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 good. At this inspection 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.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

St George's University Hospital had a values-based behavioural framework under the tagline "We Are St George's: Outstanding People, Outstanding Care." This framework was structured around four domains: Excellent, Kind, Responsible, and Respectful. It outlined expectations under categories of "What we expect to see," "What we love to see," and "What we don't want to see." These values were displayed throughout hospital corridors. The trusts strategy was refreshed for 2023-2028. The St Georges University Hospitals ED Strategic Plan 2018- 2023 listed 6 core strategic objectives which were:

1. Continue to provide safe, timely, outstanding quality urgent and emergency care for an ever changing population
2. Build an ambitious, resilient and happy workforce.
3. Stay at the forefront of emergency care through identifying, fostering and adopting clinical and service innovation.
4. Build our research activity to a world class level
5. Work in partnership with other organisation to create a strong local and national health and care system.
6. Create a building and physical infrastructure fit for an outstanding emergency department and major trauma centre.

Each objective had actions to help achieve the objective and success indicators to measure this achievement.

Despite the trust values being around for some time staff could not describe them and reported a lack of involvement in the development of the trust values. When questioned staff had basic knowledge of the trusts values but did not have an awareness of the hospital or department values or strategy.

Staff reported positive feelings about working in the ED, although they did describe and acknowledge the difficulties and pressures they faced in delivering the service in line with the values. Staff survey results indicated that although 85% of staff had a support network amongst colleagues, over 75% of staff had considered leaving their role in the last year.

Staff felt there were appropriate forums to raise concerns and discuss challenges they faced in their roles. They described a listening culture within the organisation but noted that while issues were acknowledged, actions to resolve them were not always achieved quickly, if at all.

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The trust received a warning notice section 29a on 19 December 2024. The senior leadership team were hesitant regarding the importance of breaches unrelated to patient care in corridors or patient flow. Though these breaches were still acknowledged. This demonstrated a narrow focus over a comprehensive understanding that whilst patient safety was paramount other breaches can still impact the overall quality of care and the well-being of both patients and staff.

We requested data on the ED Workforce Disability Equality Standard and Workforce Race Equality Standard, data provided was at trust level. The Workforce Disability Equality Standard (WDES) was introduced in 2019 and is designed to improve the experiences of people with a disability working in or seeking employment within the NHS. The mandated collection of evidence-based metrics helps an organisation understand more about the experience of its staff. At St George's 3.7% of the workforce had shared they have a disability on the staff record systems; staff surveys indicated that this figure was closer to 6% of the workforce. It was reported that there was a higher number of staff with a disability in lower bands. Staff with a disability were under-represented at executive and board level within non voting groups, they were positively represented in voting and non-executive director groups. Applicants without a disability was 1.26 times more likely to be appointed compared to applicants with a disability.

The Workforce Race Equality Standard (WRES) is an NHS initiative introduced in 2015 to address racial inequalities within the NHS workforce. All NHS providers are required to complete an annual WRES report. Results from this report showed that Black, Asian and Minority Ethnic workforce had increased year on year since 2019 to be representative of the local communities served by the hospital. For clinical staff there was an increase in the percentage of Black, Asian and Minority Ethnic (BME) staff across 7 of the 11 Agenda for Change bands. There was also an increase in diversity with consultant groups from 38% in 2022 to 47% in 2024. The lowest representation remains band 8a to 8d. For example, of the 25 band 8d and above posts, only 20% were held by a BME member of staff compared to 80% being held by a white member of staff.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with openness and honesty.

The trust followed the South West London Acute Provider Collaborative recruitment and selection policy. The policy provided clear processes and standards to follow. Recruitment Inclusion Specialists (RIS) were required to be available to advice interview panels on diversity. Leaders were appointed following a thorough assessment and selection process, ensuring that they met the necessary specification criteria to perform their roles effectively. Offers of employment were made subject to satisfactory references, medical clearance, checks of qualifications, right to work checks and disclosure and barring service checks. Fit and Proper Persons checks were conducted for director-level appointments.

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The clinical leadership team followed a structured job planning matrix that outlined non-clinical responsibilities, enabling the service to align leadership roles with the skills, experience, and ambitions of its staff.

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The trust promoted opportunities for staff to change roles to gain broader experience and develop leadership resilience. Several members of the consultant team had previously taken on roles such as care group lead and governance lead, allowing them to offer peer support and provide cover during leave.

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Staff benefitted from leadership courses and regular senior leadership teaching sessions from the trust. Career breaks and personal job planning were encouraged and facilitated wherever possible, supporting staff in balancing professional growth with personal commitments.

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Staff spoke positively about their experience of working for the trust and described a strong sense of teamwork within the service. Staff highlighted that their colleagues were very supportive and that they felt well supported in their roles by their seniors. The 2024 Staff survey results showed that 82% of staff described the level of friendship amongst staff in the ED as excellent or good.

We reviewed respect in the workplace steering group meeting minutes where leaders took an active role in discussions, recognised positive contributions from reception and clinical teams and acknowledged the emotional impact of workplace pressures. Meetings were used to reinforce the service's aim to ensure all staff felt part of a supportive, inclusive environment.

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The service had taken steps to recognise and respond to variation in staff experience. Leaders acknowledged challenges around inclusivity for newer and lower-banded staff. Team building events and staff development days were planned across multiple bands. Leaders recognised representation gaps including the over-representation of black staff in lower pay bands and committed to improving workplace culture and fairness.

Resident doctors reported feeling well supported in their training and development. ED consultants explained that they had regular meetings with the senior leadership team and described good communication and engagement with leaders. Nursing staff also reported that they were supported in their professional development, with opportunities available to progress their skills through additional courses.

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Patients described staff as kind, respectful and took time to explain their care thoroughly. Feedback from patients highlighted attentiveness shown by staff. The department responded to patient feedback by reinforcing expectations around communication and behaviour, demonstrating a commitment to delivering care in line with the trust's values.

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However senior staff reported being unsure of what training bank staff received. Senior staff reported limited protected time for mandatory training and no additional training time given. Post inspection the trust informed us that substantive staff were given time to complete mandatory training. There was a study leave policy which allowed access to additional educational time to study, which was all recorded on the electronic health roster. Mandatory and statutory training compliance was above 85% in all areas.

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We could not review competencies for leadership staff or the skills that demonstrated competency within the ED. We requested data on evidence of leadership competency and the trust submitted Competency Assessment Document (CAD) and responsibilities for the Nurse in Charge (NIC) of inpatient Wards competency checklist. This was blank, and the trust did not provide other leadership competency assessments for the ED's diverse leadership roles. This meant that we were unable to review competencies for leadership staff, and was unable to review the skills measured to demonstrate competency within the ED.

Reception staff reported feeling unsupported by managers and leaders, who they felt were not visible and did not routinely check on the team during busy periods. They described the environment as high-pressure when managing large numbers of patients, despite the presence of security staff.

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The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff felt encouraged to raise concerns and reported that leaders were supportive when they did so. Staff expressed confidence that actions were taken to address issues they raised, contributing to an open and transparent culture. The trust had a freedom to speak up guardian who engaged with staff regularly, providing an accessible route for raising concerns. Staff could access the freedom to speak up guardian whenever needed, ensuring that issues could be escalated through a structured process.

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The trust also had an in-date raising concerns at work policy, with the next review scheduled for March 2025. This policy provided a clear framework for staff to report concerns and reinforced the trust's commitment to supporting a speaking-up culture.

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The service showed limited diversity in their workforce for senior staff. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders took steps to ensure that some staff reflected the diverse population of people using the service. As of October 2024, the ED workforce was made up of 45.68% BME staff, 52.87% white staff. This indicated a diverse workforce, however, there was an underrepresentation of BME staff in clinical posts at Band 7 and above. The trusts Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) data showed that while the ED workforce was diverse, staff from minority ethnic backgrounds and those with disabilities were underrepresented at senior levels. Senior representation was not representative of the patient demographic using the ED. Staff survey results highlighted concerns around workload and inclusion, with only 47% of ED staff saying they would recommend the trust as a place to work. Post assessment the trust reported that that they proactively encouraged applications from underrepresented groups. The trust also had a Recruitment Inclusion Specialists (RIS) representative on all interview panels for band 7 and above positions.

The gender distribution in the service was 67% female and 33% male.

However, the trust had an ED respect forum, a proactive initiative designed to promote workforce equality, diversity, and inclusion (EDI). This forum provided an open platform for discussing Black, Asian, and Minority Ethnic (BME) representation, workforce demographics, and career progression transparency. Staff described the forum as a positive initiative that had contributed to improving staff experience, particularly for overseas nurses and doctors adjusting to working in the NHS. The forum had expanded to engage specific staff groups, including receptionists and international staff, ensuring that wider workforce perspectives were considered in discussions about inclusivity and representation.

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Staff had access to multiple staff networks, including networks for BME, disability and wellness, LGBTQ+, and women's networks, supporting an inclusive and representative workplace.

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The trust demonstrated a commitment to EDI through initiatives such as an internship programme designed for young adults aged 18-24 with autism and/or learning difficulties. This programme provided opportunities for young adults to develop skills and gain work experience, further reinforcing the trust's inclusive approach to workforce development.

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

The governance systems in place did not always identify or address risks in a timely way. This was reflected in concerns outlined in the warning notice including poor documentation, unsafe medicines management, triaging processes and information security concerns.

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There was a lack of systems and processes in place to support the confidentiality of people using the service. During our assessment, we observed staff did not always store and treat service user identifiable information in line with General Data Protection Regulations (GDPR). Staff did not recognise the need to lock computer screens or remove service user sensitive information from public view. We observed five computers where staff had left their Smart Cards inserted into the Smart Card readers. NHS Smart Cards are essential for healthcare professionals to securely access patients' information and IT systems. This created a data security breach and meant that patient data could have been accessed by the public. We observed a computer had been left unattended with a staff smart card still in place in majors B for ten minutes. We issued a section 29a warning notice and received an action plan from the trust describing mitigation steps for these risks. The time a computer remains unlocked before automatic lock-out has been reduced from 10 minutes to 3 minutes. Concerns were also communicated at daily safety huddles to remind staff to lock computer screens immediately and not to rely on the automatic screen lock.

We requested information on cyber security, and we were provided with the trusts Information Governance Management Framework and Policy. Whilst there was reference made to cyber security, we expected to review a policy for how digital information and systems were protected from digital threats. Therefore, we could not be assured that the importance of digital patient data was understood nor was it being protected at all times. Post assessment we were provided with The Network Security Policy which had been in place at the time of the assessment, but was out of date. The review date for this policy was 28 June 2024.

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The governance structure of the ED included monthly governance meetings where key risks, incidents and issues were reviewed. The service maintained two risk registers tracking both new and open risks.

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We reviewed the two ED risk registers, one for current open risks and another for new risks. At the time of the assessment, there were eight risks recorded in the new risks register and nine in the open risks register. We found the use of two risk registers had the potential to introduce confusion and operational inefficiencies. Preventing a single comprehensive overview of all potential and active risks in ED. One of the risks on the open risk register had been inputted in December 2021 with a due date of December 2022, but there was no further documentation to action this risk. Post assessment the trust informed us that there was only one risk register in the ED, and this holds the open risks that were recorded on their electronic system. New risks were those that had been raised by the service and had not been recorded on the electronic system and needed to go through either divisional or site sign off depending on the risk score.

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Safe care and treatment were compromised due to several factors; including high numbers of decision to admit (DTA), exit blocks caused by lack of capacity for inpatients and staffing levels. 20 DTAs in the ED had been normalised which had peaked to 50 DTAs. Exit blocks had an impact on the level of care within the ED department but also had a knock-on effect with ambulance off load delays and delays to 999 response times. A research paper in the Emergency Medical Journal 2022 stated an association between delays in ED admissions and all cause 30-day mortality. The authors concluded that for every 82 patients delayed between 8 and 12 hours from time of arrival, there is 1 extra death. This meant that in 2022, for this ED service the 30-day excess mortality for May was 40, June 47 and July 42. This was an excess mortality of over one patient per day every day. However, the Summary Hospital Level Mortality Indicator (SHMI) for the trust during this period indicated that the number of deaths was as expected and not higher than expected. The SHMI for the trust in March 2025 indicated that the number of deaths was lower than expected.

During our assessment we observer a high number of mental health patients with extended stays and exceeding resus capacity. This had been documented on the open risk register in August 2022, as an extreme risk. The full capacity protocol was a documented control howev er the approved full capacity protocol was only circulated in November 2024. Post assessment we were provided with evidence that showed that staff had a number of different policies in place for operating at full capacity reflecting the changing demands of the trust since 2020.

Risks identified during our assessment were not always recorded on the risk register. We reviewed mental health patients on the risk register with a RAG status of extreme however, we saw no documentation on mitigation around ligature assessment and hazards in the ED that could protect mental health patients.

VTE audits were not on the risk register despite poor performance indicated across the whole trust.

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Senior staff lacked understanding and knowledge of environmental sustainability. When questioned staff were unable to describe what it meant to their role and did not see this as a priority. In April 2024 there was a Green ED week but senior staff were not able to recall what happened or how this impacted the ED department. However, staff were aware that becoming paper light and using recycling bins enhanced environmental sustainability.

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We asked to review the last 3 months of clinical governance meetings minutes, but we were sent a blank agenda for the meeting. We also received 3 files tiled Action Log ED for 3 separate months in 2024; September, October and November. However, each log had a meeting date of 1 November 2023 and two of these logs were identical, despite being a log for two different months. The logs were brief and lacked detail. Although the department assigned a responsible officer to each of the two issues and recorded a mitigation action, the logs did not document the outcome or previous issues from other months. Post assessment the trust provided evidence that showed that clinical governance meetings were captured in governance reports. PowerPoint slides were used to record an account of the content of the meeting. A summary of the content was then shared to the wider department via a monthly governance newsletter alongside a monthly comprehensive governance report.

Staff understood their roles and responsibilities within the ED and reported that governance and management structures were well defined. The ED had a monthly governance meeting where governance leads for adults and paediatrics reported on key issues. Additionally, divisional governance meetings were held monthly, where leaders reviewed key performance indicators, complaints, risks, and workforce challenges. Governance meetings were well-structured and attended by a multidisciplinary team. We observed key topics such as mortality, safety alerts, and the trust's risk register being discussed. Outcomes from the meetings were shared through the departmental newsletter.

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The service promoted a proactive incident reporting culture, with incident report submissions encouraged and reviewed weekly. Complaints and PALS (patient advice and liaison service) handling were well structured, with the assistant general manager overseeing all complaints, with support from nursing, clinical and operational colleagues. Regular divisional complaints meetings took place to ensure timely responses, and consultant governance leads for adults and paediatrics played a role in supporting complaint resolution.

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ED leadership demonstrated a commitment to using audits to drive service improvements. Patient flow data was reviewed to measure waiting times and inform the implementation of a digital triage. Feedback from major trauma audits was also used to refine trauma response processes and improve patient outcomes.

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We reviewed policies including the initial assessment of children and young people in the emergency department policy, which was in date, with the next review scheduled for September 2026. The information governance management framework and policy were in date, with a review planned for November 2026. The emergency preparedness, resilience, and response (EPRR) policy were also in date, with the next review due in August 2025.

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Governance meetings were well-structured and attended by a multidisciplinary team, covering performance measures, safety incidents and learning opportunities. We reviewed meeting minutes where issued were actively followed up and managers responding to concerns.

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

As part of Group working the ED actively collaborated with Epsom and St Helier University Hospitals NHS Trust to share best practice and solutions, including the implementation and sharing of a full capacity protocol. This partnership aimed to improve patient flow and response strategies during periods of high demand.

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Leaders within the ED engaged with local schools to promote understanding of emergency care. A consultant, matron, and deputy general manager visited three separate schools to educate young children about the role of the service and what to expect when accessing urgent care.

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The service was in the process of establishing an ED voice group, which was a quality improvement initiative designed to engage with patients and gather feedback on their experiences using a survey. The responses would be used to invite patients to attend a session at the trust, where they would meet members of the ED team face-to-face and participate in structured focus groups. These focus groups would allow patients to discuss their experiences in different areas of the ED, helping to shape improvements in service structure, processes, and patient outcomes.

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The trust homelessness inclusion team played a significant role in supporting vulnerable patients by promoting health equity and advocating for individuals at risk of exclusion from healthcare services. The team engaged in various external boards and forums, including the Violence Reduction Network for Allied Healthcare Professionals and the Mayor of London's Violence Reduction Unit (VRU). These partnerships enabled the trust to work alongside external organisations to develop strategies to address health inequalities, improve access to services, and provide targeted support for high-risk patient groups.

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The service worked in partnership with local GPs and community services to support safe streaming and referral including collaboration with regional retrieval teams for paediatric critical care transfers and with community paediatric and safeguarding services.

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Staff described strong collaborative relationships with external partners, including the psychiatric liaison team and child and adolescent mental health services (CAMHS). These partnerships were critical in providing comprehensive care and ensuring smooth pathways for patients with mental health needs.

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The trust worked in partnership with local authorities.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contribute to safe, effective practice and research.

Leaders encouraged staff to contribute ideas for improvement and innovation, fostering a culture of continuous learning and service development. Staff were supported in identifying areas for enhancement, and the service actively pursued technological advancements to improve patient care and operational efficiency.

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Consultants in the service were responsible for both clinical and non-clinical duties, with additional leadership roles incorporated into their job planning. These responsibilities were rotated to support professional development, broaden expertise, and ensure a diverse skill set within the team. The trust encouraged consultants to take on leadership positions within the service and across the organisation, allowing them to contribute to service development and advance their professional growth. Examples of consultant leadership roles included the clinical director, who oversaw the overall management, strategic planning, and leadership of the service alongside the head of nursing and general manager. The care group lead was responsible for providing leadership and management support to the consultant and medical workforce, ensuring high-quality care, adherence to protocols, and the effective day-to-day operation of the service.

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Following our inspection, a new e-triaging system has been introduced in the service to improve access and flow. For service users who do not have access to a smart phone, devices are situated at the entrance for accessibility. For service users who are unable to use the device or English is not their first language, a streaming clinician assists with this using translation services.

The service also conducted weekly incident reviews to identify recurring themes and areas for safety improvements. These reviews played a crucial role in learning from incidents, mitigating risks, and driving continuous service enhancement.

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