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St George's Hospital (Tooting) Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 1 November 2016

St George’s Hospital in Tooting, London, is the main hospital site of St George’s University Hospitals NHS Foundation Trust. The trust serves a population of 1.3 million across Southwest London. A large number of services, such as cardiothoracic medicine and surgery, neurosciences and renal transplantation are provided and the trust also covers significant populations from Surrey and Sussex, totalling around 3.5 million people.

As well as acute services, the trust also provides a full range of community services to patients of all ages following integration with community services in Wandsworth in 2010.

St George’s Hospital provides acute hospital services and specialist care for the most complex of injuries and illnesses, including trauma, neurology, cardiac care, renal transplantation, cancer care and stroke.

St George’s University Hospitals NHS Foundation Trust employs around 8,536 whole time equivalent (WTE) members of staff with approximately 3,259 working at St George’s Hospital. We carried out an announced inspection of St George’s Hospital between 21 and 23 June 2016. We also undertook unannounced visits to the hospital on 2, 7 and 11 July 2016.

Overall, this hospital is rated as require improvement. We rated 

outpatients and diagnostic imaging as inadequate. We rated the emergency department, medical care, surgery, services for children and young people and end of life care as requires improvement. We rated critical care and maternity and gynaecology as good.

We rated safe as inadequate. We rated effective, responsive and well led as requires improvement. We rated caring as good.

Our key findings were as follows:

Safe

  • Several areas of the hospital’s estate that was in a state of disrepair. There was water ingress during heavy rain to several clinical areas we visited. Work had commenced to repair some of the affected areas, but the significant maintenance

    huge backlog, meant that this would take some time.

  • Heating and power failures which had previously affected one medical ward remained on the risk register and had not been fully addressed.

  • Some theatres were not fit for purpose. Theatres were sometimes closed due to electrical faults or unsafe temperatures. Sixteen of the 51 theatres needed to be completely refurbished. Since the inspection, we have been told by the trust, that the refurbishment of theatres 5 and 6 had been completed.

  •  The ED environment was aged

    old and this meant that some areas looked dirty, despite regular cleaning. Many parts of the department were extremely hot and uncomfortable.

  • Children and young people with mental health conditions were cared for on Frederick Hewitt Ward, but an environmental risk assessment had not been carried out to identify ligature points and other risks to their safety.
  • The storage of equipment and fluids in the ED within the major incident cupboard was unclear and created confusion about what was training equipment and what was ‘live’ equipment.
  • Many staff were trained in safeguarding adults and children and there were policies and processes in place for them to follow. However, 53% of medical staff working with children and young people had not completed level three safeguarding training, which is a requirement for all staff working with children. Safeguarding training was identified as a risk on the services risk register. Access to training was a problem; there was no dedicated trainer and no safeguarding supervision for staff.

  • There was variable adherence to infection control procedures and some medical and surgical staff ignored challenges from colleagues, which had a high impact on infection prevention and control.
  • Medicines were largely stored and managed appropriately, save for a few exceptions. For example, there were several examinations where radiographers gave contrast to patients despite PGDs not being in place.
  • Mandatory training completion by staff was low in many areas.
  • Records were well documented with fully completed care plans and legible entries that had been signed by the relevant staff member. However, there were instances where care records were not stored securely, increasing the risk of unauthorised access.
  • Medical and nursing cover across the hospital was generally good, apart from in the paediatric wards.
  • Most staff knew how to report incidents and there was evidence of learning from incidents being shared as well as changes to improve practice being made.

Effective

  • There was a lack of formal mental capacity assessments and best interest decision making as required under the Mental Capacity Act, 2005 and some patients had decisions made for them that they were capable of making themselves.

  • The Nursing Daily Evaluation Last Hour and Days of life document was a prompt sheet that was not backed up by either assessment or evaluation tools.
  • Pain was assessed and patients told us their pain was managed well. However, pain relief was not always documented in records and there could be a delay to administration of analgesia when patients arrived within the emergency department.

  • Information technology issues impacted on staff’s timely access to information and as a result records were fragmented in some areas.
  • Evidence based guidance was available and care was provided in line with the guidance.

  • We saw multiple examples of effective multi-disciplinary team working however there were shortfalls in some areas including MDT working for those at end of life or where patients required in out from both medicinal and surgical practitioners.

     

    .

  • All areas participated in national clinical audits and patient outcomes were measured. Many clinical areas showed positive results, particularly maternity and surgery.
  • Outcomes for renal patients in relation to survival rates and transplantation were excellent and were some of the best in the country.
  • A strong obstetric team focused on effective intrapartum care and staff used innovative and pioneering approaches to care with excellent outcomes. The maternity service was achieving year on year reductions in emergency caesarean sections.
  • The maternity unit was strong in fetal medicine and had done pioneering work in non-invasive testing.
  • There had been improvements in the appraisal process for nursing staff, but there were limited opportunities for training and development.

Caring

  • Staff delivered care in a kind and professional manner.
  • Although we observed and received some very positive reports of staff’s kindness and caring attitude to patients, we also received some reports from patients about a lack of empathy from staff and poor communication.
  • Patients were largely treated with dignity and respect. 
  • Most patients were positive about the care that they had received from staff and the way they had their treatment explained to them.
  • Feedback from survey results showed high levels of satisfaction by patients and relatives with most of the services provided.
  • There was sensitive support in place for bereaved parents of children.

Responsive

  • The trust had to temporarily cease national reporting of the RTT data. This was because, they could not guarantee the data they were reporting was robust and accurate.
  • Children shared ward areas with other children of a different gender or age group. Parents were asked to sign a disclaimer confirming their acceptance that their child could share an area with children of a different age or gender.

  • People were not able to access services for assessment, diagnosis or treatment when they needed to. The trust was not meeting national waiting times for diagnostic imaging within six weeks and outpatient appointments within 18 weeks for the incomplete pathways.
  • The trust was not meeting the urgent two week referral target for patients with suspected cancer and cancer waiting times on the whole were variable across the targets.
  • Follow up appointments were not always made in a timely manner and ‘Did Not Attend’ rates were higher than the England average.

  • Theatres were unable to meet demand. Cancellation of operations were frequent and some of these were not rebooked within 28 days.
  • Bed occupancy levels in surgical wards were higher than the England average, with a steady increase over 2015.
  • Patients sometimes had to wait for tests because of demand on ultrasound and MRI scanners.

  • There were a significant number of patient moves at night, between the hours of 10pm and 6am, which caused disruption and anxiety to some patients.
  • Although a hospital passport had been completed for patients with a learning disability, their care plans were not adapted to take account of their individual needs.
  • Care of people living with dementia was variable. The butterfly scheme existed but the Dalby Ward environment had not adapted to meet the needs of people living with dementia.
  • The ED was not large enough for the current throughput of patients and did not meet modern standards, which meant that in some areas, privacy and dignity of patients was compromised.

  • There was not always a systematic approach to the management of actions and learning from complaints.

  • Interpreters were sometimes used when patients were consenting to treatment and did not understand English, but at other times staff relied on relatives to interpret.

  • Not all women currently received continuity of midwife care.
  • There had been delays in access to some gynaecology clinics and procedures, although reductions in waiting times had been achieved over the previous three months by running extra clinics.

  • curtains used to screen the beds on at least four of the medical wards did not preserve people’s privacy.

  • Some patients were unhappy with having to use of disposable utensils and plastic beakers.
  • Parents were informed via text, when the child came out of theatre following surgery.

Well-led

  • Leadership across several departments was weak, with many longstanding problems failing to be addressed within a timely manner. There was a lack of strategic direction for some of the services from the top of the organisation.

  • We found a reactive rather than proactive approach to risk and environmental safety.
  • Whilst there were named executive and non-executive directors, staff working within the palliative care team considered ttere was lack of executive strategic direction for the provision of palliative care.

    for the top of the organisation. The lack of multidisciplinary team meetings (MDT) with colleagues from medical and surgical departments and other allied health professionals was an area of concern.

  • An external review of Referral To Treatment (RTT) data quality at St George’s University Hospitals NHS Trust (June 2016) found that due to a high number of unknown start times of a patient’s referral journey, patients were prevented from being treated in chronological order. The trust was also inconsistent in achieving their two week targets for patients with suspected cancer.
  • Following the inspection, the trust wrote to NHS Improvement and NHS England, to confirm their intention to temporarily cease national reporting of our RTT data. This was because, they could not guarantee the data they were reporting was robust and accurate.

  • The risk register in several divisions, did not fully document all risks identified across the departments and mitigating actions were not always sufficient to address risks. Actions taken to mitigate the risks were insufficient and timescales to fully address the risks were unclear.
  • Some staff felt able to approach their senior management team and felt well supported by their senior clinical staff. However, staff working with children and young people did not receive feedback from their appraisals and felt support was inconsistent.
  • There was no evidence that a vision and strategy for maternity was being jointly developed with midwives and obstetricians.
  • There was low morale among theatre staff and consultant surgeons. Some consultant surgeons were not working with a multidisciplinary approach and were not engaged in the divisional objectives.
  • Black and minority ethnic staff felt that they were not given the opportunities that less experienced white staff had in some areas.

  • Engagement of patients and the public in the improvement of services was evident.
  • There were examples of the development of services and the introduction of new practices to take the service forward.

  • We saw innovation across some areas, including participation in research, journal publication and use of social media to disseminate key information to staff.

We saw several areas of outstanding practice including:

  • Outcomes for renal patients in relation to survival rates and transplantation were excellent and some of the best in the country.

  • The outcomes achieved by the specialist medical and surgical services provided by the hospital.

  • The effectiveness of maternity care delivered by the hospital.
  • The responsiveness of the neonatal unit to parents whilst their baby was on the unit and the support provided by the outreach nurse.
  • The involvement of children of varying ages on the interview panel as part of the recruitment process for ED paediatric nurses.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure all premises and facilities are safe, well-maintained and fit for purpose.
  • Ensure all care is delivered in accordance with the Mental Capacity Act, 2005, when appropriate.
  • Review

    Improve all its governance processes, so that patients receive safe and effective care.

  • Ensure the RTT data is robust and accurate so that patients are given appointments and treatment based on their needs and within national targets.
  • Ensure serial numbers of prescriptions (FP10s) for prescribers are always monitored for use.
  • Ensure staff

    radiographers only administer medication (contrast media) where appropriately authorised Patient Group Directions (PGDs) or valid prescriptions are in place.

  • Ensure the fit and proper persons’ requirement regulations for directors is

    are always complied with.

  • Ensure the paediatric ward environment, staffing and training requirements are suitable for treating and caring for children and young people with mental health conditions.
  • Ensure medicines are stored in an appropriate manner, by keeping cupboards locked when not in use.
  • Ensure the process for decontamination of nasoendoscopes is always compliant with guidance.

In addition, the trust should:

  • Maintain patient privacy, dignity and confidentiality at all times.
  • Review the fluid storage within the ED major incident cupboard to ensure that training equipment is not stored with ‘live’ equipment.
  • Ensure staff consistently follow guidance related to the prevention of healthcare associated infections with specific regard to hand hygiene.
  • Ensure the equipment stored on Pinckney Ward is cleaned and there are systems in place for monitoring the cleanliness of equipment returned to the ward.
  • Ensure all staff caring for children receive level 3 safeguarding training.
  • Ensure the process for investigating serious incidents is timely and undertaken by people trained in investigation so they understand the root causes of an incident and identify measurable action.
  • Minimise the cancellation of operations and when this cannot be avoided, they are rescheduled within 28 days.
  • Reduce the moves of patients to wards that are not appropriate.
  • Ensure there are robust arrangements in place, which staff are conversant with, in relation to the recognition and escalation of deteriorating patients.
  • Ensure divisional and trust priorities are shared by personnel of all grades and professions who work together to promote the quality and safety of patient care.
  • Address the low morale among theatre staff and consultant surgeons.
  • Replace damaged furniture in patient/clinical areas so that they can be thoroughly cleaned.
  • Ensure that all patients within the ED ‘streaming’ area are assessed within a private area.
  • Ensure staff can observe the patients whilst they are waiting in their outpatient departments.
  • Ensure patient electronic records are not easily visible or their paper records are not easily accessible by the public.
  • Improve the percentage of telephone calls answered by staff in the outpatient department are within the service level agreement targets.
  • Communicate effectively with patients when outpatient clinics overrun.
  • Ensure there is sufficient diagnostic equipment (including cystoscopes) to supply day surgery, main theatres and endoscopy.
  • Ensure staff are appropriately inducted to the clinical areas to which they are employed to work. 

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Inadequate

Updated 1 November 2016

Effective

Requires improvement

Updated 1 November 2016

Caring

Good

Updated 1 November 2016

Responsive

Requires improvement

Updated 1 November 2016

Well-led

Requires improvement

Updated 1 November 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 1 November 2016

Overall we rated maternity and gynaecology services as good although we judged some aspects of the services to be outstanding:

  • Year on year reductions in key indicators for maternal outcomes.
  • The acute gynaecology service offered a highly effective and timely service in acute gynaecology and early pregnancy.
  • There was outstanding performance in relation to supporting women who had pregnancy loss.
  • The service provided safe and effective care in accordance with recommended practices.
  • There were well-developed care pathways in maternity services for women identified as being ‘at risk’ because of medical conditions or vulnerability and the service had staff with expertise in several specific conditions of pregnancy.
  • Staff were confident about reporting incidents and said learning from these was shared with staff.
  • Midwives and doctors worked well together as a team without hierarchy.
  • There were clear pathways for all pregnant women to access the right services for their needs, with excellent access to specialist midwives.
  • Staff demonstrating compassion and patience towards women.
  • Staff were conscious of the need to protect the dignity and privacy of women in all areas of the service.
  • Antenatal clinics were available at many locations in the community thus minimising women’s need to travel.
  • There were many good examples of pioneering work and innovative practices such home monitoring of hypertension in pregnancy, using a mobile phone app.

However:

  • Not all women received continuity of care from midwives.
  • Leadership required improvement as there was no evidence that midwives were being involved in developing the strategy for maternity in line with evolving national developments.
  • Midwives felt concerns they had expressed about the management of the service were not listened to at executive level or board level.

Medical care (including older people’s care)

Requires improvement

Updated 1 November 2016

We rated this service as requires improvement because:

  • The environment and supporting infrastructure within some parts of medical services was unsuitable/unsafe and environmental issues on some wards impacted on staff’s ability to meet patients’ individual needs. Environmental issues also impacted on staff’s ability to protect patient’s privacy and dignity.
  • Feedback from patients on the kindness and compassion of staff was predominantly good, but we also saw examples of patients’ privacy and dignity not being respected and were given examples of a lack of empathy and poor communication by some staff.
  • Medicines were not stored in accordance with the provider’s medicines management policy, and therefore posed a risk to patient safety. People’s rights were not always protected under the Mental Capacity Act 2005 because when patients did not have the capacity to make some decisions for themselves, there was no evidence of a two stage mental capacity assessment or information about how the best interest decision was made.
  • Processes to identify and assess patient’s individual risks and respond to their individual needs were not fully implemented. There was an open culture of incident reporting and staff received some feedback from incidents and complaints. However, action plans from these did not always fully address the issues and were not comprehensive.

However, we also found:

  • Outcomes for renal patients in relation to survival rates and transplantation were excellent and were some of the best in the country.
  • Good multi-disciplinary working and collaboration with external agencies and commissioners to improve services.
  • Practice was evidence-based and the service participated in a full range of national clinical audits. Results indicated good performance in relation to the majority of these.
  • Patients were given information and explanations to enable them to understand the plans for their care and treatments and participate in their care.
  • Although the service faced challenges in the recruitment and retention of staff and this contributed to challenges in achieving and maintaining staff competency, action was being taken to mitigate the impact of this.

Urgent and emergency services (A&E)

Requires improvement

Updated 1 November 2016

We rated this service as requires improvement because:

  • SStaff did not use observe appropriate security in using computers.

  • The design and use of accommodation in some areas did not protect patients’ privacy and dignity, or the confidentiality of patient discussions with clinicians.
  • No skin assessments were completed for patients, including those in the department a long time who were at risk of pressure sores.
  • The storage of equipment and fluids within the major incident cupboard was unclear and created confusion about what was training equipment and what was ‘live’ equipment.
  • The new rapid assessment and triage (RAT) system had been implemented in a very quick timeframe and this meant there was a disconnection between how senior managers saw the process working to how it was operating day to day.

However;

  • The department had a strong audit and research programme with participation in a number of national research studies and evidence of improvement and learning following audits.
  • Major trauma patients outcomes were good and the department performed well in a trauma peer review.
  • There were multiple examples of effective multi-disciplinary team working.
  • Staff reported they felt well supported by their department managers and senior clinicians, especially with a consultant in the department 24 hours a day.

Surgery

Requires improvement

Updated 1 November 2016

We rated this service as inadequate because:

  • Some theatres were not fit for purpose. Theatres were sometimes closed due to electrical faults or unsafe temperatures. There were also water leaks following rain in some theatres, wards, pre-assessment unit and the day surgery unit.
  • Theatre air handing units (AHU) were at risk of failing intraoperatively due to the age of the plant. This was on the divisional risk register and rated as ‘extreme’.
  • Two of the theatres in St James’ Wing (5 and 6) were closed at the time of our inspection for refurbishment, including electrical repairs and the installation of laminar flow. Sixteen of the 51 theatres needed to be completely refurbished.
  • Since the inspection, we have been told by the trust, that the refurbishment of theatres 5 and 6 had been completed.
  • The system for managing theatre stock was not effective and this resulted in items running out before theatre staff had ordered replacements. Theatre staff spent time looking for items in other parts of the hospital and sometimes surgeons or anaesthetist did not have their preferred equipment. The equipment purchase and replacement programme had been affected by budget cuts.
  • Some medical and surgical staff ignored challenges to their infection control practices.
  • The processes for reporting and investigating serious incidents (SIs) were slow and did not always identify factors that contributed to incidents.
  • The trust had temporarily ceased national reporting of the RTT data. This was because, they could not guarantee the data they were reporting was robust and accurate.The surgical division made additional checks to limit the risk of losing track of patients, but some patients were not receiving treatment within the expected time from referral. There were sometimes additional delays when patients had to wait for tests because of demand on ultrasound and MRI scanners.
  • Theatres were unable to meet demand. Cancellations of operations were frequent and some of these were not re-booked within 28 days.
  • Patients sometimes had to wait for tests because of demand on ultrasound and MRI scanners.

Intensive/critical care

Good

Updated 1 November 2016

We rated this service as good because:

  • We saw good evidence of learning from incidents and varied methods of disseminating learning points, including the ‘Big 4’ and work based social media. Learning from serious incidents was shared across the units.

  • The leadership team demonstrated appropriate responses to issues identified, such as gaps in the critical care service specification standards (D16) 2015, a review of the current outreach provision and increased in-house training opportunities for staff.

  • Suitable processes and development opportunities were in place to ensure nursing staff working on the units were competent. We also saw training and learning opportunities for doctors on CTICU and GICU and feedback from these staff members was positive.

  • We saw staff following evidence-based practice via specific clinical guidelines across the ICUs, for example the

  • The ICUs had a comprehensive audit programme in place to ensure audits were completed at appropriate intervals to monitor quality and safety. We also saw evidence of suitable responses to address audit findings, for example with regards to reducing pressure ulcers.

  • There were minimal non-clinical transfers out of the ICUs and few patients were discharged from ICU out of hours. Performance in this area was better than the national average for GICU and CTICU.

  • Patient and relative feedback was very positive about the care provided across the ICUs and staff were frequently described as considerate and respectful. Relatives told us they felt suitably involved in patient care and hospital feedback forms showed most relatives were as involved as they wanted to be in decisions about their loved one’s care.

  • We saw some specific examples where staff anticipated and met specific patient needs, such as nursing a patient in accordance to their religious beliefs on GICU and supporting a patient through a marriage ceremony on CTICU.

  • ICNARC data demonstrated that patient outcomes, including mortality and readmission rates, were as expected. Good outcomes were also achieved for patients who had their chests opened on the unit in emergencies.

However;

  • We were concerned about a potential culture of under reporting incidents. This was due to low incident numbers, staff feedback and minutes from the morbidity and mortality meetings that indicated incident reports were not always completed when they should have been. This had not been identified as an issue by the leadership team.

  • The risk register did not fully document all risks identified across the units and mitigating actions were not always sufficient to address risks.

  • The leadership team did not identify oversight of the satellite areas as an area for concern, despite us identifying some safety concerns in these areas such as poor completion of resuscitation trolley checks on CTICU.

  • Arrangements for doctors’ inductions on NICU were not robust and were not addressed when concerns were raised by staff. Feedback about teaching opportunities for doctors working on NICU was not positive.

  • Processes for managing patient risk on the hospital wards and providing critical care support were not optimised. Patients had to become sufficiently unwell to trigger a National Early Warning Score of six or more before a referral to the critical care team would be triggered.

Services for children & young people

Requires improvement

Updated 1 November 2016

We rated this service as requires improvement because:

  • There was a high level of staffing vacancies on the neonatal unit and paediatric wards, which meant the service had high use of agency and bank staff. Agency staff were not able to carry out all the procedures undertaken by permanent staff and contributed to delays in caring for patients.

  • Children and young people with mental health conditions were cared for on Frederick Hewitt Ward, but an environmental risk assessment had not been carried out to identify ligature points and other risks to their safety.

  • 53% of medical staff had not completed level three safeguarding training, which is a requirement for all staff working with children. Safeguarding training was identified as a risk on the services risk register. Access to training was a problem; there was no dedicated trainer and no safeguarding supervision for staff.

  • There was no pharmacy service available for paediatric oncology patients out of hours or at weekends for children admitted as emergencies or whose condition required changes to their medicines.

  • Equipment stored in the Pinckney Ward storeroom was not routinely checked. Equipment could be returned or removed without checking if it had been cleaned.

  • Staff were not always able to access clinical information about a patient whilst records were being transferred across to the new electronic patient record system resulting in delays proving children with their medicines.

  • Nursing staff did not feel supported by their leaders. They had not received feedback from their appraisals and felt support was inconsistent. They told us the culture did not feel open and staff were sometimes reluctant to raise issues.

However:

  • Children were monitored to identify any deterioration in their condition.

  • The results of investigations into incidents were discussed in departmental and governance meetings and action was taken to follow up on the results of investigations

  • Staff could access clinical guidelines and policies which were regularly updated and based on national guidance.

  • The service contributed to a wide range of national audits and undertook local audits on the quality of services provided.

  • There was effective multidisciplinary working between teams based in the trust and with other organisations and networks.

  • Overall levels of mandatory training were good and staff were supported with training.

  • Parents and families all spoke positively about the care provided and the support they received.

  • Governance structures were in place at ward level through to the new divisional structure and beyond to the board.

End of life care

Requires improvement

Updated 1 November 2016

We rated this service as requires improvement because:

  • We found the palliative care team to be highly skilled and knowledgeable; however we found them to be a generalist service not a specialist palliative care service. They reviewed all dying patients, but did not provide specialist palliative care.The palliative care team and ward staff told us that the palliative care team did not provide training to ward staff within the hospital to enable the ward teams to look after non-complex patients without support from the palliative care team.

  • Numbers of patients being referred into the palliative care services had increased year on year and which made the service unsustainable unless they provided a specialist services..

  • Whilst incidents were reported, the staff weren’t always able to locate incidents on the datix system to show us.

  • Patient records were not securely stored.

  • We found no evidence that patient pain assessments scales were used.

  • The palliative care out of hours service provided by Trinity Hospice, did not have a formal service level agreement in place.

  • The end of life care strategy was an action plan not a strategy and there were no clear pathways to achieve the results detailed within the document.

  • The ‘nursing daily evaluation last hour and days of life’ document was a prompt sheet, which was not backed up by either assessment tools or any evaluation tools to show whether the prompt had been addressed.

  • There was lack of strategic direction for the palliative care for the top of the organisation. The lack of multidisciplinary team meetings (MDT) with colleagues from medical and surgical departments and other allied health professionals was an area of concern.

However

  • There was an open and transparent culture within the service. Incidents were mostly reported and learning was shared.

  • Patients were treated with dignity and respect and staff were caring and supportive. The relatives we spoke with were happy with the care that they and their family members were receiving.

  • Anticipatory medicines were prescribed in a timely manner and were available when required by patients.

  • 85% of patients on fast track discharge were able to go to their preferred place of care last year.

  • The Macmillan Cancer Centre offered advice and support to patients with cancer and their relatives.

  • The spiritual centre provided for people of faith or those of no faith, remembrance services were held annually and services of many faiths were held on a regular basis in the centre. The chaplain attended both the end of life programme board and operational groups, which demonstrated the trust recognised the importance of religious and spiritual input to the delivery of the end of life care service.

  • The trust had appointed an end of life non-executive director one moth prior to our inspection.

Outpatients

Inadequate

Updated 1 November 2016

We rated this service as inadequate because:

  • An external review of Referral To Treatment (RTT) data quality at St George’s University Hospitals NHS Trust was published in June 2016. This found that due to a high number of unknown start times of a patient’s referral journey, patients were prevented from being treated in chronological order. The trust was also inconsistent in achieving their two week targets for patients with suspected cancer.
  • Following the inspection, the trust wrote to NHS Improvement and NHS England , to confirm their intention to temporarily cease national reporting of our RTT data. This was because, they could not guarantee the data they were reporting was robust and accurate.

  • There were several examinations where radiographers gave contrast to patients despite PGDs not being in place.
  • The systems in place for the prevention of healthcare associated infections with specific regard to hand hygiene, were not being consistently followed throughout the outpatient department. Monthly clinic hygiene and cleaning audits were completed by the contracted cleaning provider, however, the results did not reflect the cleanliness of the areas we inspected.

  • The design, maintenance and use of facilities and premises did not keep people safe at all times. Some of the areas were cramped and very busy.

  • Staff were not able to observe the patients waiting in their departments.

  • Staff struggled to maintain patient privacy and confidentiality, mainly due to the lack of space and overcrowding of certain clinics.
  • There was limited audit of patient waiting times for clinics and all the clinics we attended over-ran.
  • Staffing levels had been critically low and the outpatients had been running at approximately 50% vacancy rates. However, the staffing structure had been reviewed and vacancy rates were much improved in outpatient administration areas. Availability of records for outpatient clinics had improved since the last inspection although we found the records were easily accessible by the public during clinic sessions, often left in unsupervised areas.
  • The introduction of the Electronic Data Management System had ongoing issues and extra capacity was needed to ensure further roll-out.
  • Trust level Did Not Attend (DNA) rates (9%), were consistently worse than the England average (7%), between September 2014 - August 2015.

However:

  • Most staff had completed mandatory training.
  • Staff were aware of their responsibilities within adult and children safeguarding practices and good support was available within the hospital.
  • Staff followed consent procedures and had a good understanding of the Mental Capacity Act 2005.
  • Staff were committed to delivering good care, but morale was low and they felt under pressure.

  • Staff were caring and involved patients, their carers and family members in decisions about their care.
Other CQC inspections of services

Community & mental health inspection reports for St George's Hospital (Tooting) can be found at St George's University Hospitals NHS Foundation Trust.