St George's Hospital (Tooting)

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• 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 assessment we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant there was not always adequate service leadership and leaders and the culture they created did not always assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the governance of the service.

This service scored 79 (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 shared vision, strategy, and culture. This was based on diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The surgical service had a clear vision which was focused on delivering safe, high quality, patient centred care. Leaders described their strategic direction as including developing a world class major trauma centre, investing in recruitment and retention, and maintaining their diverse workforce, improving their financial position, utilising theatres better and improving resourcing and training around managing mental health patients. This supported the trust’s overall vision and strategy to provide ‘outstanding care, together.’

The trust had developed a Green Plan to support the delivery of their overall strategy and become an environmentally sustainable organisation. Through this plan the trust aimed to take action to ensure the settings in which they provide care were as low carbon as possible, ensuring energy efficiency, and using renewable energy sources where possible. We saw that this was supported within the service in their development of SMART theatres which along with improving patient experience and efficiency aimed to improve sustainability and reduce theatre energy consumption through automation.

Staff and leaders were able to demonstrate a positive, compassionate, listening culture that promotes trust and understanding between them and people using the service and is focused on learning and improvement.

Staff throughout surgical services were welcoming and friendly and focused on providing high quality care for their patients. Leaders promoted a positive culture which supported and valued staff both formally and informally. As an example, in regular newsletters issued to staff we saw that staff achievements were celebrated, and professional development was promoted and encouraged.

Staff consistently told us they were proud to work at the hospital. They were passionate about their work, and we saw this in our observations of positive and supportive relationships between staff at all levels.

Leaders embodied the culture and values of their workforce and organisation and led with openness and honesty. However, leaders did not always demonstrate they had the appropriate oversight of risk to keep people safe.

Although there were mechanisms in place to ensure all risks identified by the service were reviewed on a rotational basis evidence we reviewed showed that leaders did not always have appropriate oversight of risks. For example, the risk register did not entirely reflect all risks in the service and concerns we found during our inspection such as audit compliance or previous never events. However, there was a clear management structure with defined lines of responsibility and accountability. Care group leads were in post for most specialities who fed into a clinical director, general manager, and head of nursing for each triumvirate of the division. Local leadership was provided by matrons and ward managers. Leaders had the experience, capacity and capability to ensure that the organisational vision could be delivered, and risks were managed.

Staff we spoke with said that leaders were open, visible, and approachable. Staff felt leaders were engaged, they also told us they had access to training and regular appraisals, although some staff members described informal appraisal mechanisms, and the service had low appraisal rates across all staff groups.

Leaders were alert to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff. They addressed this through listening events and tailored training and initiatives, although we were not provided with any evidence of the impact of this.

We saw evidence that the trust was looking to establish an inclusive talent management approach. We also saw evidence of development pathways for staff of all levels within the service. Staff across wards and theatres consistently told us how they were supported to access courses and gain additional qualifications.

The trust had an appropriate and up to date Raising Concerns at Work Policy. Staff and leaders promoted staff empowerment to drive improvement. Staff were encouraged to raise concerns. The trust had a Freedom to Speak Up (FTSU) Guardian with whom staff could raise concerns about any issues.

We saw evidence of Freedom to speak up awareness included in protected teaching time and staff we spoke with told us they knew how to find contact details of freedom to speak up guardians should they need it. Staff told us there was a culture of speaking up where staff actively raised concerns.

We saw in the trust Freedom to Speak Up Report 8% of staff from the surgery service had raised concerns with the Freedom to Speak Up Guardian between April 2024 to September 2024. Following the inspection, the trust informed us that these were all advice calls relating to absence policies and human resource processes.

The service did not always promote 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.

The divisional workforce was made up of 61.1% people from ethnic minority groups, 35.8% white and 3.1% unknown. There was an under representation of people from ethnic minority groups in band 8 posts and in people from ethnic minority groups in very senior manager posts. We saw evidence that the trust had identified the overrepresentation of ethnic minority groups in lower bands and that this informed their plans to establish inclusive talent management, however we did not see evidence that the service was also working to address this. As part of the division's priorities for responding to staff survey data we saw that one of the priorities identified was 'career development opportunities'. As part of this, the service planned to have a recruitment inclusion specialist for all roles band 6 and above and to establish developmental roles focussed on succession planning. However, we did not see evidence of a timeframe for the identified priorities to be addressed.

The trust had an in-date Equality, Diversity, and Inclusion in Employment Policy (EDI). Leaders told us about the introduction of a Justice, Equity, Diversity, and Inclusion programme (JEDI), which serves to promote EDI and ensure staff are heard in response to feedback from staff surveys.

Staff had access to multiple networks including:

• BAME Staff Network
• DAWN (Disability and Wellness) Staff Network
• LGBTQ+ Staff Network
• Women's Staff Network

The service did not have clear responsibilities, roles, systems of accountability and good governance. Staff did not act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate.

There was a lack of effective systematic governance for the service. We reviewed the service risk register, and although all risks had recent updates, we found that not all risks identified within our inspection such as poor VTE assessment completion, missed medication administrations and low Immediate Life Support mandatory training compliance were identified and recorded on the service risk register. This did not provide the leadership with overall effective assurance and oversight of risk.

Although each risk was given a risk rating and level and allocated a risk manager, we found that the risk register did not include actions. However, after the inspection the trust provided a full extract of the risk register which included actions to address risks. We saw that the service produced divisional risk reports which provided control measures, actions, identified assurance in the effectiveness of control measures and gaps in assurance for some of the risks on their register.

From data we reviewed it was not clear that action was taken in response to risk assessments and audits. We reviewed risk assessments for fire safety on two wards where actions had been identified to address risks however it was not clear whether the risks had been addressed. During our inspection we observed that some obstructed escape routes identified as a risk in fire risk assessments remained obstructed by equipment, indicating that the risk had not been addressed and we did not see this reflected on the service risk register. LocSSIP audit data and reports we reviewed between April and September 2024 did not outline any actions or learning points despite most specialties performing below 98% overall and compliance in DSU general theatres as low as 50% in the debrief between April 2024 and June 2024. However, after the inspection evidence was provided of learning and actions implemented.

Although we observed good practice within surgical theatres during the inspection, data showed that the service did not always comply with national safety standards. We were not assured by this data that the service had embedded learning from previous never events. We were informed of a never event which occurred within cardiac surgery in December 2024. Between October 2024 and December 2024 audit data showed that there was 65% compliance in the briefing element of safety checklists in cardiac theatres and 78% in the debrief, there was no audit data available for the consent and procedural verification, sign in, sign out and time out. The service also audited communication effectiveness, engagement, and attitude with NatSSIPs2, cardiac theatres demonstrated the poorest compliance of 73%. However, the data showed 98% compliance in cardiac theatres staff knowledge of NatSSIPS 2. We did not see that audit compliance or previous never events were included on the service risk register, the never event which occurred in cardiac surgery was also not included on the surgery learning response log. Following the inspection the trust informed us that cardiac surgery was managed by a separate division. However, evidence provided from the Divisional Incident Review Group Meeting for this division dated 30th January 2025 stated that the surgery division was leading on the patient safety incident investigation (PSII), furthermore we found at the time of the inspection that this was not recorded on the surgery division PSII tracker. We did see that Never Events were routinely discussed at group board meetings.

Staff we spoke with had a good awareness of governance processes and knew how and where to escalate their concerns. Staff had access to a range of policies, procedures and guidance which was available on the provider’s intranet. Ward and theatre teams held regular team meetings to discuss incidents, audit results, and safety alerts. We reviewed a sample of meeting minutes from teams within the surgical service and found most showed discussion of patient feedback, incidents, and learning. Part of the agenda of some of these meetings included welcoming new staff as well as recognising achievements.

There was a governance framework for theatres across the trust that included Queen Mary’s Hospital. There were clear lines of accountability. The theatres and anaesthetics directorate had consultant, management and nursing governance leads. Operationally there were care group leads, deputy and associate managers and matrons. This included a matron dedicated to theatres at Queen Mary’s hospital. Divisional teams held their own monthly meetings with the care groups or specialities in their divisions. There was a theatres transformation board that met monthly to review performance and theatre utilisation, this included where surgical lists were provided for other Southwest London NHS trusts. Monthly governance meetings were held to review issues such as mandatory training compliance, incidents and risks. Other meetings included directorate meetings, care group meetings and monthly protected teaching for staff.

There was effective workforce planning including for managing major incidents or emergencies. The service had business continuity plans in place for various scenarios.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff shared information and learning with partners and collaborate for improvement.

Staff and leaders engaged with people, communities, and partners to share learning, develop, and improve patient experience that results in continuous improvements to the service. They used these networks to identify new or innovative ideas that led to better outcomes for people. The service worked with other organisations for the benefit of service users. This included the citizens advice bureau, charities, and local system partners.

Staff encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. The service had not embedded continuous learning, innovation and improvement across the organisation and local system. Staff did not always actively contribute to safe, effective practice and research.

Recurrent never events in the service suggest learning from previous incidents is not yet fully embedded. However, there were processes to ensure that learning happened when things went wrong. Changes to practice were made when safety issues were identified including a 'no photo, no surgery' amendment to local standards in relation to removal of skin lesions to minimise the risk of incorrect lesion being removed. As part of learning from previous incidents leaders also introduced theatre protected teaching time attended by all staff groups. Topics of learning included human factors, training in civility, consent, and NatSSIPs 2. Staff told us there were various learning opportunities available.

Staff we spoke with told us they were supported by their managers to access development opportunities and develop their leadership skills. The service was actively involved in research. Junior medical staff told us they were happy with research and trauma opportunities in the hospital.

Staff were involved in various quality improvement projects. The service was active in trying to improve and respond to individual patient care needs. The service had developed a patient initiated follow up pathway as well as a free initiative to provide access to programmes for individuals with joint pain in collaboration with an independent provider.

The service was innovative in their approach to patient care. The service has undergone a digital transformation project to implement the use of SMART theatres. We were told that in the weeks following the inspection there was an ambition to track the patient journey from the minute they arrive in the SAL to theatres and to recovery. This initiative aimed to improve efficiency, patient experience and reduce energy consumption and improve sustainability.