St George's Hospital (Tooting)

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse, and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant people were not always kept safe and protected from avoidable harm.

The service was in breach of legal regulations in relation to delivery of safe care and treatment and premises and equipment within the service.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. However, lessons were not always learnt to continually identify and embed good practice.

Between January 2024 and December 2024, the trust reported 7 Never Events across St George’s Hospital with 6 located in surgery and theatres. These are serious, preventable patient safety incidents that should never occur, if the available preventative measures are implemented. These incidents were thoroughly investigated with outcomes and learning points identified. Leaders described processes to share learning following incidents, improve the culture within theatres and gave examples of changes to practice because of incidents; however, it is not yet clear whether the mechanisms that were put in place will be fully effective at preventing future incidents. Staff told us that because of previous incidents protected teaching time was introduced each month to upskill staff. Staff also told us about initiatives to prevent incidents, for example consenting and marking patients with the assistance of full-length mirrors to allow patients to also confirm the location for their surgery and to reduce the risk of wrong site operations. However, the number of recurrent never events provided limited reassurance that the service had appropriate preventative measures in place to protect people from harm and suggests learning from previous incidents is not fully embedded.

The service managed patient safety incidents and made efforts to learn from incidents throughout the service. Staff recognised and reported incidents appropriately and knew how to raise concerns using the hospital’s electronic incident reporting system in line with the hospital’s incident reporting policy. Managers were responsible for investigating incidents and sharing the learning.

Most staff we spoke with were able to explain the duty of candour. When things went wrong, staff apologised and gave patients honest information and suitable support, in line with the hospital’s Duty of Candour (Being Open) policy. We saw examples of thorough investigations of incidents being performed and where duty of candour had been applied.

Managers debriefed and supported staff after a serious incident. We reviewed a selection of surgical team meeting minutes and saw that incidents and learning was routinely discussed. There were arrangements for identifying, recording, and managing risks, issues, and mitigating actions. We saw evidence that the service regularly reviewed safety, performance and risk through the Divisional Risk Review group and Divisional Governance Groups which reported key quality, safety and performance metrics to the trust’s patient safety and quality group. We saw evidence that the service identified some risks through different sources such as audits, incidents, patient and staff feedback, and risk assessments. However, we found that not all risks identified within our inspection were identified and recorded on the service risk register, this meant that we could not be assured that all risks were managed appropriately such as poor audit compliance and low mandatory training compliance.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

We received positive feedback from staff regarding communication and multidisciplinary team working. We saw that the service worked collaboratively and in a joined-up approach regarding safety that involved patients along with staff and other partners. We observed that surgeons attend to inform patients of any on the day cancellations. Care and support were organised with patients and partners to ensure continuity; staff told us that for trauma surgery patients repatriation pathways to local pathways were performed quickly and are typically accepted within 24 hours.

As part of handover before shift changes, the nurse in charge read a safety briefing to the team. This was a briefing where staff were made aware of patients who were high risk such as those who were unstable, susceptible to falls or had a high national early warning scores (NEWS2) score. In addition, patients with known safety risks were highlighted so that staff allocations for the day were safe and appropriate.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

We reviewed the service’s safeguarding adults and children policy. This was in date and available on the hospital intranet system. The policy detailed individual responsibilities, processes for reporting and escalation of concerns and who to contact.

All clinical staff were trained to the required level 2 and 3 safeguarding adults and level 2 and 3 safeguarding children. The service’s compliance rates in safeguarding training exceeded the hospital’s target of 85% for all staff groups.

Staff we spoke with could demonstrate a good understanding of safeguarding vulnerable adults and children and were able to articulate different forms of abuse such as domestic violence and female genital mutilation (FGM). Staff knew how to escalate concerns to their manager and safeguarding lead. We saw safeguarding posters around the wards and patient areas with information on how to raise safeguarding concerns.

The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Monthly audits were undertaken to monitor Venous Thromboembolism (VTE) risk assessment completion and showed assessments were not always completed in a timely manner. Audit data we reviewed between October and December 2024 showed that improvement was required in all surgical wards to meet trust compliance targets of VTE assessed within 14 hours of admission. We saw a reminder to governance leads to complete VTE assessment for admitted patients was included as an action on the Divisional Governance Group action log in September 2024. However, the audit data did not show an improving trend, and we could not be assured that effective action was being taken to improve compliance.

We reviewed audit data for Local Safety Standards for Invasive Procedures (LocSSIPs) and National Safety Standards for Invasive Procedures (NatSSIPs 2) and found varied compliance in completion. Between July to September 2024, we found that of 14 specialties in 29 theatres across DSU and inpatient theatres, 6 had below 95% compliance in overall surgical checklist completion and 7 had below 100% compliance. However, during our inspection we observed that the service used the NatSSIPS2 eight sequential standards for the safer surgery checklist effectively, this was consultant led and performed in line with national guidelines.

Staff informed us that they carried out risk assessments for patients having elective surgery preadmission in line with national guidance. The service used electronic risk assessments. The service had policies in place to improve care, for example suspected sepsis management pathways. Staff reviewed the risk assessments with the patient, which enabled appropriate provisions to be identified and put in place. Staff completed and updated risk assessments including manual handling, pain, water-low score, pressure ulcers, malnutrition during admission. Staff had access to translation services for patients whose first language was not English. From the records we reviewed we saw evidence that risk assessments had been completed with patients.

Staff were aware of and understood escalation protocols for deteriorating patients and the use of NEWS2. We checked patients’ NEWS2 charts and found them to be correctly filled in. We also saw that appropriate action, such as increasing the frequency of observations in line with increasing scores was done at the right time. Staff understood the process for managing medical emergencies and the service had appropriate resuscitation equipment available if required.

People we spoke with felt able to give their views and we observed staff being educated about the roll out of Martha’s rule across the hospital, which will empower patients, families, carers, and staff to ensure that their concerns are listened to and acted upon.

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the inspection we visited several theatres and 8 surgical wards, looked at the environment on each of them and randomly sampled the equipment in use in these areas. Limitations on space and storage of equipment in the corridors on some wards was previously assessed as posing a risk to evacuation in the event of fire. We saw that action plans available within fire risk assessments, however these actions were not signed or dated. During our inspection we also observed that some escape routes remained obstructed by equipment, indicating that the risk had not been addressed and appropriate action had not been taken to ensure safe escape routes in the event of a fire.

However, despite limited space within some wards, SSDEC and the waiting area of the SAL, we saw that storerooms were well-ordered and well stocked. Dirty utility rooms were clean and substances hazardous to health were well managed. The service generally had suitable premises and equipment and maintained them well and access to wards and theatres was by swipe card access locked doors.

Emergency trolleys were easily available within the service. We checked the emergency trolleys in the SAL, wards and theatre areas and found that they were secured with a plastic snap lock, so it was clear if someone had accessed the resuscitation equipment. Equipment in emergency trolleys was checked routinely. Record check sheets showed that checks had been signed to confirm compliance with national standards. We also checked various consumables and found they were sealed and in date.

Equipment we checked such as defibrillators and suction machines had up to date electrical safety tests. Staff kept substances which met the Control of Substances Hazardous to Health (COSHH) regulations in a locked cupboard in a room accessible by staff only. We saw these were stored appropriately.

Staff worked together well to provide safe care that met people’s individual needs and made sure staff received effective support, supervision and development. However, the service did not always make sure there were enough qualified, skilled and experienced staff.

Staff received training appropriate to their role. New staff to the trust received an induction, which included mandatory training; the divisions compliance for this was 90%, which exceeded the trust target of 85%. The compliance rate for information governance mandatory training was 91%, which fell short of the trust target of 95% for this module. The topic with the poorest compliance rate of 61% was Resuscitation Immediate Life Support (ILS). Our review of evidence did not demonstrate that there was appropriate monitoring and mechanisms to ensure there was always sufficient staff available with up-to-date ILS training. We saw that low ILS compliance was included in the service workforce report as a non-compliant challenge and improving mandatory training compliance was discussed in Divisional Governance Group meetings, however this was not reflected on the service risk register or governance action log to provide assurance that staff with appropriate resuscitation training were available to keep people safe. The trust data showed the worst compliance within the service for mandatory training was amongst medical staff who achieved 76% compliance. However, overall compliance with Advanced Life Support was 88% and Basic Life support was 85%. Mandatory training modules were a mixture of face to face and online training. Modules included but were not limited to, safeguarding adults and children, equality and diversity, Mental Capacity Act and the Deprivation of Liberty Safeguards, infection control, immediate life support, advanced life support and basic life support.

The service generally had enough medical staff with the right qualifications to keep patients safe, however leaders also described vacancies within the plastic surgery specialty. We saw that a shortage of neuro and cardiac anaesthetic consultants to deliver elective recovery and emergency cover was identified as an extreme risk on the service risk register, data we reviewed following the inspection showed effective action was taken to address this and there had been successful recruitment into consultant positions in both neuro and cardiac anaesthesia. Nursing staff told us they could access medical staff when needed. Physician associates formed part of the team and were utilised well and appropriately throughout the service. There was a safe provision of physiotherapy, occupational therapy, and psychologist input where necessary for patients following surgery.

Staffing levels were reviewed and planned in a timely manner by ward managers. Staff generally reported good levels of staffing and use of bank staffing where there were shortfalls, with low to no use of agency staffing. Although, staff in the SAL told us they felt that there was not always sufficient staffing on the weekend and that at times due to the complexity and number of patients, additional staff were needed.

During our inspection we saw there were appropriate staffing levels and skill mix allocated to theatres, recovery, and the surgical wards. The actual staffing levels largely met the planned levels.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All the areas within the service we inspected were clean and had suitable furnishings, which were well-maintained. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. Data requested showed that there was between 98% and 99.5% compliance against cleaning audits between October and December 2024, the trust target was 100%. Theatre areas were visibly clean. There was access to hand sanitisers throughout the hospital and good hand hygiene was promoted. Audits of staff hand hygiene consistently showed that the service exceeded the trust target of 95% compliance between October and December 2024.

We reviewed the infection control policy which was in date and accessible on the hospital intranet. The policy was comprehensive, and staff could easily access it. Staff had support from the site IPC team and medical microbiology to manage concerns, including over the weekend.

The service completed monthly infection control audits and monitored numbers of healthcare associated infections and surgical site infections (SSI). In the 12 months prior to the inspection, the service reported 28 healthcare associated infections. The service reported 6 cases of MSSA infection against a trust threshold of 0. SSI surveillance data showed the hospital was identified as an outlier nationally in inpatient and readmission SSI risk for reduction of long bone fractures. However, data we reviewed following the inspection showed between October and December 2024, the trust reported 0.7% SSI, which is below the national benchmark of 0.9%. We saw evidence that the service was establishing a Task and Finish Group to review policies and practices, and the IPC team was reviewing the surgical site surveillance procedure to address this. Whilst we saw this was being addressed at board level, we did not see evidence of monitoring by the service. We did not see evidence of SSIs discussed in Divisional Governance Group minutes, included in directorate performance reviews, or identified on the service risk register.

There was easy access to personal protective equipment (PPE) such as gloves and aprons. Staff followed IPC principles and were bare below the elbow. We observed theatre staff wearing appropriate PPE in theatres. If a patient was infectious, a sign was put on the door of their room to indicate this to staff and visitors.

Waste management was handled in line with national standards, with different colour coding for general waste and clinical waste. All clinical bins were seen to be operated with pedal lids and were not overfilled. Most sharps bins were found to be correctly labelled and not filled above the maximum fill line, although temporary closure devices were not always used.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff did not always involve people in planning.

We saw from patient records there were some missed administration and delayed medicine doses. However, the service had a process for identifying and supporting people requiring time critical medicines and there was an improvement observed since our inspections of maternity in October 2024 and urgent and emergency care in November 2024. Staff generally provided patients with information about their medicines. Patients told us they received information about newly prescribed medicines and were given the opportunity to ask questions about them, however one patient commented that they were not always kept informed of changes in their medications. Pain audits undertaken from the last quarter showed mixed compliance with completion of pain scores. However, patient records we reviewed showed that patients’ level of pain was assessed as part of their observation records. Most patients we spoke with told us their pain had been managed appropriately, and they generally received pain relief in a timely manner. We saw in records that patients had been prescribed and administered pain relief, and this had been recorded accurately.

Staff told us sometimes time critical medicines would not be administered on time as prescribed due to medicines not being available on the ward. Staff were encouraged to report medicine related incidents and learning from incidents was disseminated across the group. We saw evidence that medication incidents and learning was discussed at team meetings. Staff told us that they felt fully supported by the pharmacy team. Pharmacy staff were readily available in hours and out of hours, and the pharmacy on call service support was easily accessible.

We observed in the day surgery unit that staff would prepare syringes for medication for use during cases before the start of the operating list. We found that it was not always clear when they had been prepared as they were not labelled with the date and time of preparation. We highlighted the need to strengthen governance around the preparation of syringes in theatres in advance of cases to improve safety and prevent infection at the end of our inspection.

Medicines were generally stored safely and securely, and access was limited to authorised staff, however, we found on one ward that a cupboard was faulty and did not always lock. Staff told us they had previously raised concerns about unlocked fridges and medicines cupboards in anaesthetic and post anaesthetic rooms that were not in use during daily theatre lists. The provider told us a risk assessment was in place which stated anaesthetic drug cupboards could be left open during daily theatre lists; however, we emphasised the need for the trust to ensure that medicines are secure when theatres are not in use.

The service had a process for obtaining relevant patient history for medicines reconciliation on admission to the service. The trust had an electronic prescribing and medicines administration (EPMA) system in place.

Staff received training in medicines management and their competency was regularly assessed. Pharmacy staff told us they offered additional training for more complex areas of medicines management.

Controlled drugs were stored in line with legislation and records of administration were mostly completed in line with guidance. The most recent controlled drug audits across the service showed compliance above 90% for theatres, wards, and SSDEC.