St Matthews Hospital

On this page

• 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

The provider had adequate systems and processes in place to learn from complaints, incidents and deaths. Staff reported incidents as expected, which were reviewed by senior staff, and reported into the hospital clinical governance meetings. This enabled regular monitoring and analysis of any trends or themes, enabling senior staff to focus upon further learning and training for staff. Learning was shared across the whole of the organisation, not exclusively within St Matthews hospital. This meant that staff were made aware of learning from incidents in other units. Managers produced a monthly learning alert and cascaded to all staff. Leaders also shared areas of good practice, encouraged problem solving, and offered regular reflective sessions, de-briefs and some incident specific learning analysis. Staff undertook many clinical audits to monitor the quality of the service. We observed that audit findings were actioned and added to the hospitals ongoing improvement and sustainability plan. Feedback was welcomed from patients using the service, as well as from relatives of patients at the service. The provider had made some changes to the menu’s offered following recommendations and feedback from patients. Staff reported a supportive leadership team who were approachable and open to new ideas. Managers encouraged evidence-based practice when providing care and treatment, which was evident in care plans, risk assessments and policies seen. We were not informed of any research staff working at the hospital were involved with, at the time of assessment.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Governance, management and sustainability during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had systems and processes in place to support learning from complaints, incidents, deaths, and previous CQC inspections. The provider produced a monthly learning alert to communicate this learning to staff. We also noted some visible posters related to learning from recent events at the hospital during our visit. Staff discussed individual patient risks and recent incidents during routine shift hand overs. Staff had been involved with learning analysis and had the opportunity to attend de-brief meetings and / or reflective sessions to discuss and reflect upon specific risks following incidents.

Managers monitored the quality of care regularly through undertaking observations during walks around the hospital. In addition to this the hospital had an audit timetable to ensure specific areas of care and treatment were examined regularly. It was clear that deficits identified through internal audits were acted upon, to maintain and continue to improve and / or maintain standards. The hospital had an improvement and sustainability plan in place, with various actions identified. Senior staff had identified most issues reported through internal audits. Each item had a priority rating and identified which staff group were responsible for actioning. Leaders had listened to feedback from patients and had introduced initiatives around the menu and the variety offered. Senior staff had been involved in a local quality and safety learning group, in collaboration with a local NHS trust, and another large independent provider. Work to come out of this included the introduction of the 'culture toolkit' at St Matthews hospital. This initiative enabled staff to give anonymous feedback relating to the culture within the organisation. This work was ongoing, with leaders collating results to help them improve.