St Mary's Hospital

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• 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained the same. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation relating to governance.

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.

The evidence showed some shortfalls. The service did not always understand the challenges and the needs of people and their communities.

The trust had a working and improving together strategy for 2024-29 with a vision of working together to deliver excellence in care for our patients and communities. This was underpinned by their values of compassion, accountable, respect and everyone counts.

The Trust set out its strategic aims through True North goals. These are clear, high‑level priorities that provide direction, align organisational effort, and support sustained improvement. They enable leaders to maintain focus on key quality and safety outcomes—such as patient experience and safety—while managing operational pressures.

For urgent and emergency care, the trust identified a strategic aim of no avoidable delays for patients. Measures included ambulance handovers within 15 minutes and patients being seen and managed within four hours in the emergency department. At the time of assessment, performance, against the four‑hour standard remained below the national target.

The trust had not fully demonstrated an understanding of the needs of its local population, particularly older people, despite serving an area with a high proportion of frail patients. While a responsive frailty team was in place with an established frailty consultant practitioner role to support the emergency department, there was limited development of services aligned to population need. This included the absence of frailty Same Day Emergency Care (SDEC) facilities.

The service had a positive staff culture where staff worked effectively together. We observed staff of all grades and disciplines collaborating and communicating with respect. We saw examples of how this benefitted patient care. We saw caring interactions between staff and patients despite challenges around capacity.

The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support.

Across the evidence reviewed, we identified a number of interrelated risks that had the potential to impact patient safety, experience and outcomes.

While leaders demonstrated awareness of some of these risks and had introduced initial mitigations, these were not consistently embedded or effective in practice. Furthermore, gaps in workforce capacity and designated leadership roles suggested that oversight was not yet sufficiently robust to fully understand, monitor, and address these risks in a systematic and sustainable way. Staff we spoke with told us the departments leadership team were visible and approachable, and well-integrated in the department. Staff felt supported by leaders to develop their skills and take on more senior roles.

The urgent and emergency care services operated under a clearly defined tripartite leadership model, providing executive oversight, professional nursing leadership, and clinical governance across all areas of unplanned care. The overall accountability sat with the deputy director who had operational and performance responsibility for UEC services.

Operational management was led by the UEC general manager who was supported by the UEC service manager. Together, they were responsible for day-to-day operational delivery, performance monitoring, patient flow, and service improvement. The structure also included a dedicated non-clinical operational support.

Clinical governance and medical accountability sat with the clinical director for unplanned care, supported by the clinical director for UEC. Consultant leads and medical teams reported through this structure, ensuring clinical standards, evidence based practice, supervision, and audit compliance. This arrangement ensured clear medical leadership and accountability for clinical outcomes, pathway delivery, and quality improvement.

Staff had access to a range of management and leadership programmes including band 5-7 education programme. Another leadership program included the CESR program for development into consultant roles.

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.

Staff had access to the freedom to speak up policy which provided information on how to speak up and what to expect to happen after speaking up.

The trust had freedom to speak up (FTSU) guardians who were available should staff want to raise any concerns. Staff were aware of who these were and told us they felt they could raise concerns without fear of reprisal.

Data provided to us post inspection showed that the trust had received a total of 24 new concerns raised and had identified patient and service user safety and management issues to be one of the top themes from the trust annual report on the guardian service from April 2025 to September 2025.

Staff told us there was a culture of speaking up, they felt safe and supported in doing so, and without fear of detriment. Staff gave us examples where they had raised concerns with their managers. We were told these were treated sensitively and seriously, and managers worked with the members of staff to resolve the concern. Staff we spoke with were happy with the outcome and felt comfortable raising concerns again.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff had access to the trust-wide equality, diversity and inclusion policy; however, at the time of the inspection this was out of date, having last been reviewed in November 2025. Following the inspection, the trust provided evidence that the policy had been reviewed and ratified, with validity extended to March 2029. Staff received equality and diversity training as part of their mandatory training.

The trust had 4 staff equality networks that met bi-monthly. This included race equality, disability and long term conditions equality and neurodiversity equality.

The trust published quarterly equality, diversity, inclusion and talk newsletter which contained information on upcoming events and information about programmes and support. The newsletter for March 2026 included information on Diwali celebrations, disability history month and health inequalities update.

Additionally, the trusts People and Organisational Development Strategy complemented their wider workforce and clinical strategy, as well as their inclusive culture which was defined by our organisational vision and values.

The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Whilst the service had some governance systems and processes, these were not effective to identify and mitigate risks to patients. We found multiple issues across the service in performance, patient safety, environmental risks, infection control, documentation and maintaining patient privacy and dignity. These issues had not been identified or mitigated effectively and still posed a risk to patients.

Outcomes for patients were not always positive. Performance against the NHS 4 hour target was consistently low in the 12 months prior to our inspection. The service missed their monthly performance target on 10 occasions during the 12 month period. Data showed performance ranged from 68% to 78% against an improvement trajectory of 70 to 78%. Long waits in the department led to untimely care and treatment which posed a risk to patients. Delay in timely assessments can result in severe or fatal outcomes.

We had concerns regarding the level of clinical oversight within the waiting room. During the two-day assessment, our observations identified that staff were not consistently present to provide adequate supervision. This created a risk that patients could deteriorate without timely recognition or intervention.

A review of the trust’s incident data over the previous six months identified at least two incidents where patients were at potential risk of harm due to insufficient oversight in the waiting area. Although the trust had implemented measures to address this, these had not been fully effective in practice. For example, while a waiting room registered nurse role card had been established and was intended to support clinical oversight, it was not embedded in daily practice. Staff were unable to clearly articulate its use when asked, and we did not observe it being consistently applied during our assessment.

At the time of inspection, there were gaps in the department’s audit and assurance framework. Formal, standalone audits for triage and streaming were not in place, although work was underway to develop dedicated emergency department audits tailored to the service.

In addition, the department had not undertaken peer review or benchmarking activity since 2024, which limited external assurance and oversight available to leaders. This gap had been identified, with plans to address it at the next governance meeting, where actions and forward plans were to be agreed.

In January 2026, a refreshed UEC operations group was formally implemented to strengthen operational grip and governance. The group was structured around three core operational pillars and encompassed the entirety of UEC including acute assessment unit (AAU)/SDEC/UTC.

The department operated systems to ensure they shared information with external organisations effectively, in a timely way, for example, accidents and incidents were reported to the relevant authorities, including the CQC. However staff told us sharing of information with specialties in the mainland was at best via email from clinician to clinician, and via personal messaging. Sharing patient information via standard email or personal messaging is generally considered unsafe because these platforms often fail to meet the stringent legal and security requirements necessary to protect sensitive health data.

Governance meeting minutes we reviewed showed staff from different areas of the service attended and were involved in discussion about the service and how improvements could be made.

The trust carried out morbidity and mortality reviews in the department and delivered these to staff with learning points and themes which had been identified.

The department reported risk to patient safety as there was no follow up process when patients for UTC/ED do not attend their UEC face to face appointments to be their top risks. A number of controls were in place to provide assurance which included safeguarding team being made aware and providing them with a weekly report of children who were not brought for expected attendance. Additionally, the ability to manage surge in demand in the emergency department was rated as the second highest risk on the register.

The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The trust worked in partnership with its frailty team, which provided responsive support to the emergency department. However, despite serving a population with a high proportion of older people, there were limited integrated pathways with community and system partners. In particular, there were no facilities for frailty Same Day Emergency Care (SDEC).

Staff described how they sought to work collaboratively by placing older patients in side cubicles within the ED majors area, where available, to promote privacy and dignity, and by liaising with palliative care services when appropriate. However, staff were not aware of specific end-of-life prescription packs, indicating opportunities to strengthen shared protocols and communication across services.

In addition, the trust did not have a designated emergency department lead for geriatric emergency medicine, frailty, or trauma to drive integrated working across organisational and community boundaries. Leaders explained this was due to a shortage of consultants in post, which limited their ability to fully develop partnership-driven pathways for older people. The department collaborated and worked in partnership with stakeholders to support the delivery of the service and support joined-up care. They shared information and learning with partners to improve the service. These included the local authorities, ambulance services and various external agencies.

For patients experiencing mental health illness, the department worked closely with a liaison psychiatry service to ensure a joint approach to the provision of mental health care and assessment for patients in the ED, including ensuring timely assessment, patient advocacy and risk management.

The trusts security team had worked closely with the coastguard helicopter to become the first NHS trust to start flying into hospitals again.

The department also worked closely with the local police and shared key information which enabled safeguarding and consistency for service users and ensured concerns were identified and acted upon both timely and collaboratively.

The trust held regular meetings with external stakeholders and agencies with a standing agenda items and topic specific content relevant to the system focus. While some of the transition groups had now concluded, operational collaboration was fully embedded through established routes, where issues and shared learning were routinely discussed. These forums ensured that good practice was consistently shared across services and that any emerging challenges were addressed jointly and promptly.

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.

Leaders encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage.

The trust had a quality steering group who met monthly to discuss improvement projects which were led by the trusts improvement team and highlight areas of improvement. We reviewed the presentation for the month of February 2026 which included the facilitation of a strategic reflection workshop with the ambulance division to review delivery of the current 5-year strategy.

All quality improvement projects were recorded on the trust quality management system. At the time of the inspection the trust reported there were 71 active projects in progress.