9 December 2022
We inspected the Maternity service at this location as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.
We will publish a report of our overall findings when we have completed the national inspection programme.
We carried out a short notice announced focused inspection of the Maternity service, looking only at the safe and well led key questions.
Our rating of this maternity service stayed the same. We rated it as Good. We rated safe as Requires Improvement and well-led as Good.
You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.
Guy’s and St Thomas’ Hospital NHS Foundation Trust provide maternity services at St Thomas’ Hospital and local community services. The maternity service has over 6000 births per year, 6000 NHS births and 300 private patient births.
- Antenatal Clinic
- Antenatal Ward
- Community Midwifery
- Fetal Medicine Unit
- Home from Home Birth Centre
- Hospital Birth Centre
- Maternity Assessment Unit
- Post Natal Ward
- Westminster Maternity Suite (private wing)
24 March 2016
Overall we found medical care services at St Thomas’ were good.
The safety of medical care services was good. There was a positive culture of incident reporting; staff understood and fulfilled their responsibilities to raise concerns and report incidents. We found measures for the prevention and control of infection met national guidance and standards of hand washing and cleanliness were consistently high and regularly audited. We found there were sufficient doctors and registered nurses on duty; staffing levels were tracked four times a day across the hospital. Patients who were deteriorating received a speedy response and had their care reassessed.
We rated the effectiveness of medical care services as good. Staff were well supported with access to training, clinical supervision and development. Use of NICE guidance was used across a range of conditions. There was a programme of national and local audits regarding clinical practice in place. Patients were assessed by a dietician when screening suggested a risk of malnutrition.
Patients’ nutritional needs were assessed with
recorded and risks identified. Consultants covering acute medicine were available seven days per week. Patients were asked for verbal consent to be treated and we saw consent forms to treatment forms had been signed by the patients prior to medical procedures.
We rated the caring aspects of medical care services as good. Patients received compassionate care and were treated with dignity and respect. Patients and their relatives were positive about their experience of care and the kindness afforded them. Patients told us they were involved in decisions about their care and treatment and were given the right amount of information. The trust's performance in the Family and Friends test (FFT) was consistently higher had a higher than average response rate to the Friends and Family test (FFT) than the England average.
We rated the responsive aspects of medical services as outstanding. The admissions ward was overseen by multidisciplinary medical teams who undertook assessments and provided a rapid response to reduce
unavoidable admission and improve early discharge. The hospital proactively managed patients discharge. Where a patient's discharge was delayed this was escalated to the discharge team to progress. Most patients 79%, (21,405) experienced no ward move and were treated in the correct speciality bed for the entirety of their stay. Patients had their needs assessed and fundamental care rounds were undertaken at different times of the day. Formal complaints were managed through the Patient Advice and Liaison Service (PALS), they were investigated with learning points identified and fed back to staff.
We rated the well-led aspects of medical services as good. Staff were aware of the trust and acute medicine vision and incorporated this as part of their daily work. The culture within the division was one of openness and honesty. There was an appropriate system of clinical governance in medical services that identified quality and risk issues. Staff reported they were supported by their managers and department heads. We found staff and patients were engaged with the development of medical care services, and saw examples of innovative practice.
24 March 2016
We rated the hospital services good for safety. There was a robust and open process for ensuring that clinical incidents were reported and investigated and that lessons learnt from them were fully shared with all staff. Robust safeguarding systems were in place. Patient risks were appropriately identified and acted upon with clear systems in place to identify and manage a baby, child or young person’s with a deteriorating medical condition.
We assessed the effectiveness of care provided as good. There was participation in audits and care and treatment was provided in line with professional guidance. The hospital was effective at coordinating its multi-disciplinary teams to ensure the best outcomes for patients. While not all services operated seven days a week, services were flexible to meet patients’ needs.
We rated the care provided as outstanding. We saw many examples in all areas of the hospital to demonstrate that the hospital was delivering compassionate care. Parent feedback unanimously supported this. Sensitive emotional support was offered to patients, parents and staff. Parents told us they had a good understanding of the care their baby or child was receiving and felt the hospital involved them in the care their children received. Friends and family test outcomes were also highly complimentary of the service. Children and their families were treated with compassion, dignity and respect.
We rated the responsiveness of the service to the needs of patients and their families as good overall, although there were some elements that were outstanding. We found many examples where the hospital and its staff had made special efforts to meet the needs of children, young people and their families. Examples of initiatives were a fasting reduction initiative for children having surgery, communication boxes on wards to help communicate with nonverbal children or those who did not speak much English, and clinics being timed so secondary school children would not miss too much school. Joint clinics were organised so that young people could meet their ongoing care team to help ease the transition to adult services. However, there were challenges in meeting referral to treatment times in some specialities, and dealing with year on year increases in demand with limited scope to increase capacity in the medium term.
Complaints and concerns were taken seriously. They were responded to promptly to achieve resolution. Feedback was actively sought from parents, children and young people about their current care experience, and where possible changes to improve the quality of care were introduced in response to suggestions.
We found leadership in ELCH to be outstanding. The vision to establish Evelina as a comprehensive specialist children’s hospital within a regional clinical network was well understood and supported by staff.
The hospital had a strong clinical governance structure, focused on reducing clinical risk, monitoring quality and improving patient outcomes. There was committed,supportive leadership at local, service and hospital levels, and clear reporting lines for escalating risk, disseminating information and monitoring standards, We found an open and transparent culture with motivated and compassionate staff who were well informed about the hospital’s priorities as well as those of the wider trust, and felt they had a genuine role in shaping the development of the hospital. Staff valued the democratic culture and were passionate about supporting children and their families through sickness,. There was an ethos of continuous improvement. Families and patients also felt involved in developing the hospital through consultation and effective communications.
24 March 2016
There was a proactive safety culture for reporting and learning from incidents. Critical care management were aware of on-going risks; these were recorded on the department risk register and largely reflected our inspection findings. Safety thermometer results and patient outcomes, particularly for patients receiving ECMO, were good. Patients were cared for by safe numbers of staff, using evidence-based interventions. Caring staff obtained consent prior to procedures and maintained patient privacy and dignity.
The critical care service was flexible to the needs of patients and successfully used a “never say no” admissions policy. Few patients were transferred out of hours and the proportion of delayed discharges from critical care was better than in other similar units. The critical care environment was cramped with little spacing between beds. However this issue was being addressed with a HDU rebuild and a new critical care unit. Staff and patients were engaged in developing plans for the new units and providing feedback about the service.
Substantial participation in national and international research projects was apparent and we saw evidence of many departmental contributions to journal articles, book chapters and clinical guidelines. New innovations in critical care including telemedicine were being trialled and plans for formal implementation were in place.
Staff knowledge of safeguarding and Deprivation of Liberty Safeguards (DoLS) was variable across the service despite a high uptake of training in this area and safe practice relating to this was not embedded. Staff appraisal rates were low and less than the recommended 50% of nursing staff had a post registration award in critical care nursing.
24 March 2016
Staff who worked in the specialist palliative care team (SPCT) demonstrated a multidisciplinary approach to caring for their patients.
They worked cohesively with generalist nurses and medical staff, respecting each other’s skills, experience and competencies in a professional manner that benefited the patients they cared for.
Staff at St Thomas’ Hospital provided skilled and compassionate end of life care to patients. The SPCT was effective and provided face to face support seven days per week including 24/7 community visiting. Due to staff shortage at the time of the visit on call was restricted to visits until 9pm and calls taken until 11pm. The Consultant rota remained unchanged during this period.
There was good leadership of the SPCT, with staff commenting on how senior managers were visible, approachable and willing to help out. They also provided consistent and prompt guidance and support. We found many examples of innovative practice, including the AMBER care bundle and a range of training courses for staff in end of life care such as the Sage and Thyme training model, simulation days and Schwartz rounds. We saw staff in the bereavement office had sourced funding to provide family members with sympathetically designed cloth bags so they had a more discreet way of taking home personal belongings of a deceased patient, rather than use a plastic hospital property bag.
The hospital had a long term vision and strategy plan around end of life care. This was in its infancy and staff commented that it needed to be revised and made more achievable. Nevertheless staff spoke very positively of the multi-disciplinary team approach; the importance of quality outcomes for patients and the focus on providing care that was based on individual need. We saw, for example, that staff had arranged for the painting materials belonging to one patient nearing the end of life to be brought to the ward so they could continue with their art. The SPCT encompassed national guidance into its end of life care protocols and practice such as the NHS guidance – Priorities for the Care of the Dying Person and One Chance to get it Right - developed by the Leadership Alliance for the Care of Dying People (LACDP). It also referred to the NICE quality standards for end of life care.
Bereavement support was available from the SPCT social workers, chaplaincy and the bereavement office. We saw patients were cared for with dignity and respect. Medicines were provided in line with guidelines for end of life care. Staff facilitated rapid discharge of patients to their preferred place of death. Feedback from patients and relatives, both in person during the inspection and gathered by the hospital in its own bereaved carer survey, was overwhelmingly positive.
The hospital was in the process of moving to wholly electronic based records. We found that during this process staff needed to use three different software systems as well as paper records, which led to some confusion and uncertainty around where to find key information. This was particularly noticeable with regard to 'do not attempt cardiopulmonary resuscitation' (DNACPR) forms. We found that in some patients’ notes their condition indicated a mental capacity assessment would have been appropriate but staff had not carried one out. We were told there were sometimes delays in relatives being issued with a death certificate due to the unavailability of doctors to complete the paperwork.
From January to December 2014 there had been 971 deaths at the Trust.
9 December 2022
23 July 2019
We visited the outpatients services at St Thomas’ Hospital for three unannounced inspection days from Tuesday 2 April to Thursday 4 April 2019. During our inspection we inspected clinics in the Gassiot House Outpatient Centre, the diabetes, cardiology, pain, pelvic floor, ears nose and throat, ophthalmology, colorectal, emergency vascular and chest clinics. We spoke with 45 members of staff including doctors, nurses, allied health professionals and ancillary staff. We also spoke with the outpatients leadership team, and 17 patients and relatives. We reviewed seven patient records and checked many items of clinical and non-clinical equipment.
We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.
We rated it as requires improvement because:
- The trust had many patients with overdue follow up appointments and it was unclear how the trust was managing the risks to these patients.
- The trust’s ‘did not attend’ rate was higher than the England average.
- The service was not meeting the referral to treatment (RTT) targets for certain specialities.
- The trust wide data showed a backlog of patients waiting longer than 18 weeks was 9810 in February 2019 and in March 2019, the backlog was 10048. In January and February 2019, there were 32 patients waiting over 52 weeks for both months.
- The service provided mandatory training in key skills to all staff and but not all staff completed it to meet the trust targets.
- The trust was not auditing their patient waiting times from the time of first appointment from when they first checked into the appointment and the time when the patient was seen by the clinician.
- The service provided care and treatment based on national guidance and evidence of its effectiveness.
- Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
- Staff felt supported and motivated and there was a positive culture within the workplace.
24 March 2016
There were clearly defined vision and strategies for each surgery service that included working with other directorates and other organisations to provide the best health outcomes for all. There was strong clinical leadership with visible presence and nurses were empowered.
There was a proactive approach to seeking out and embedding new and more sustainable models of care. Quality improvement was a part of all staffs daily roles and all staff were continuously striving to improve services.
Patients were supported, treated with dignity and respect and involved in their care and treatment. Patients told us that the care was kind, compassionate and they felt listened too. We observed a number of interactions where patients and their families were involved in their care and helped with their emotional needs. The average response rate to the friends and family test was 35% with respondents most commonly recommending the service.
There were sufficient numbers and mix of all staff to provide safe care. There was good retention of nursing staff and management of turnover. There was a very low use of bank and agency nurses. Staff were qualified and had the skills and expertise to carry out their roles effectively in line with best practice. Care was coordinated and staff were worked collaboratively to understand and meet the needs of patients.
There had been nine never events in 12 months and we found the World Health Organisation (WHO) safer surgery checklist needed to always be fully used. However, although we found an open culture of learning from incidents, learning was not shared across directorates.
Staff were knowledgeable on the needs of their local population and service users. Access and flow was well managed by the service by working with the whole hospital. Waiting times and cancellations were minimal.
24 March 2016
The vision and strategy of the team working within the department was one of striving for excellence, which was demonstrated through a continuous programme of clinical and professional development. This was delivered by a cohesive, highly enthusiastic team that worked in a culture of mutual respect and trust.
Our review of over 190 individual pieces of evidence and discussions with over 30 members of staff, revealed that the department was led by a team who embedded transparency and openness in the day-to-day working of the department. Staff were encouraged to report incidents and did so confident in the knowledge that learning would take place from them. Investigations into incidents and complaints were robust, impartial and emphasised service improvement.
Although the ED had not consistently met the government’s 95% target for admitting, transferring and discharging patients within four hours of arrival, staff had numerous procedures in place to mitigate the impact of this. The use of an effective streaming process for arriving patients had contributed to a very high performance in ambulance handover times, including no black breaches in the year leading to our inspection. Streaming and triage processes had been streamlined by a highly collaborative team that had conducted pilots and research to assess the safest and most efficient methods of registering and treating arriving patients. The drive and ability of staff to conduct on-going projects in order to improve the efficiency and quality of the service was evident in many other areas, including the flexible deployment of staff and a programme of specialist training that was highly regarded and facilitated by dedicated practice development nurses.
The clinical effectiveness of the department was sustained by a substantial number of audits that were overseen by consultants and senior nurses. Audits demonstrated that consultant sign-off in severe sepsis and the management of neutropenic sepsis patients had improved from 2014 to 2015. Junior staff were encouraged to conduct audits in areas of interest to them and each nurse acted as a link for an area such as infection control or dementia.
Most of the interactions we witnessed between staff and patients were positive and were based on compassion and respect. Where we saw that some individuals dealt with patients brusquely or without regard for their distress, senior staff had plans in place to address poor attitudes. We saw evidence that past approaches to dealing with such issues had been effective. Feedback we received from patients was mostly positive but some people did comment negatively on some of the unfriendly interactions we had seen. We considered such instances to be isolated and we found that the majority of patients held the ED in high regard, as evidenced from the frequent thank you letters and cards staff had received.
The ED was frequently presented with challenges to care and treatment based on the local population, including social care needs of homeless people and treatment needs for people who had overdosed on recreational drugs. Staff had led a number of innovative programmes to better support such patients and to improve their long-term health outcomes. Such approaches had led to substantive relationships with other local service providers, such as those who supported homeless people and those who experienced domestic violence. A well-established mental health liaison team was very highly regarded by the ED staff we spoke with and helped them to care for patients with psychosis and other mental health problems. We identified eight distinct projects that had been carried out by staff to help them care for people with complex needs whilst maintaining the overall clinical standards of the department. The projects served to enhance the scope of the service as well as to contribute to the feelings of achievement we found amongst staff.
The ED was undergoing a major rebuild that had changed the configuration and capacity of the current department. Plans and developments had been communicated to patients and staff had implemented a number of procedures to mitigate the impact of the building works. This had included a 24-hour streaming process and a 24-hour receptionist function in the majors unit. Staff had attended planning meetings with designers and architects to give their input into the new department design, particularly around the design of cubicles for patients with psychiatric needs.
Consideration had been given to the treatment of patients who had learning difficulties or who were not able to communicate verbally. In addition, a well trained and competent security team played a key role in the ED and enabled staff to treat patients with psychiatric needs safely. Staff had a good understanding of the Mental Capacity Act (2005), safeguarding procedures, dementia and their responsibilities for patients who had a Deprivation of Liberty Safeguards authorisation in place.