St Helier Hospital and Queen Mary's Hospital for Children

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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

The service delivered care and treatment in line with national guidance, and staff used evidence‑based policies to support safe and effective practice. Staff assessed patients’ needs on admission and used recognised tools to guide treatment, escalating concerns when diagnostic delays or changes in condition occurred.

Staff took part in audit and quality improvement activity, and findings contributed to changes in practice.

Multidisciplinary teams worked together to deliver coordinated care. Staff monitored outcomes through audit programmes and used this information to inform improvement.

Staff supported patients to make informed decisions about their treatment.

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 did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service delivered care and treatment in line with national guidance and recognised best practice. Staff understood and used evidence-based protocols when planning and providing care. Patients generally received treatment that followed clinical standards, and staff acted when care needed to be changed to keep people safe and improve outcomes.

When patients were admitted, staff assessed their needs and used recognised tools to guide decisions about treatment and support. They monitored patients’ clinical needs during their stay and updated care plans when conditions changed. For example, when diagnostic test results were delayed, staff escalated the issue and adjusted treatment plans to avoid unnecessary risk. This showed that staff used structured processes to maintain safe and effective care.

The trust maintained systems to ensure its clinical policies were up to date, evidence-based and formally approved. There was a clear process for reviewing and ratifying policies, and documents referenced relevant national standards, including the five CQC domains. Policies included an equality impact assessment, supporting inclusive and evidence‑based design. Governance records showed that policies were directly linked to national guidance. For example, during a review of the National Cardiac Arrest Audit, leaders confirmed that the Managing Acutely Ill Patients Policy and the Decisions Relating to Resuscitation Policy were consistent with national recommendations for emergency care and end‑of‑life decision making.

Staff had access to clinical policies through the trust intranet, and documents clearly stated where the latest approved version could be found. Governance meetings also identified where policies needed strengthening. Audits highlighted gaps in guidance and led to a revised policies being prepared for approval by the senior leadership team.

The service had a specific focus on older people and those living with frailty, although practice was not yet consistent. At St Helier Hospital, the proportion of patients aged 65 and over with a clinical frailty score (CFS) recorded varied widely over a 12‑month period, ranging from 6.5% in April 2025 to 27.7% in June 2025. This showed that a key assessment for older people was not applied reliably for all patients. In response, the trust took part in the National Frailty Improvement Collaborative. As part of this programme, it aimed to introduce consistent frailty scoring at the point of entry, make that score visible across systems from the emergency department to community teams, and improve outcomes. The specific aims included reducing the number of people with frailty, waiting more than 12 hours in the emergency department and increasing the number discharged home within two days following a home‑based assessment.

The service used audit and quality improvement work to check whether care followed best practice and to drive change. Sepsis management was an important example. Audit data showed that structured sepsis risk assessments had improved significantly, helped by staff training and the introduction of the sepsis module within the electronic patient records system. Senior clinicians reviewed patients at higher risk more consistently, which supported more timely decisions about treatment.

Staff were involved in a range of targeted quality improvement projects linked to national guidance. For example, there were audits on venous thromboembolism (VTE) prophylaxis to check whether patients at risk of blood clots were assessed and treated according to guidance, and an audit of the acute coronary syndrome (ACS) pathway to review care for people presenting with heart attacks and related conditions. A separate project in the acute medical unit focused on early and safe mobilisation, led by a Band 6 nurse. This aimed to reduce the risk of patients becoming deconditioned during their stay and to shorten the length of time they needed to remain in hospital. These projects showed that staff used data to improve care.

The service also monitored how it used diagnostic tests to support evidence-based care. It reviewed performance against service level agreements with its external imaging provider and monitored the number of referrals that needed additional justification. This work supported better use of guidance such as iRefer, which helps clinicians to request scans only when they are likely to benefit the patient. By doing so, the service aimed to avoid unnecessary tests and ensure timely access for those who needed imaging most.

Discharge planning followed evidence-based principles. Staff checked that patients understood their treatment plans and gave clear instructions about medicines and follow‑up appointments. Where people needed ongoing support or monitoring after leaving hospital, staff referred them to community services to help maintain continuity of care and reduce the risk of readmission.

Staff were aware of best practice and worked within agreed clinical protocols. Learning from audits, national programmes and incident reviews was shared through governance meetings and local quality improvement work. Staff described how this learning had informed changes in sepsis care, frailty assessment and mobilisation practice.

Staff worked collaboratively across teams and services to deliver safe and effective care. Pathway reviews showed that multidisciplinary teams were involved in patient care from admission through to discharge. Staff communicated clearly when patients moved between the emergency department, the acute medical unit and the inpatient wards, using structured handovers and documenting key information to maintain continuity of care.

Specialist collaboration was recognised as essential for safe patient flow. A workforce review carried out in November 2025 identified that additional in‑reach support from gastroenterology, cardiology and respiratory teams was needed to strengthen specialist input and improve hospital flow. This showed that the trust had recognised capacity pressures and was planning to enhance specialist availability to support safer patient pathways.

Medical, nursing, pharmacy and therapy teams coordinated patient care and discharge arrangements. Pharmacists reviewed prescriptions and worked with doctors to optimise medicine use, while therapy staff supported rehabilitation and mobility planning. Staff escalated delays in diagnostics and liaised with other departments to minimise the impact of these delays on patient flow. This showed that teams understood their roles and worked together to resolve challenges promptly.

However, there were gaps in the consistent application of cross‑disciplinary support. Physiotherapists told us that nursing staff on older people’s wards were sometimes over‑reliant on physiotherapy teams for mobilisation, especially for patients with neurological or respiratory conditions. They believed this may have been due to a lack of confidence or uncertainty among nursing staff about whether mobilisation fell within their remit. The matron confirmed that staff had received training but acknowledged that confidence and time pressures might have affected practice. Physiotherapy assistants were not always able to attend patients every day, which meant some patients were not mobilised as frequently as expected. This indicated a need for clearer role understanding and further confidence‑building among ward staff.

We saw no evidence that criteria‑led discharge (CLD), including that nurse‑ or therapy‑led discharge, was being used on the elderly care wards, despite national guidance promoting these models to support timely, safe discharge. Therapy staff told us patients typically received around 30 minutes of therapy a day on three days each week, and there was no routine weekend therapy provision apart from respiratory cover. They felt this contributed to delays for patients who needed rehabilitation before they could leave hospital, particularly for those on complex discharge pathways. Some senior clinicians also told us that MDT processes did not always include wider system partners, such as community services, social care, care homes and voluntary sector providers, which limited opportunities to coordinate support across the whole pathway

During our observations of the multidisciplinary team (MDT) meetings throughout the day, the discussions often repeated the same information rather than progressing decision‑making. The meetings were largely medically led, and although they did include nursing staff, therapists, and discharge coordinators, they did not consistently draw on the full MDT to review clinical, functional and discharge needs in a holistic way. National good practice (SAFER patient flow bundle and NHS England guidance on interdisciplinary discharge planning) stresses the importance of nurse‑led and therapy‑led discharge processes, as these roles are central to assessing mobility, functional ability, social needs and safe discharge criteria. When these professionals are not fully utilised within MDT reviews, the team may miss opportunities to identify rehabilitation goals, address functional barriers early and progress patients towards timely, safe discharge.

Staff involved community services early in discharge planning to support continuity of care. This collaboration formed part of the local health and care partnership organisation, which replaced fragmented systems with an integrated, neighbourhood‑led model. The service offered acute‑level care at home through virtual wards, urgent community response and integrated frailty beds, enabling smoother transitions out of hospital. Internally, action plans for B5 and C5 wards addressed themes of poor communication by requiring standardised handovers and consistent patient updates. This showed that the service was working to improve information‑sharing and coordination across the patient pathway.

Staff described clear escalation routes and said they felt supported by colleagues across disciplines. Patients received timely specialist advice and intervention when required, and staff confirmed follow‑up arrangements with community teams to reduce the risk of readmission.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service had arrangements in place to monitor and improve outcomes for patients, and these processes were used to inform priorities within medical care. Local and national audit findings, patient complaints, incident reviews and themes from previous assessments contributed to identifying the areas requiring improvement.

The service participated in national clinical audits and national confidential enquiries relevant to the specialty, which helped ensure practice aligned with legislation, national standards and evidence‑based guidance. During 2024/25, the trust participated in 94% of eligible national clinical audits and 100% of national confidential enquiries, which demonstrated a strong commitment to learning from national benchmarks.

The service used routinely collected data to set measurable goals for improvement. Targets for 2025/26 included improving the proportion of patients receiving a venous thromboembolism (VTE) risk assessment within 14 hours of admission, increasing compliance with delirium screening, and reducing higher‑grade pressure ulcers. There was also a specific aim to standardise falls reporting and reduce the rate of falls causing moderate or above harm. Between June and November 2025, assurance audits were completed across medical wards for pressure‑ulcer prevention, falls prevention, bed‑rail safety, nutrition and hydration, and dementia and cognition support.

There were clear processes for responding when outcomes fell below expected standards. Following safety concerns in the treatment of interstitial lung disease (ILD), leaders initiated an internal case review, held multidisciplinary discussions on affected patients and commissioned an external review by the Royal College of Physicians.

Actions to improve patient flow were also linked to outcomes. The hospital flow programme was introduced to address safety concerns associated with overcrowding and delayed admissions from the emergency department. The service monitored stranded and super‑stranded patients, discharge delays and length of stay, and used this information in operational meetings and complex‑discharge panels.

Staff were supported to contribute to improvement work. More than 300 staff members had received specialist quality‑improvement training, including medical, nursing and operational staff within medical care. Team members described being involved in improvement activities, such as projects to strengthen sepsis assessment, improve early mobilisation and enhance documentation on admission and discharge. The emphasis on patient‑centred care was highlighted through organisational priorities to improve patient experience and emotional support, and local teams reported positive impact from events where patient stories were shared to celebrate good care.

Staff supported patients to make informed decisions about their care and treatment. Pathway reviews showed that staff explained treatment plans clearly and checked that patients understood the information before continuing. Patients were given time to ask questions, and staff encouraged them to raise any concerns. When care changed, staff updated patients and confirmed consent before proceeding.

Staff assessed mental capacity when required and followed the principles of the Mental Capacity Act (MCA). When patients lacked capacity, staff involved family members or advocates and recorded best‑interest decisions in the patient notes. The service provided accessible information, including easy‑read booklets on the MCA and Deprivation of Liberty Safeguards (DoLS), to help patients and relatives understand their rights and the decision‑making process.

Staff used interpreters and communication aids for patients with language or communication needs. They adapted their approach for people with cognitive impairment or sensory loss, such as hearing difficulties, ensuring that consent remained valid and informed. Staff also had access to specialist tools for people with learning disabilities, including a structured framework for making appropriate reasonable adjustments (TEACH) and pain assessment tools for non‑verbal patients. Hospital passports and health action plans were used to guide person‑centred decision‑making.

The service monitored the quality of consent documentation, especially for end‑of‑life decisions. Mortality audit records included checks on whether a patient’s capacity had been documented and whether patients or relatives had been consulted about treatment‑escalation plans and do not attempt cardiopulmonary resuscitation (DNACPR) decisions. However, these audits identified inconsistencies. For example, in a sample from January 2024, there were cases where neither patient nor relative consultation had been recorded. A formal complaint similarly highlighted a case in which staff had not met the communication needs of a patient who was hard of hearing and neuro‑divergent, which resulted in an action plan to strengthen shared decision‑making.

Governance arrangements provided oversight of MCA and DoLS processes. The patient safety and quality group noted a rise in Court of Protection cases in July 2025. This prompted a review of local MCA/DoLS practice and led to the redesign of level 3 safeguarding training. This showed that the service recognised gaps in practice and took steps to improve staff competency in this complex area.

Staff told us they received training linked to learning disability care, including communication tools and the use of reasonable adjustments. A clinical policy for acute psychiatric presentations supported staff in deciding when to involve psychiatry and clarified that confused older people were generally more appropriately supported by medical teams.