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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 18 December 2019

Our rating of services stayed the same. We rated them as requires improvement because:

  • Staff did not always complete and update risk assessments for each patient. Documentation in patient files was inconsistent and not always completed; and in medical care, consent forms were not always completed in full.
  • Some services did not keep detailed records of patients’ care and treatment. Some records were not clear, up-to-date, stored securely or easily available to staff providing care.
  • Some services did not control infection risks well. Some staff did not use equipment and control measures to protect patients, themselves and others from infection. Some areas of the emergency department were not visibly clean.
  • Some facilities and premises were not always ideal and in need of modernising or refurbishment. For example, some of the departments and wards were excessively hot in the summer months due to lack of air conditioning.
  • There were gaps in management and support arrangements for staff, such as appraisal, supervision and professional development. The number of nursing staff who had received an annual appraisal was below the trust target in many wards and departments.
  • People could not always access the service when they needed it and did not receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
  • Not all risks on some risk registers were completed thoroughly.
  • Services provided mandatory training in key skills to all staff, however, not all staff had completed the training required.

However;

  • Staff had training in key skills and understood how to protect patients from abuse. Services managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve services.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Services planned care to meet the needs of local people and took account of patients’ individual needs.
  • In children and young people services, staff found innovative ways to enable children and young people to manage their own health and care when they could and to maintain independence as much as possible.
  • Most services had enough staff to care for patients and keep them safe, despite there being vacancies in many areas.
  • The trust scored highly in the Sentinel Stroke National Audit Programme (SSNAP). On a scale of A-E, where A is best, the trust achieved grade A in latest audit.
Inspection areas

Safe

Requires improvement

Updated 18 December 2019

Effective

Requires improvement

Updated 18 December 2019

Caring

Good

Updated 18 December 2019

Responsive

Requires improvement

Updated 18 December 2019

Well-led

Requires improvement

Updated 18 December 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 18 December 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service provided mandatory training in key skills to all staff however not all staff had completed it. Medical staff in the division did not meet the trust target for most mandatory training and safeguarding training modules.
  • Staff did not always complete and update risk assessments for each patient. Documentation in patient files was inconsistent and not always completed, and consent forms were not always completed in full.
  • The service did not always have enough staff, including nurses and doctors, with the right qualifications, skills, training and staff told us this was a potential risk to patient safety.
  • Records of patients’ care and treatment were not always stored securely or easily available to all staff providing care. Electronic records were not always accessible in a timely manner and paper records were not always securely stored. We saw paper records that included patient identifiable information and do not resuscitate forms accessible in folders and were not secure or marked as confidential.
  • The service did not always coordinate between pharmacy and ward staff use systems and processes to safely store medicines. We found examples of fridge temperature recordings consistently higher than the recommended temperature and ward staff were not clear what action had been taken. Staff could not be sure the medicines was safe to use.
  • The catheter laboratory had aging equipment that needed replacing and two beds had been decommissioned as a result. There was a risk of further equipment failure and a temporary mobile catheter laboratory had been commissioned by the trust. The trust is a designated heart attack centre. Following the inspection, the trust advised us that a business case for the provision of equipment was approved by the board in September 2019.
  • Patients were at a higher risk of readmission following discharge when compared to the national average. The risk of readmission for both elective and non-elective treatment was higher than the national average in two of the top three specialities by number of admissions.
  • The service did not encourage black, Asian and minority ethnic (BAME) to join the staff BAME network where they could seek support. Staff we talked to were not aware of the network and senior staff were not able to direct us to information on the intranet for staff to access.

However:

  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The division had worked hard to reduce the number or patient falls. We saw examples of initiatives such as “bay watch”, where a designated member of staff always remained in a bay to assist patients and patients were provided with socks with grip to prevent slips. All staff we talked to had a good awareness of initiatives and why they were important.
  • The trust scored highly in the Sentinel Stroke National Audit Programme (SSNAP). On a scale of A-E, where A is best, the trust achieved grade A in latest audit.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.

Services for children & young people

Outstanding

Updated 18 December 2019

Our rating of this service improved. We rated it as outstanding because:

  • The Children’s service had made significant improvements in safeguarding training and supervision, meeting the individual needs of children and young people, reduction of surgical site infections, improved outcomes in the National Diabetes audit, management of risks, maintaining dignity and respect, meeting guidelines for consultants to review patients within 14 hours of admission and the leadership of the service. Many of the issues identified in our previous inspection had been addressed or there were effective plans to address.
  • The service had enough staff to care for children and young people to keep them safe. However, some departments were still heavily reliant on bank and agency staff, but a successful recruitment campaign meant this would be addressed. Staff had training in key skills, understood how to protect children and young people from abuse, and managed safety well. Although the staff qualified in speciality on the neonatal unit and paediatric intensive care unit did not meet the national guidelines, it had improved since our last inspection. The service controlled infection risks well. Staff assessed risks to children and young people, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave children and young people enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children and young people, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff recognised and respected the totality of the needs of children, young people and their families. They always took their personal, cultural, social and religious needs into account, and found innovative ways to meet them.
  • Staff treated children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Feedback from people who used the service, those close to them and stakeholders was always very positive about the way staff treated people.
  • Staff found innovative ways to enable children and young people to manage their own health and care when they could and to maintain independence as much as possible.
  • There were innovative approaches to providing integrated person-centred pathways of care that involve other service providers, particularly for people with multiple and complex needs.
  • The service planned care to meet the needs of local children and young people and took account of their individual needs and made it easy for them to give feedback. Children and young people could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. A Children’s Strategy Priorities was awaiting final ratification, some staff had knowledge of this. Staff understood the service’s values, and how to apply them in their work. Staff felt more respected, supported and valued since our last inspection. Morale was still low in some areas but improving. Staff were focused on the needs of children and young people receiving care. Staff were clear about their roles and accountabilities. The service engaged well with children and young people and the community, to plan and manage services. All staff were committed to improving services continually.

However:

  • The neonatal unit was not still meeting British Association of Paediatric Medicine staffing standards for units providing neonatal intensive care. The standards require 70% of nurses to be qualified in the specialty. However, this had improved since our last inspection; 58% were now qualified, compared to 40% at the time of the last inspection. The paediatric intensive care unit was still not meeting national standards requiring 70% of nurses to be qualified in the speciality. However, this had improved since our last inspection and 63% were now qualified, compared to 61% at the time of our last inspection. The service had a tangible plan to ensure this standard was met within the next 12 months.
  • The number of nursing staff who had received an annual appraisal was below the trust target in many wards and departments. Across the whole service 72% of nursing staff had received and appraisal which (trust target 95%).
  • There were still 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. Staffing levels on the inpatient wards had been increased following an establishment review, although the trust still did not have enough staff of the right qualifications, skills, and training. Due to a recent successful recruitment programme the service would be over established with nurses in September 2019.
  • Some facilities and premises were not always ideal and in need of modernising or refurbishment, but we didn’t observe this having an adverse effect on the care patients received. For example, some of the departments and wards were excessively hot in the summer months due to lack of air conditioning.

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.

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.

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.

Surgery

Good

Updated 18 December 2019

Our rating of this service improved. We rated it as good because:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people and took account of patients’ individual needs.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff mostly felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • The design of the environment did not always follow national guidance. Many ward areas were cluttered with equipment at various points throughout the day (for example, when receiving orders). However, leaders and housekeeping staff we spoke to confirmed there was a transformation programme underway to improve this.
  • Vacancy, turnover and sickness rates amongst nursing staff did not meet the trust’s target, although the service was taking action to address this.
  • From April 2018 to March 2019, 75.3% of required staff in surgery at St George’s Hospital received an appraisal compared to the trust target of 90%. This meant the trust could not be assured that all staff received an appraisal of their work performance.
  • People could not always access the service when they needed it or receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not line with national standards.

Urgent and emergency services

Requires improvement

Updated 18 December 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service did not control infection risk well. Staff did not use equipment and control measures to protect patients, themselves and others from infection. Some areas of the emergency department were not visibly clean.
  • Staff did not always complete risk assessments for each patient swiftly. They did not remove or minimised risks and did not update the assessments.
  • Staff did not keep detailed records of patients’ care and treatment. Records were not clear, up-to-date, stored securely and easily available to all staff providing care.
  • The service did not use systems and processes to safely prescribe, administer, record and store medicines.
  • People could not always access the service when they needed it and did not receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards. Patients did not receive treatment within agreed timeframes and national targets.
  • It was not easy for people to give feedback and raise concerns about care received. There was a lack of patient information displayed in public areas on how to raise a concern. This was something we found on the previous inspection.
  • Not all staff understood the service’s vision and values, and how to apply them in their work.

However:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.

Outpatients

Requires improvement

Updated 18 December 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The trust returned to reporting on their referral to treatment time (RTT) data for the St George’s Hospital site. However, this reporting was still in its early days. This meant the outpatient department could not yet be fully assured that all patients had received their appointments.
  • The trust’s target for completion of mandatory training was not achieved in some areas.
  • Staff did not always audit practice regularly to check whether they had made improvements for patients care and treatments.
  • Systems to monitor the effectiveness of care and treatment were not embedded in the service.
  • There were gaps in management and support arrangements for staff, such as appraisal, supervision and professional development. Appraisal rates for some staff groups working in the outpatient services were below the trust target.
  • Most staff and middle grade managers were not aware of what was on their department’s risk register.
  • Not all risks on the risk register had associated actions, a date for review or a date by which actions to be completed and the risk owner.
  • There was not always a registered nurse available to manage the outpatients’ clinic, some clinics were managed by healthcare assistants as compared to qualified nurses, however all clinics had a registered nurse oversight.
  • We uncovered issues with heavy workloads for some key staff and a lack of senior staff support in some areas of the outpatients’ department.

However:

  • The service provided mandatory training in key skills and most staff completed the training in line with the trust’s target.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up to date, and generally available to all staff providing care.
  • Medicines in outpatients were managed safely. Medicines and prescription pads were kept locked when not in use.
  • Care and treatment were provided based on national guidance. Speciality clinics followed relevant national guidance and participated in national and local audits.
  • People were treated with compassion, kindness, dignity and respect, when receiving care. Staff communicated with people in a way that supported them to understand their care and treatment.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff managed clinical waste well.
  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
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.