• Mental Health
  • NHS mental health service

St Mary's Hospital

Overall: Good read more about inspection ratings

Greenhill Road, Armley, Leeds, West Yorkshire, LS12 3QE (0113) 305 5000

Provided and run by:
Leeds and York Partnership NHS Foundation Trust

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Background to this inspection

Updated 20 March 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We inspected the service on 4, 5 and 6 December 2017, 1 and 2 February 2018. The inspection was announced because we wanted to ensure people, their relatives and staff were available to support the process.

Across the five days of inspection, four adult social care inspectors and two experts by experience supported the inspection. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. We used a range of methods to seek feedback and observe the service provided. We visited people in their own homes, contacted staff and relatives via telephone and carried out two focus groups. One focus group was with people and their families and another was with members of staff.

Before the inspection, we reviewed all of the information we held about the service. This included information we received from the provider since the last inspection. We sought feedback from the commissioners of the service prior to our visit. The registered provider completed a provider information return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We used all of this information to plan our inspection.

We spoke or spent time with 28 people and 10 of their relatives. We spent time in the communal areas and observed how staff interacted with people and some people showed us their bedrooms. Some people were unable to speak with us and we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

During the visit, we spoke with the registered manager and three senior managers who represented the provider. We spoke with 15 members of staff including support managers, deputy support managers, senior support workers and support workers. We also spoke with four visiting professionals during the inspection.

We reviewed a range of records including 11 people’s care records, including care-planning documentation and medication records. We looked at three staff recruitment files and a range of records relating to the management of the service. A variety of policies and procedures developed and implemented by the provider, were also looked at.

Overall inspection


Updated 20 March 2018

We inspected St Mary’s Hospital on 4, 5 and 6 December 2017 and 1 and 2 February 2018. The inspection was announced because we wanted to ensure people, their relatives and staff were available to support the process.

At the last inspection in July 2016 we found the provider had breached two regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to medicines management and overall oversight of the service including appropriate reporting of incidents. The service was rated overall Requires Improvement.

An action plan was submitted to us by the provider outlining how they would improve. We saw improvements had been made in all areas at this inspection and the provider was no longer in breach of any regulations. The service is now rated overall Good.

The service provides care and support to people living in 16 ‘supported living’ settings, so that they can live as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support. 91 people were supported at the time of the inspection.

The care service has been developed and designed in line with the values that underpin the ‘Registering the Right Support’ and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and/ or autism using the service can live as ordinary life as any citizen.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People received an extremely person centred service. Staff had excellent knowledge around how people communicated and they used this to empower people to make their own decisions and direct their own care. The use of positive behavioural support had meant people were less anxious and confident enough to access their community and live as ordinary a life as possible. Care plans reflected the person centred detail staff needed to know to support people how they preferred.

Staff training in specialist areas such as postural management meant people experienced less discomfort or pain due to their physical disabilities and improved mobility and independence. Staff felt supported by their managers and enjoyed the range of training on offer to develop their skills. Their improved knowledge helped them deliver effective support for people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible, the policies and systems in the service supported this practice. Staff understood how to recognise abuse and report issues of concern to protect people.

People and their families were able to describe the positive outcomes achieved because they received such high quality person centred support. Staff treated people with respect and dignity at all times. Staff looked to problem solve and worked to support people to achieve their aspirations. We saw examples of people improving their health, accessing their dream holiday, starting a new hobby and using technology to control their own environment.

The leadership and culture of the service was positive. Managers empowered their staff to have ideas and be part of developing the service. There was energy behind continuous improvement and we saw people were innovatively involved in developing the service.

New quality assurance processes were in place to help the provider ensure quality was consistent. Systems were in place to ensure staff were recruited safely and that the health and safety aspect of delivering support was well managed. The registered manager was working to ensure staffing was reviewed in conjunction with the local authority so people received a consistently responsive service.

Other CQC inspections of services

Community & mental health inspection reports for St Mary's Hospital can be found at Leeds and York Partnership NHS Foundation Trust. Each report covers findings for one service across multiple locations