St Helier Hospital and Queen Mary's Hospital for Children

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

At our last assessment we rated this key question good. At this assessment, the rating has remained good. This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

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

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff across the service demonstrated a commitment to person-centred care, ensuring that patients were involved in decisions about their care and treatment. The involvement of multidisciplinary teams, including doctors, nurses, dieticians, and physiotherapists, facilitated comprehensive care planning that responded to the individual needs of patients. People told us they felt listened to and involved in decisions, as did their families and carers. Ward rounds we observed were comprehensive and person centred. Staff also used patient passports and liaised with specialist teams and dementia champions to ensure individual needs were met. We saw symbols displayed above patient beds to highlight information for the team to be aware of for example falls risk and dementia. This ensured that all staff are immediately aware of key patient needs and potential risks, promoting safety and enabling a more responsive and personalised approach to care.

Staff demonstrated respect and compassion in their interactions with people. We saw examples of cultural and spiritual needs being considered. Prayer spaces were available, and dietary requirements were accommodated. The patient records that we reviewed reflected that individual needs were assessed, and care planning was informed by this.

There were some shortfalls which meant care was not always joined-up, flexible or supportive of choice and continuity. However, the service understood the diverse health and care needs of people and their local communities.

Staff worked collaboratively across wards and theatres to maintain continuity of care. We observed effective handovers between surgical and recovery teams, with clear communication about patient needs and treatment plans. Due to a lack of capacity in the Intensive Therapy Unit (ITU) and High Dependency Unit (HDU) some patients were cared for in the recovery area for prolonged periods. This could compromise patient safety and care quality, since the recovery area does not have adequate facilities, equipment, or staff to monitor and treat patients with high dependency needs. One member of staff raised concerns about recovery staff not having the appropriate training to manage high dependency patients. However, leaders told us when this occurred this was done with support from the critical outreach team or ITU staff.

The service's use of electronic health records did not always enable seamless communication between different departments and specialities to support continuity of care as patients moved between services. We observed that in some areas such as the eye day care unit staff used paper records as well as electronic health records. Using both paper and electronic systems could create duplicated work and increases the risk of inconsistent or incomplete patient records. Which can hinder communication between teams if all staff cannot access both record sets. We also observed an occasion where an issue in recording the electronic consent and checklist resulted in delays in theatres. Multiple staff members reported that ongoing issues with the electronic health record system had disrupted their ability to deliver patient care. Work was ongoing to address these issues, leaders told us the Electronic Patient Record team were prioritising addressing the biggest risks with the system, by meeting with staff to understand system issues and maintaining a tracker for weekly progress and changes. Staff were encouraged to report incidents with the system and review processes were established, with regular division incident reviews and system implementation reviews.

The service planned and organised services, so they met the needs of the local population working in collaboration with system partners to analyse what people’s needs were and how they could best meet them. The service was attentive to the diverse health and care needs of its patients, aiming to provide joined up and flexible care. The service also used patient-initiated follow up in some specialties, which allowed patients and carers who agree to this pathway to initiate their follow up appointments as and when required. This allowed the service to be more responsive and flexible to changing needs, so patients could access support when they need it most, reducing unnecessary appointments and improving the overall efficiency of the service.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service made efforts to provide accurate, up-to-date information to patients, to help them understand their care, treatment options, and any changes to their treatment plans. Patients had access to information leaflets and clinicians were observed taking time to answer patients’ questions and ensuring they understood the information provided. Leaflets complied with the Accessible Information standard. Patients in the SACU said they were kept updated and informed and staff explained reasons for delays.

People’s individual needs to have information in an accessible way were identified, recorded, and shared. These needs were met and reviewed to support their care and treatment in line with the Accessible Information Standard. This included making reasonable adjustments for disabled people and interpreting and translation for people who did not speak English as a first language.

Information gathered about patients or others was not always held in secure systems. Access to computerised patient records was password protected with a secure login. However, we did see some patient information on paper having been left on desks and not supervised and some staff not closing computer records after stepping away. We raised this with staff on the day who took immediate actions to address the concerns.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

We saw signage encouraging people to give feedback with QR codes which people could scan to provide feedback digitally. Staff understood how to handle complaints and could provide examples of feedback from complaints. Complaints were used to improve care and treatment where possible. Feedback was gathered through Friends and Family Tests and the trust’s complaints processes, and themes were shared with staff during huddles and meetings. Martha’s rule was also being trialled at the Mary Moore Ward. Martha’s Rule is a patient safety initiative that empowers patients, families and staff to request an independent medical review if they feel their concerns about a patient’s care are not being adequately addressed. This encouraged patients and their families to escalate concerns and ensure their views were heard.

Patients said staff listened to their concerns and acted on them. We saw examples of how patient feedback was used to drive improvements. For instance, waiting times in the eye unit were staggered after patients raised concerns about prolonged waits for procedures, and visual alerts were added to patient bed boards in response to complaints about time-critical medications not being administered promptly. We observed staff involving patients in care planning discussions. Friends and family test responses indicated that’s patients felt the care they received was good.

Staff were knowledgeable about the complaint-handling process and could articulate the steps taken to manage complaints. When concerns or complaints were raised, staff demonstrated a thorough and sensitive approach to handling them. The trust target was to resolve complaints within 25 working days. However, a review of the complaint tracker showed that some complaints took 55 working days or longer to receive a response. Regular weekly meetings were conducted to review all complaints within the division, ensuring ongoing monitoring and enhancement of compliance practices.

Leaders acknowledged the need to enhance patient engagement mechanisms and expressed intentions to develop a patient forum dedicated to supporting service improvement efforts, although no specific timeframe was established. Recruitment for the quality team was ongoing to further facilitate these initiatives.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

The trusts performance in referral to treatment times was generally better than the England average, however, both the trust performance and the England average were below national standards. Data we reviewed showed that in October 2025 within the division 322 patients had been on waiting lists for over 52 weeks. Leaders described ongoing work to improve referral to treatment times. This included initiatives aimed at improving waiting lists throughout the service, including collaboration with the outpatient transformation team to optimise ophthalmology clinics and the implementation of telephone triage clinics in foot and ankle surgery, which had led to reduced patient wait times. Leaders also told us they continued to face challenges in reducing waiting times for upper gastrointestinal procedures and cholecystectomies. These delays meant that people did not always receive the care and treatment they need when they needed it, which could create inequity in access.

Patients often experienced long waits in the SACU. Staff told us waiting times could be up to 4 or 5 hours. We observed that the waiting area in the SACU was full, with some patients telling us they were waiting for over 4 hours. As most bays available in the unit were being used to care for inpatients there was reduced space to see patients in a timely manner and to perform procedures.

Managers worked to keep the number of cancelled appointments and operations to a minimum. Between July and September 2025, there were 261 last minute cancellations of procedures, of which 10 breached the standard for rescheduling within 28 days. In November 2025, 9.38% of cases were cancelled on the day of the scheduled procedure, with clinical need cited as the primary reason for the majority of cancellations.

The trust had previously performed well in theatre utilisation locally. After introducing the new electronic patient record system, utilisation had declined as clinical activity was reduced. In November 2025, capped theatre utilisation across the trust was 74.9%, which was below the Getting It Right First Time (GIRFT) recommended level of greater than 85%. This shortfall meant fewer procedures could be scheduled, increasing waiting times for surgery and negatively impacting the ability to access timely care. Improving theatre utilisation formed part of the trust’s theatre transformation programme.

The trust’s performance in length of stay for elective and emergency admissions was generally higher (worse) than average. This can reduce bed availability and delay admissions for others, which limited timely access to care. A shortage of rehabilitation facilities for individuals with complex discharge needs contributed to poorer length of stay performance. Staff told us that recent initiatives, including length of stay workshops with matrons, ortho-geriatricians and anaesthetists, had led to moderate reductions in hospital stays. To help mitigate the lack of rehabilitation facilities, the trust was using bed-based rehabilitation options. A transfer of care hub was under consultation, intended to standardise and streamline discharge processes. This would replace the existing situation in which discharge coordinators across the trust used varying methods. However, some flow and discharge coordinators we interviewed expressed dissatisfaction about possibly leaving their current teams. Weekly length of stay reviews attended by divisional representatives and the site team sought to optimise the flow of patients who were medically fit for discharge. Multi-agency discharge events (MaDE) which brought together external stakeholders from across the local health system to support improved patient flow across the system were seen as beneficial in improving flow in the service although these were infrequent and progress was not sustained between the events.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

People experienced care that was fair and inclusive, and the service worked to reduce inequalities in outcomes. Staff demonstrated awareness of individual needs and made reasonable adjustments to support people with protected characteristics, including those with learning disabilities, dementia, and carers.

The trust demonstrated its commitment to reducing health inequalities through published pledges and targeted programmes. For example, dementia and delirium champions were appointed across surgical wards, and safeguarding and mental health advocates were available in outpatient areas. Veteran patients were identified and supported through the Veteran Aware initiative. As a result, these individuals benefited from care that was sensitive to their unique experiences and needs, ensuring that they felt recognised and respected within the healthcare setting.

The service had clear processes to identify and support unpaid carers. Carers were recognised as partners in care and involved in discharge planning. The trust’s Adult and Young Carers Charter set out commitments to communication, empowerment, and wellbeing, and carers and relatives told us they felt listened to and respected.

People with learning disabilities and autism were supported through initiatives such as easy-read information, and a pilot scheme for identification wristbands in the emergency department. This facilitated the smooth transition of care for these individuals when they required surgical intervention, enabling staff to quickly identify their needs and make reasonable adjustments. These measures aimed to improve communication, safety, and timely care. Staff were trained to make reasonable adjustments, such as offering side rooms, flexible appointment times, and easy-read materials. The Learning Disability and Autism Steering Group provided oversight and promoted best practice, including the use of hospital passports and engagement with carers.

Staff compliance with mandatory training in Equality, Diversity and Human Rights was good, and this helped ensure that people were treated with dignity and respect and that staff understood their responsibilities under equality legislation.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The service demonstrated a proactive approach in supporting patients to plan for life changes and their future care needs. People were supported to make informed choices about their care and plan their future care while they had the capacity to do so. These plans included decisions about future treatment and care, such as do not attempt cardiopulmonary resuscitation (DNACPR) requests, and were shared with relevant professionals to ensure continuity. When people wanted to express their wishes about cardiopulmonary resuscitation, staff told us they were supported to do so and could change their mind if they wished.

However, staff did not receive mandatory training on end-of-life care awareness to manage such patients. As a result, there was a risk that staff may lack the necessary knowledge and confidence to provide appropriate support, potentially leading to inconsistencies in the quality of care delivered to people nearing the end of their life. This could affect the ability of staff to communicate sensitively, recognise individual needs and wishes, and ensure that care is delivered in a dignified manner, ultimately impacting patient experience and outcomes.