St George's Hospital (Tooting)

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support, and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

We did not rate this key question at our last inspection. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.  

We have not awarded this service a score for Effective.

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

The service did not always make sure women and birthing people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing, and communication needs with them.

Staff were able to describe how they assessed and reviewed patient needs from the antenatal and postnatal period to provide holistic support. However, there were some gaps in the completion of risk assessments, particularly in triage. In July 2024, there was a 6.6% abandoned call rate in the maternity telephone triage. This meant that there were delays in assessing the needs of women and birthing people. There were also delays in women and birthing people accessing appropriate support from suitably qualified staff. Following the inspection, the trust informed us that abandoned calls made to maternity telephone triage during working hours were monitored and the individual was called back by a midwife. However, out of hours when the line was on divert, the caller information was not available and therefore a return call could not be made. The trust was in the process of developing practices to allow them to collect more information regarding abandoned call rates and to audit their processes to gain further information.

Where there were cases of baby loss, the service completed the perinatal mortality review tool (PMRT). An audit of this data looked at whether staff were documenting the language spoken by the woman or birthing person and whether interpreting services were required. From January to June 2024, the audit found that 95% of the cases included had the spoken language documented correctly and 19% required an interpreter. Half of the cases where an interpreter was required had no documentation if there was an attempt to book an interpreter for every contact. An external report into perinatal mortality commissioned by the trust in 2023 found there was limited evidence of interpreter services being made available. This demonstrated that further work was required to ensure the service can assess the needs of all those who use it and ensure an equitable standard of care.

Audits and incident investigations completed by the trust did highlight issues with documentation and risk assessments not being fully completed however insufficient action was taken to address the issues. A trust audit looking at the use of the Maternity Early Obstetric Warning Score (MEOWS) found that “additional concerns” were correctly documented in 55% of notes looked at as part of the audit. This was below the trust target of 80%. Similar results had been identified in previous audits and appropriate action had not been taken. This could put women and birthing people at risk of harm.

Local guidance deviated from national guidelines in several areas. For example, trust policy required hourly CTG review and two hourly “fresh eyes”, deviating from the 2022 National Institute for Health and Care Excellence (NICE) guideline of hourly “fresh eyes”. This deviation was risk assessed and agreed by at the Divisional Governance Meeting, however, appropriate measures were not put in place to ensure that women, birthing people, and babies were kept safe.

Women and birthing people were given information and advice about their health, prenatal and postnatal care. They told us during the inspection that they felt well supported by the multi-disciplinary team and felt they were involved in the assessment of their needs.

The service did not always plan and deliver women and birthing people’s care and treatment with them, including what was important and mattered to them.

Staff followed trust policies to plan care for women, birthing people, and babies however this was not always in line with evidence-based practice and national guidance. Staff did not always follow national guidance or best practice around triage provision, management of cardiotocography (CTG) traces, and GAP/GROWTH Assessment Protocol (GAP) to monitor fetal growth. The trust had completed risk assessments to detail why they were not following national guidance, and these decisions had been agreed at the Divisional Governance Meeting. Post inspection, the trust updated its local guidance on the management of CTG traces to align with national recommendations. The trust stated that the 36-week ultrasound offered to pregnant women and birthing people detects more cases of small for gestational age (SGA) and growth-restriction compared to following GAP. A Maternity and Newborn Safety Investigations (MNSI) team investigation in November 2024 stated that the trust’s SGA detection rate for babies born at 37 weeks and above who weighed on or below the 10th centile at birth was 64%, compared to the national average of around 54%.

Local policies, protocols, and guidelines were reviewed regularly and available for staff to access on the intranet and some hard copies were available. The service completed regular audits to ensure the service was effective and check improvement over time. The venous thromboembolism (VTE) October 2024 audit result showed that 90% of the cases examined had the correct assessment completed which was above the trust target of 80% and ensured that women and birthing people were receiving the correct venous thromboembolism management.

In the “Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries” (MBRRACE) perinatal mortality surveillance report based on births in 2022, the stabilised and adjusted perinatal mortality rate at the trust was around average when compared to similar trusts and health boards. Trust data supplied following the inspection, showed that there were 6 stillbirths between August and October 2024 and the number of stillbirths which occurred before 37 weeks was above the trust target in September and October 2024. Data on outcomes, such as stillbirths, was regularly discussed at clinical governance meetings with staff.

Staff used a nationally recognised screening tool to monitor women and birthing people at risk of malnutrition and referred women to the dietitians when needed.

The service did not always work well across teams and services to support women and birthing people.

Communication within the service was unstructured. Staff held regular and effective multidisciplinary meetings to discuss patients and improve their care; however, they were not always structured. We observed that staff did not introduce themselves or use the Situation, Background, Assessment, Recommendation (SBAR) format during the handover meetings observed. We observed multiple interruptions during the labour ward handover and the co-ordinator had to leave before the end. This disrupted the flow of information, could potentially lead to key information being missed and could prevent the team from working together to achieve the best care and treatment for people using the service. However, multidisciplinary staff considered patients’ individual needs, circumstances, ongoing care arrangements, and expected outcomes during the handovers and ward round meetings observed.

Staff reported that they had access to the information they needed to appropriately assess, plan, and deliver care and treatment, however we found evidence that prescriptions were not always updated when women and birthing people were moved between different areas.

Staff we spoke with reported that there was good, collaborative working between all members of staff within the multidisciplinary team, particularly in the maternal medicines team. Information was shared between teams and services effectively to ensure continuity of care of women, birthing people, and babies. There was a multidisciplinary team for all people who used the service where there were safeguarding concerns, long term conditions, mental health needs or other additional needs. Staff gave several examples of how they had worked with other professionals such as GPs, education teams, the justice system and social services to support vulnerable women and birthing people (such as teenage mothers) and those in prison to ensure good levels of care.

Staff reported a number of initiatives run by the multidisciplinary team to support women and birthing people. For example, the smoking cessation project was run by a multidisciplinary team to reduce the risks of smoking in pregnant people and mothers. The service also had a comprehensive birth reflection service which was run by midwives, with obstetric support, to ensure parents received appropriate support following difficult births. We observed staff, including doctors and midwives, working together as a team to benefit women, birthing people, babies, and their families.

The service worked collaboratively with system partners, such as the Integrated Care Board (ICB), other maternity services within their Local Maternity and Neonatal System (LMNS) and maternity improvement advisors. We saw evidence of regular meetings with the maternity improvement advisors for the trust and agreed actions to improve services.

Women and birthing people could access information and advice about their health, care and support from the hospital maternity pages on the internet, printed leaflets as well as from staff during their appointments.

In the 2024 Care Quality Commission (CQC) maternity survey, service users scored “Staff Working Together” at an average of 8.7 out of 10 (with 10 being the highest). This was about the same when compared with other trusts.

The service supported people to manage their health and wellbeing to maximise their independence, choice, and control. The service supported people to live healthier lives and, where possible, reduce their future needs for care and support.

The service had relevant information promoting healthy lifestyles and support on the wards, website, and internet. Staff assessed each woman’s and birthing person’s health when admitted and provided support for any individual needs to live a healthier lifestyle.

The service also promoted women, birthing people, and their families to maintain a healthy lifestyle by providing information and antenatal classes on various topics. This included healthy eating, physical activity, maternal mental health, paternal mental health, smoking cessation, substance misuse, sexual health and pelvic floor exercises. Staff described the multidisciplinary smoking cessation project which had been set up to support women and birthing people.

During inspection we found a range of initiatives designed to help support people to live healthier lives. Staff told us the service had good infant feeding support on the ward and a good breastfeeding initiation rate, as both midwives and band 3 midwifery support workers were trained as lactation consultants, and there was good initiation rates of breastfeeding in women and birthing people who have used the service.

From our observation and the records reviewed, we noted that staff explored women and birthing people’s emotional wellbeing and mental health and referred them to the perinatal mental health services when needed. The 2024 CQC maternity survey found that, on average, people using the service scored the service 6.8 out of 10 (10 being the highest) when asked about whether they received information and explanations they needed following the birth of their baby. This score was similar to other trusts.

During our inspection, people using the service told us they felt supported to manage their health and wellbeing in a way that made sense to them, and they felt like they were supported by staff to live a healthy lifestyle.

The service did not always routinely monitor people’s care and treatment to continuously improve it. Staff did not always ensure that outcomes were positive and consistent, or that they met clinical expectations.

The service did not follow national guidance on the interpretation of CTG traces or the frequency of “fresh eyes” assessments of CTG traces as detailed in the NICE guidelines for fetal monitoring in labour (2022). This had been risk assessed by the trust and the decision had been agreed at the Divisional Governance Meeting, however not following national guidance could put women, birthing people, and babies at risk of harm. We found that there were insufficient monitoring systems in place to ensure that standards of care were being maintained despite these deviations from national guidance. Following the inspection, the trust put several improvements in place to ensure the safety of people who used the service. The new electronic notes system used drop down boxes to ensure that standard terminology was used when describing CTG traces and the frequency of “fresh eyes” had been changed to align with NICE recommendations.

Local guidance for monitoring fetal growth did not meet national recommendations as the service did not use individualised growth charts or complete symphysis fundal height measurements to monitor fetal growth during pregnancy. However, the service offered women and birthing people an ultrasound scan at 36 weeks. NICE guidelines on antenatal care published in 2021 stated that women and birthing people should be offered symphysis fundal height measurement at each antenatal appointment after 24 weeks unless they were having regular growth scans. This deviation in NICE guideline was risk assessed and agreed at the Divisional Governance Meeting. An MNSI team investigation from November 2024 stated that the trust’s growth restriction detection rate for babies born at 37 weeks and above who weighed on or below the 10th centile at birth was 64%, compared to the national average of around 54%.

The previous inspection carried out in 2023 found that compliance rate for carbon monoxide monitoring was below national recommended guidance. Evidence submitted by the service showed that this was still an area for improvement. In the maternity services quality report presented to the trust board in September 2024 stated that there was an ongoing drive to ensure that carbon monoxide monitoring was recorded at 36 weeks.

The service was working towards achieving the Saving Babies Lives Care Bundle Version 3.

Processes were in place to drive improvement and to ensure good clinical practice was embedded. Managers and staff carried out a comprehensive programme of repeated audits to check improvement over time. Managers shared audit results via emails and during team meetings and made sure staff understood information from audits through the 5 facts shared learning emails that were circulated. There was an audit plan in place with multiple trust guideline audits being completed which covered the whole of the maternity pathway. Several audits were completed regularly, and an action plan was put in place if the results was lower than the trust target. However, we identified some audits where poor performance was identified and there was no evidence actions were taken to drive forward improvements. For example, the triage audits completed between January to September 2024 identified poor record keeping. This was also raised as a concern following our previous inspection in 2023. The missing data made it difficult to make firm conclusions and meant that potential areas for improvement were missed.

The trust monitored outcomes through data collected through the maternity dashboard. Data supplied by the trust from their maternity dashboard showed that, the service achieved their threshold of less than 5% of births resulting in third- or fourth-degree tear every month in the period of October 2023 to October 2024.

The service completed a high percentage of caesarean sections. Data supplied by the trust from their maternity dashboard for the period October 2023 to October 2024 showed that they were consistently above their threshold of 28%. This meant that more women had caesarean sections and 49.5% of these were non-elective. However, the service was a tertiary referral centre which cared for women and birthing people with high-risk pregnancies or complex medical needs. Data supplied by the trust following the inspection, showed that the caesarean section rates at St George’s Hospital (Tooting) are significantly below (better than) the national average.

Data supplied by the trust showed that, an average of 4.5 women and birthing people were readmitted to the service per month with an average length of stay of 7.4 days between May and October 2024. The biggest reason for readmission was infection (6). An average of 13.3 babies (up to 28 days of age) were readmitted each month between May and October 2024. This means that an average of 13.3 babies needed to return to hospital each month after they had been discharged because they were unwell.

Leaders tracked the effectiveness of care and treatment provided by monitoring staff and patient surveys, looking at patient outcome results, monitoring and benchmarking maternity information dashboards and looking for themes and trends in care responses and complaints. Staff told us about the high dependency unit (HDU) provision on the ward and there were HDU trained nurses and midwives who covered the service. The service had portable monitors which allowed staff to offer HDU care anywhere in the maternity unit. Staff described good multidisciplinary team working between staff in the HDU, anaesthetics, and obstetrics teams to improve outcomes.

The service had completed several quality improvement projects to improve the standards of care. Midwives completed a thematic review of “baby falls” which occurred on the post-natal ward. As a result, action was taken to improve safety by introducing “safe sleeping rounds” ensuring safe sleeping advice was followed and in turn reduced the risk of falls. A poster around baby falls was created to improve awareness for staff, women, birthing people, and their partners or relatives.

Following an MNSI investigation, a quality improvement project took place focusing on sending appropriate placentas to histopathology. The project involved education for staff and audits which resulted in increased in compliance in the number of appropriate placentas sent to histopathology by staff.

The service had introduced a maternal vaccine clinic resulting in 60% higher vaccination rate compared to 2 years ago. This meant that more women and birthing people were being protected from illnesses which could harm them or their baby. The service was a centre of national and international excellence for fetal medicine.

Patients and their families we spoke with as part of the inspection spoke positively about their experiences and the care they received.

Staff understood how and when to assess whether a woman or birthing person had the capacity to make decisions about their care and made sure women and birthing people consented to treatment based on all the information available. Staff gained consent from women and birthing people for their care and treatment in line with legislation and guidance and clearly recorded consent in the woman's and birthing person’s records.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. People we spoke with during the inspection were aware of the importance of consent. During our inspection, we observed a consent form being completed appropriately and we observed staff explaining risks appropriately to the individual before completing a procedure.

Several audits had been completed by the service looking at consent and whether this was appropriately documented by staff. One audit, completed in November 2024, looked at whether consent was documented prior to an elective caesarean section date and whether the consent form was signed by the relevant clinician and patient. The results showed that 100% of the notes included were signed by both the clinician and the women and birthing people and 90% were signed prior to the caesarean date. Both results were above the trust’s target of 80%.