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 is the first assessment for this key question. This key question has been rated Good. This meant people’s outcomes were good, and people’s feedback confirmed this.

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 scored the service as 3. The evidence showed a good standard. The service made sure women’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

All staff we spoke to told us they were supported and they worked together to make sure women made informed decisions based on best practice guidance. Staff were able to describe how they assessed and reviewed women’s needs from the antenatal to postnatal period to provide holistic support.

Women were given information and advice about their health, prenatal and postnatal care. They told us during the assessment that they felt well supported by the multi-disciplinary team and felt they were involved in the assessment of their needs.

Staff carried out risk assessments for women during antenatal care in line with national guidance. These included social assessments, risk assessments for blood clots and mental health assessments. Staff made referrals to consultant led clinics for women with medically high-risk pregnancies. Risk assessments for women were in line with national guidance.

Continuity of Carer teams supported women who it was identified, through booking or risk assessment, would benefit from being seen by the same midwife and care team throughout their pregnancy.

Notes were comprehensive, and all staff could access them easily. The trust used an electronic records system. We reviewed 4 records on inspection and found records had appropriate documentation relating to patient needs.

There was minimal evidence for intrapartum care on site due to low activity (MLU with 12 deliveries in 18 months), the majority of the information can be found in the (Main site) report.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Maternity services had systems in place to support the delivery of care in line with national guidance, including National Institute for Health and Care Excellence (NICE) standards and the NHS Maternity Incentive Scheme (MIS). The Maternity Incentive Scheme (MIS) is a national NHS England programme designed to improve the safety and quality of maternity care by incentivising trusts to demonstrate compliance with a defined set of evidence‑based safety actions.

Senior leaders evidenced that the service remained compliant with all MIS Year 7 safety actions for the duration of the reporting year. Safety Actions 1–10 are the core requirements of the MIS. We reviewed evidence relating to Safety Actions 1–10, this showed it was collated and submitted through the Future NHS Collaboration Platform in line with national requirements.

The service had a structured process in place to manage clinical guidelines, policies, standard operating procedures, and pathways to support alignment with NICE guidance and other national recommendations. A designated guideline coordinator monitored review cycles and identified documents requiring update due to changes in national guidance, local practice, or review dates. Senior leaders communicated changes in national guidance through monthly newsletters, departmental alerts, during huddles and through presentations to staff.

Draft documents were reviewed through relevant multidisciplinary clinical forums, including antenatal, intrapartum, postnatal, and perinatal safety groups. Where documents included medicines or drug therapies, senior leaders sought additional review through medicines governance arrangements before approval.

In December 2024 the service had achieved Stage 3 Baby Friendly Accreditation. The Baby Friendly Initiative (BFI) Stage 3 assessment (by UNICEF UK) is the final evaluation step for healthcare facilities to achieve full Baby Friendly accreditation. It evaluates whether the services’ policies and staff training are successfully translating into actual, high-quality care for mothers, babies, and parents.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well across teams and services to support people. They did not always share their assessment of women’s needs when people moved between different services.

Due to the smaller size of the service, staff benefitted from being supported directly by the lead midwife. Information was also communicated to the main hospital site by the community matron who worked across both birthing centres. Staff told us that local leaders were always available if they needed to communicate patient needs for escalation.

Midwives had access to specialist midwives for support and guidance and there were specialist midwives to meet the needs of women. For example, the service was able to refer women to the perinatal mental health midwives or maternal mental health services.

However, staff told us the maternity leadership team rarely visited community bases or midwifery led units. There was minimal evidence on site due to low activity (MLU with 12 deliveries in 18 months), the majority of the information can be found in the (Main site) report.

We scored the service as 3. The evidence showed a good standard. The service supported women to manage their health and wellbeing to maximise their independence, choice and control. The service supported women to live healthier lives and where possible, reduced their future needs for care and support.

Staff supported parents to live healthier lives by assessing each woman’s health throughout pregnancy and during labour. They provided support for any individual needs to live a healthier lifestyle.

The Trust maternity website signposted parents to services for smoking cessation, safe sleeping, foods to avoid during pregnancy, and advice on vitamins and supplements. There were also details on the vaccinations that were recommended for pregnant people.

Parents were also signposted to services that supported emotional wellbeing such as national maternity charities. There were also links to the NHS England perinatal pathway website which can be used by parents to find services and helpful information to support emotional wellbeing.

There was a wide range of relevant information promoting healthy lifestyles and support on display boards throughout the service. This included leaflets and posters with clear guidance and advice. We saw that within bathrooms there was discrete information around domestic abuse and how to seek support and advice. We saw that Maternity carbon monoxide (CO) was completed on women at booking and 36-week appointments and there was good compliance with this. CO testing is a quick, painless breath test offered to pregnant women to check for exposure. It is recommended this is performed to protect both mothers and babies from oxygen deprivation.

The service organised a regular event with local doulas, antenatal educators and birth workers to share information on informed choice, accessing birth centre and continuity of carer.

We scored the service as 2. 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.

There was minimal evidence on site due to low activity (MLU with 12 deliveries in 18 months). Following our inspection trust supplied outcome data that was not location specific, therefore the majority of the information can be found in the (Main site) report.

We scored the service as 3. The evidence showed a good standard. The service told women about their rights around consent and respected these when delivering person-centred care and treatment.

Staff took all practical steps to enable patients to make their own decisions. Midwives understood how to assess women’s capacity to make decisions. When women lacked capacity, staff supported women to make decisions within their best interests.

The service carried out audits within the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), to support best practice in MCA and the best interest decision-making for the woman and her baby.

There was minimal evidence on site due to low activity (MLU with 12 deliveries in 18 months). Following our inspection trust supplied outcome data that was not location specific, therefore the majority of the information can be found in the (Main site) report.