St George's Hospital (Tooting)

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last inspection we rated this key question inadequate. At this inspection, the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety despite some improvements. There was still a risk that people could be harmed.

We have not awarded this service a score for Well-led.

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

The service had a vision and a strategy, however there was a lack of evidence to show that the strategy had driven improvements in culture, equity, inclusion, and engagement. Leaders did not always understand the challenges and the needs of people and their communities.

The service had a vision for what it wanted to achieve and a strategy to turn it into action, however there was a lack of evidence to show how this strategy was being tracked to ensure progress was being made. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. The maternity service strategy focused on improving care and staff wellbeing, promoting equality, diversity and inclusion, and creating a workspace where all people feel valued and respected. However, no evidence was supplied by the trust to show how the success of the vision and strategy was being measured or what work has already been undertaken as a result.

The trust wide Workforce Race Equality Standard (WRES) 2024 report highlighted that the population of staff from black and ethnic minorities had continued to increase, however they were underrepresented at executive level. There had been an improvement in 7 out of 10 indicators on the WRES according to the data from 2024 and this showed an improvement from our previous inspection. The likelihood of staff from black and ethnic minorities entering a formal disciplinary process improved from 1.67 to 1.48 (the average for London in 2023 was 1.41). The percentage of staff from black and ethnic minorities who had experienced harassment, bullying or abuse from patients and staff had reduced. This showed an improvement from the previous inspection however, staff we spoke with reported further advancements were needed in this area. During the inspection, staff from the black and ethnic minority backgrounds told us that there were limited career development opportunities. Therefore, more could be done to improve the experiences of staff from black and ethnic minorities.

An external maternity report in 2023 highlighted that staff did not always feel supported, reported a blame culture, and felt their views were not valued when raising concerns. These findings were echoed in a maternity safety champion report from May 2024 which reported that senior midwives were not consistently listened to and felt excluded from decision-making. Staff we spoke with, during the inspection, understood equality, diversity, and human rights and felt that lessons learned from incidents or complaints were shared across sites in a proactive way.

Some work had been completed by the trust to improve the culture, for example, a Band 7 away day was introduced to improve working relationships among senior midwives. The staff we spoke with during our inspection reported an improvement in the service culture and reported no concerns regarding bullying and harassment. However, we received anonymous reports from members of staff detailing poor culture within the service following the inspection. Although the trust has started to introduce initiatives to improve the culture of the service, improvements were not fully embedded and further work was needed.

In the 2024 staff survey, staff in the maternity department gave an average score of 5.6 out of 10 (10 being the highest) when asked about whether they felt recognised and rewarded, which was an improvement from the 2023 score (5.3). Initiatives had started within the service to improve motivation of staff for example the introduction of the E-pin board which contained praise for colleagues as well as announcements such as engagements or staff completing challenges for charity.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. There was no stable leadership team with high unplanned turnover of leaders. Leaders did not always understand and manage the priorities and issues the service faced.

There was a clear management structure in place with defined lines of responsibility and accountability. However, there had been a high turnover of leadership staff within the service, including multiple changes to head of midwifery. Post inspection, the Deputy Director of Midwifery and the Director of Midwifery had left their post in November and December 2024 with new staff appointed to interim posts. These changes resulted in a lack of assurance regarding consistent direction and improvement, potentially affecting care quality. The trust also informed us, post inspection, that a new Obstetric Clinical Director (CD) post had been recruited and would commence in post from March 2025, with the outgoing CD remaining in post until the handover was complete.

Leaders we spoke with were not always fully aware of the issues or current challenges faced by the service to deliver high quality care such as the gaps in the documentation of risk assessments completed and the telephone triage cover out of hours not meeting the recommendations made by the Royal College of Obstetricians and Gynaecologists. Leaders did not take appropriate action when risks were identified such as areas of poor practice identified in audit results or the risk of baby abduction.

The service was supported by maternity safety champions and non-executive directors. The majority of the staff we spoke with knew who their maternity safety champions were, however, some did not. We observed display posters of the maternity safety champions in the maternity areas during inspection. Further work was needed to ensure all multidisciplinary staff were aware of their maternity safety champions and their role and purpose.

Service leaders supported staff to develop their skills, take on more senior roles and take part in leadership development programmes to aid career progression. However, not all staff from ethnic and minority backgrounds felt supported in their career progression.

We found that leaders were well respected, approachable, and supportive. Staff we spoke with told us they were well supported by their line managers, ward managers, and matrons. Staff reported good access, visibility, and support from the divisional and trust leadership team.

Leaders understood how health inequalities affected treatment and outcomes for women, birthing people, and babies from ethnic minority and disadvantaged groups in their local population. The service utilised the together project maternity passport to allow staff, women, birthing people, and their families to work together to plan care and help highlight possible areas of inequality to ensure these could be addressed. The service had a maternity strategy in place which focused on tackling health inequality, however, there was a lack of evidence to demonstrate how effective the strategy was being to reduce inequalities.

Staff and Leaders had considered and understood national maternity specific recommendations such as the Ockenden report.

People did not always feel they could speak up and that their voice would be heard.

The maternity improvement advisor team worked with the trust to improve the service. The maternity improvement advisor November 2023 report was reviewed and highlighted that the Freedom to Speak Up (FTSU) guardian had clear oversight of the service, but staff felt there was a blame culture which inhibited freedom to speak up. There were clear policies, systems, and processes in place to promote FTSU and there are clear lines of feedback from the FTSU guardian to the maternity directorate. The FTSU report was presented to the trust board regularly.

Majority of staff we spoke to during inspection, reported an improved speaking up culture and felt able to raise concerns without fear of reprisals from senior staff. The safety champion report from May 2024, however, highlighted that some staff feared reprisals if they raised concerns. Staff we spoke to were aware of how to raise concerns and knew who their FTSU guardian was. Staff reported senior leaders were open when incidents occurred. However, post inspection, we received whistleblowing concerns from staff around under qualified staffing, low staffing levels, bullying, staff feeling unheard, undervalued, staff discouraged to report incidents, staff feeling stressed, low morale, and staff not feeling listened to.

The 2024 Care Quality Commission (CQC) maternity survey highlighted that women and birthing people gave an average score of 8.0 out of 10 (10 being the highest) when asked about whether they felt concerns were taken seriously once raised. This score was about the same as other trusts.

The service did not always value diversity in their workforce. Staff did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff from black and ethnic minorities told us that there were limited development and career progression opportunities, however they reported that there was a range of continuing professional development courses available. The service did not have anything in place to improve the development or career progression opportunities for staff from black or ethnic minority backgrounds. However, they did identify learning opportunities following the 2024 staff survey which discuss training and coaching opportunities for all staff.

Leaders did not actively ensure staff and leaders were representative of the population of people using the service. The trust completed a WRES report which included information for the whole trust including maternity. The 2024 report showed that the population of staff from black and ethnic minorities continued to increase. However, those from black and ethnic minorities were underrepresented at executive level. A report by the maternity improvement advisors found that more could be done in relation to equal opportunities in the workplace.

The Workforce Disability Equality Standard (WDES) report was also published by the trust covering the whole trust, not just maternity. The 2024 report showed that the number of people employed by the trust who view themselves as having a disability had increased. However, there was a higher number of these staff working in lower, non-clinical roles. The report also highlighted that staff with disabilities were underrepresented at executive and board levels.

Evidence provided by the trust following the inspection highlighted that, not all staff felt respected, supported, and valued. This was evidenced by the results of the 2023 staff survey which showed that more could be done to ensure staff felt recognised and rewarded for the work that they did.

There were systems in place to review and improve the culture of the organisation in relation to equality, diversity, and inclusion. The trust had 4 equality networks that staff were actively involved in. This included black and ethnic minority, women, LGBTQ+ and disability and wellness networks. These groups aimed to improve disparities in the experiences of staff with protected equality characteristics or those from excluded or marginalised groups.

The trust had systems in place to ensure reasonable adjustments were made to support staff with disabilities to carry out their roles well. There were policies, processes, and systems in place to prevent and address bullying and harassment at all levels and for all staff. However, leaders did not always take action to prevent and address bullying and discrimination at all levels for all staff.

The service did not have clear responsibilities, roles, systems of accountability, or good governance. Staff did not act on the best information about risk, performance, and outcomes.

There have been significant changes in the maternity leadership structure post inspection with the Director of Midwifery, Head of Maternity Governance, and Deputy Director of Midwifery roles becoming vacant. These changes in leadership will lead to a period of adjustment and the service will need to work hard to ensure current plans to drive improvements are maintained.

The service was previously inspected by the Care Quality Commission (CQC) in 2023 and a breach of regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 was identified. A further breach of regulation 12 of the Health and Social Care Act 2008 was identified following this inspection with similar concerns identified, such as medicines management and low completion rates for mandatory training and appraisals. This demonstrates that governance processes need to be improved to ensure that women, birthing people, and their babies are protected from harm.

Some staff we spoke with found it difficult to locate policies on the intranet. They reported some elements are outlined in other policies rather than being a stand-alone policy which made them difficult to locate. For example, staff were unable to locate the baby abduction policy, and they were unclear about what the process was. The baby abduction policy was later found by the inspection team within the safeguarding policy.

The policies we reviewed as part of the inspection were current and were available for staff to access on the trust’s intranet page. However, there was a lack of structure which meant that guidelines were found in different areas of the intranet and out of date policies were still available alongside the current policies. There were two policies seen by inspectors covering anticoagulation and thrombosis, one of which was out of date.

We found instances where staff were not following local guidance. For example, trust guidance stated that ST Analyser (STAN) terminology should be used when analysing cardiotocography (CTG) traces however, on inspection, we found a variety of systems used when analysing and discussing traces. Following the inspection, the trust introduced a new electronic notes system with drop down boxes which standardises the terminology used by staff.

The maternity service was unable to evidence compliance with the Maternity Incentive Scheme (MIS) for year 4, demonstrating compliance in 5 out of 10 safety actions required. However, they were able to evidence full compliance with all 10 safety actions for year 5 of the programme.

The trust had a risk register in place; however it failed to identify risks observed during our inspection, including appraisal target compliance, out-of-hours medical cover, and action plans for out-of-range fridge temperature. The breastmilk fridge temperature action plan submitted by the trust following the inspection, stated that the breastmilk fridge should be placed on the risk register following the May to October 2024 audit which found that the fridge temperature was outside the recommended range 52.3% of the time. By not including these risks on the maternity risk register, service leaders and trust board did not have full oversight of the risks within the department and appropriate actions were being missed. This could put people who use the service at risk of harm.

However, the trust had a risk management policy in place with a flow chart detailing the processes in place. The risk register included risks such as shortage of midwifery staffing and the multiple patient record systems. The risk register was discussed at clinical governance meetings and the quality committee meetings.

Since the last inspection, the service had improved the governance structure to strengthen the governance and trust board oversight, however further improvements were required. We saw evidence of more rigorous evidence gathering and analysis since the last inspection and leaders had established clearer accountability by implementing a new group accountability framework. Since the last inspection, the service had further strengthened their governance structure following internal and external review around their governance structure and processes. Incident and risks were discussed at various governance meetings and information was cascaded to staff through newsletters, handovers, and emails. However, there was a significant number of incidents which had not been investigated in a timely manner.

Staff understood their role within the wider team and took responsibility for their actions. Staff we spoke with knew how to escalate issues to leaders, the clinical governance and divisional management teams, however appropriate action was not always taken. Information was then shared back to sub-committees and all staff. We saw examples of how this learning was shared, for example the 5 facts shared learning emails sent to staff.

Staff reported there had been a change in how incidents were reviewed and graded particularly post-partum haemorrhage (PPH) of more than 1.5 litres and third- or fourth-degree tear. There was regular dissemination of information to ensure staff were aware of learning from incidents. Staff described a multidisciplinary team approach which was open to all. This was an improvement from the last inspection. However, further work was needed for training of staff around the grading of harm when reporting incidents within the service. The trust was able to evidence that all PPH and tear grading errors were corrected to ensure incidents were graded appropriately. However, evidence seen following the inspection demonstrates that further improvements in incident categorisation and grading are needed to ensure all learning opportunities are explored.

There were systems and processes in place for workforce planning. The Safer Staffing Paper, presented to the trust board in October 2024, recognised the complex staffing challenges that the maternity service had experienced, for example high sickness rates. A trust review into staffing was reported in May 2021, using data from the Birthrate Plus tool, and a further review was being completed at the time of the inspection. The May 2021 staffing review recommended one midwife to 24 births. The Safer Staffing Paper written by the trust reported that the service had 1 midwife to 23 births to ensure the safety of women and birthing people.

The service understood their duty to collaborate and work in partnership; however, the service did not consistently demonstrate how it was actively improving to meet the needs of the community it serves.

The 2023 Wandsworth Health Watch report found a significant number of people felt that their ethnicity had negatively influenced the maternity care they received. At the time of the inspection, there was a lack of evidence that the service was actively working to improve the experiences of black and ethnic minority women and birthing people. Although a maternity vision and strategy were developed which discussed the issues of health inequalities, there was insufficient evidence to show that the trust was actively working towards this and that progress was being monitored.

Information was available in a select number of languages, which didn’t reflect all the languages spoken in the communities which use the service. There was ongoing work to ensure the service continued to meet the communication needs of its diverse population to ensure information was available in the top languages spoken by women and birthing people who accessed the service.

There were processes in place to collaborate with external stakeholders and agencies to ensure joined up care was delivered and to share any learning to ensure continuous improvement. The service also collaborated with external stakeholders and agencies, for example the Maternity and Newborn Safety Investigations (MNSI) team and maternity services within their network to drive improvements in the care received by women, birthing people and babies. Senior staff members attended a wide range of meetings with different agencies for example the Local Maternity Neonatal System (LMNS). During the inspection we met with members of the safeguarding team who described the range of external meetings they attended to ensure all vulnerable people who used the service got the support they needed.

Leaders worked collaboratively with the Maternal and Neonatal Voices Partnership (MNVP) to keep women and birthing people at the centre of care. The MNVP held regular meetings which were attended by representatives from the leadership, obstetric, and governance teams as well as service users. We reviewed minutes from the MNVP meetings and there was a clear structure for feedback to allow service users to share their birth experiences to drive improvement. The trust actively engaged with the MNVP “Whose Shoes?” event in May 2024. This event was attended by staff from the trust, representatives of the MNVP as well as service users. There was no evidence of improvements that have been made in response to this. An action plan was developed between the trust and MNVP, which included working to engage with those from black and ethnic minorities, however there was no evidence to demonstrate meaningful action was being taken. The MNVP were involved in co-production of guidelines, information leaflets, and engaged with charity organisations to improve the service.

Senior leaders had engaged with the Black Lives Matter organisation, undertaken unconscious bias training, and scheduled a leadership away day to further delve into equality and unconscious bias. The Public Health Consultant Midwife was leading an antiracism campaign with the aim to improve the service culture and the experience of people who used the service.

The service was enrolled in the Maternity Safety Support Programme (MSSP), and the service worked collaboratively with their maternity improvement advisors to address the areas for improvement which had been identified and received feedback to ensure continuous improvement. Staff and leaders recognised they were on an improvement journey.

The women and birthing people we spoke to during the inspection reported feeling involved in the planning of their care. Staff and leaders were open and transparent when we spoke to them as part of the inspection.

The service focused on innovation across the organisation and local system however there was a lack of oversight and governance. Staff did not always actively contribute to safe, effective practice. The service has repeatedly been found to be in breach of the Health and Social Care Act (2008).

Whilst the service was completing regular audits, results repeatedly showed areas for improvements in practice however appropriate actions had not been taken. The Maternity Early Warning Score (MEOWS) audits and the triage waiting time audits repeatedly showed that documentation needed to be improved however sufficient action was not taken. We found evidence that there had been incidents which had been associated with poor documentation meaning women, birthing people, and their babies were exposed to risk. In addition, there were often delays in responding to incidents which impacted on the ability of the service to learn and improve as a result of incidents.

Local guidelines deviated from recommendations made in national guidelines in a number of 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”. Although this deviation was risk assessed and agreed at the Divisional Governance Meeting, appropriate measures were not taken to ensure that women, birthing people, and babies were safe from harm. There was insufficient oversight from senior leaders.

The trust was continuing to work to address some of the concerns raised at the last inspection. The percentage of staff with an appraisal remained significantly below the trust target particularly for non-medical staff. Mandatory training compliance levels were also low. Following the inspection, we saw an action plan to improve compliance. The service was previously found to have breached regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 following the last inspection. A further breach of regulation 12 of the Health and Social Care Act 2008 was identified following this inspection with similar concerns identified, for example concerns around safe staffing levels. Although some actions were taken following the previous inspection, learning was not fully embedded.

Staff told us about the multiple innovation projects that have occurred within the service. For example, they were the first NHS trust to introduce ASPRE (Aspirin for Evidence-based Pre-eclampsia Prevention) screening in 2020 which aimed to reduce perinatal mortality and reduce ethnic disparities. There were multiple quality improvement projects underway at the trust and there were quality improvement boards around the wards to feedback to staff. For example, the midwives had completed a thematic review of “baby falls” which occurred on the post-natal ward and aimed to improve safety by introducing “safe sleeping rounds” to ensure safe sleeping advice was being followed.

The service involved the MNVP and people who used the service in developing and evaluating improvement and innovation initiatives. The service shared improvements and learning following incidents with other trusts in their LMNS.

The service continued to drive improvement by increasing the range of training available for staff, for example providing ‘make birth better’ courses and the birth trauma resolution training course for staff.

The service had processes in place to ensure that learning occurred when things went wrong. From October 2023 to October 2024, PPH exceeding 1.5 litres surpassed the 4% threshold for 5 months. This meant that more women and birthing people experienced significant bleeding following the birth of their baby. The service revised guidance to reduce PPH rates reflecting that women and birthing people who had given birth before tend to have a shorter second stage of labour.

The service took an active role in research and was involved in several research projects. The service was generally able to demonstrate learning from incidents and staff were able to describe how the emergency procedure was reviewed in the antenatal clinic following an incident. However, further improvements were needed around documentation and risk assessments.