- NHS hospital
St George's Hospital (Tooting)
Assessment report published 28 August 2025
Contents
Ratings
Our view of the service
Date of assessment:
- 16 and 17 October 2024 maternity.
- 4 November 2024 to 5 November 2024 urgent and emergency services (ED).
- 28 and 29 January 2025 surgery.
Epsom and St Helier University Hospitals NHS Trust and St George's University Hospitals NHS Foundation Trust formed a hospital group and appointed a Group Chief Executive in August 2021 (following the appointment of a Chairman in Common in 2019) and a single executive team in February 2022.
St Georges University Hospital provides urgent and emergency services, medical care, critical care, end of life care, maternity, outpatient, surgery and medical care services. This assessment looked at maternity services due to a previous inadequate rating. Surgery due to aged ratings and concerns regarding Never Events and at urgent and emergency services due to aged ratings and information of concern. We inspected all quality statements across the five key questions: all services looked at was rated as requires improvement. The rating from maternity, surgery and urgent and emergency services were combined with ratings of medical care, services for children and young people, critical care, end of life care and outpatient from the last inspection. See our previous reports to get a full picture of all other services at St Georges University Hospital. The rating of St Georges University Hospital remains requires improvement.
In our assessment of maternity we found some improvements had been made in specific areas. There was an improvement in the categorisation of incidents and in the provision and facilities for families who experienced bereavement. Staff said the culture and the way multidisciplinary teams reviewed incidents had also improved. However, despite these improvements, there were still some areas of concern that had not been resolved from the previous inspection. Staff did not always complete risk assessment documentation appropriately for each woman or birthing person. Medicines were not always managed safely. The design, maintenance and use of facilities, premises, and equipment did not always follow safety standards. Some equipment safety checks were out of date and daily checks had not always been completed. The service provided mandatory training and appraisals in key skills to all staff but did not always ensure everyone had completed it. The service did not have enough maternity staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. Staff monitored the effectiveness of care and treatment via audits however, appropriate action was not always taken in response to this. There was no stable leadership team within the service. Following the inspection, under Section 29A of the Health and Social Care Act 2008, we issued a warning notice to the provider. We took this action as we believed women, birthing people or babies would or may be exposed to the risk of harm if we had not done so.
In our assessment of surgery services we found the risks to people had not been consistently assessed and mitigated and we were not assured that learning from previous incidents had been embedded fully. Care was not always delivered in line with national clinical guidance, and evidence-based best practice. The service was not always easy to access and at times patients experienced long waits in the hospital for their surgery. The governance systems in place had failed to identify and rectify some of the concerns found at this assessment. However, staff were kind, caring and compassionate. Staff and teams worked together well to deliver good person-centred care. The service was in breach of the legal regulation relating to safe care and treatment. We were not assured that the service appropriately assessed risks to the health and safety of patients receiving care or treatment and did all that was reasonably practicable to mitigate any such risks
In our assessment of urgent and emergency services we found there were a few improvements. However, there were still concerns that had not been resolved from the previous assessment as well as new concerns. Medicines were not always managed safely. Staff did not always complete risk assessments and update them swiftly. Staff did not keep detailed records of patients' care and treatment and records were not always clear and up to date. The environment did not consistently support safe care. Some equipment was out of date and premises were not secure. Patients at risk of deterioration were not always promptly assessed and documentation was inconsistent. Overcrowding was an ongoing issue where privacy and dignity was not always maintained in corridors and triage areas. Following the inspection, under Section 29A of the Health and Social Care Act 2008, we issued a warning notice to the provider. We took this action as we believed the service had not managed patient acuity appropriately during streaming and triage processes and medicine management, including delayed administration of time critical medicines. Breaches were also found around poor standards of documentation and information security.