediatric immediate life support course. Current compliance for adult and children’s ED was 96% and 83% respectively.

Consultants and locally employed doctors (LEDs) were subject to the trust‑wide annual appraisal process and received appropriate support, with each doctor allocated a named appraiser during the appraisal cycle. This provided oversight of competency, professional development, and fitness to practise.

Postgraduate doctors in training were allocated both an educational supervisor and a clinical supervisor with dedicated time included within job plans to support supervision, training, and safe clinical practice.

There were two security staff on duty to cover the entirety of the hospital site. Staff could call for them to attend when there was a risk of violence or aggression.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection prevention and control arrangements did not provide assurance that patients, staff, and visitors were being protected from the risk of avoidable infection. During discussions with staff, it was identified that a patient in a side room had a confirmed diagnosis of Clostridioides difficile (C. diff); however, staff caring for the patient were not aware of this. There was no appropriate signage or alert displayed outside the room to inform staff or members of the public of the required infection prevention precautions.

Although there was no mandatory mask policy in place at the time of the visit, two members of staff were observed not wearing face masks correctly, which may increase the risk of transmission. In addition, some of the hand hygiene facilities within the department were found to be unavailable, as hand sanitiser dispensers were either empty or broken. This reduces opportunities for effective hand decontamination and does not fully support compliance with infection prevention and control standards.

The trust had an Infection prevention control (IPC) policy in place along with a suite of polices which related to IPC. These included antibiotic resistance bacteria policy, cleaning policy and strategic cleaning plan and waste management policy.

There were hand washing facilities within the department. We observed staff maintaining good hand hygiene during the inspection.

Staff adhered to the 'bare below the elbows' policy when providing care and treatment. Disposable aprons and gloves were readily available. Staff used them when delivering care and treatment to patients to reduce the risk of cross infection.

Patients we spoke to on the day of the inspection told us that staff always had personal protective equipment (PPE) on and washed their hands. We saw evidence of cleaning; cleaning staff were visible in the department, and they used appropriate signage to show when areas (floors) were wet.

The department undertook monthly infection prevention and control audits to assess the cleanliness of the environment and equipment. The audits recorded compliance rates of 94.21% in the adult ED and 95.74% in the paediatric ED. Where areas for improvement were identified, the trust developed action plans with clearly defined actions and target completion dates. We reviewed the December 2025 action plan, which outlined required actions and documented completion timescales, supporting ongoing monitoring and improvement of the clinical environment.

The trust had a two-stage audit process in place for hand hygiene and PPE with areas undertaking self-audits supplemented by peer audits. The department reported a compliance of 100% for adult ED, paediatric ED and SDEC for the month of January 2026.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

We found treatment rooms to be locked with CCTV. Storage of medication including controlled drugs and medical gases were appropriate and safe.

Controlled drug checks were completed twice daily. Fridge temperature monitoring was recorded every day in daily shift logbooks. We reviewed this and found these to be complete for all areas within the department with no gaps identified.

Emergency trolleys were stocked and checked regularly with evidence of this seen. Pharmacy staff supported the department with stock management and incident investigation and there was a dedicated ED pharmacist.

Within the department, the review of recent incidents involving medicines showed that the main themes related to prescribing and administration. A smaller number involving dispensing, IT or equipment issues, controlled drug handling and medical gases; the majority resulted in no harm, low harm, or near misses.

In response to prescribing related themes identified, the trust had implemented a PSIRF) aligned quality improvement programme, using multidisciplinary process mapping and thematic review to understand wider system factors. Progress against actions was monitored through established governance arrangements, providing assurance that medicines related incidents are generating shared learning and sustained improvement in patient safety.