St George's Hospital (Tooting)

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• 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

This was a focused follow‑up assessment for this service. At our last inspection, we rated this key question as inadequate. During this assessment, the rating improved to requires improvement. We specifically looked for evidence that the breach relating to safety and risk had been addressed. The service had made improvements and was no longer in breach of regulations. However, not all changes had yet been fully embedded in practice. This meant some aspects of the service were not always safe, and there remained an increased risk that people could be harmed.

We assessed elements of two quality statements for the safe domain. We looked at how the service established and maintained safe systems of care, and how they ensured medicines and treatments were safe and met people’s needs, capacities and preferences.

We have not awarded this service a score for Safe.

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

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Following our previous inspection, the trust had initiated several targeted workstreams to improve waiting times for walk-in patients arriving at the emergency department (ED). Walk-in patients are those that do not arrive by ambulance.

The service had developed and implemented a Standard Operating Procedure (SOP) to strengthen clinical oversight in the waiting area. The SOP outlined an escalation process to be followed when 6 or more patients were waiting to be streamed, or when any patient had waited more than 15 minutes for their initial assessment. This included escalation to the nurse in charge or the matron of the day, who would assist with streaming. If they were unable to support, an additional member of staff would be moved from the first assessment area. We observed the escalation process working effectively. When waiting times reached 20 minutes, the matron of the day attended the waiting area to assist, and the wait reduced to 6 minutes.

The service had also introduced an electronic check-in system for walk-in patients. This involved patients scanning a QR code on a smart electronic device, entering their personal details and the reason they presented to the ED. This streamlined the amount of time patients waited to be checked in and triaged. Patients who did not have a smart electronic device or were unable to use one, were able to check-in with the streaming nurse. The service had electronic devices patients could use if needed, however the streaming nurses told us it was just as quick for them to check the patient in. For patients where English was not their first language, the streaming clinician completed the pre-registration section utilising a language line for support. A patient survey undertaken in January 2026 showed 89% of patients who used the electronic check in system found it easy to use.

Since our last inspection, the streaming staffing establishment had been updated to include an additional paramedic or Emergency Nurse Practitioner during peak hours (10:00–20:00). This ensured two staff members were available to stream patients throughout the busiest periods, helping to reduce waiting times. Staff told us the presence of a senior clinician in the streaming area had been particularly beneficial for junior nurses, who reported improved support, supervision and access to senior decision‑making. Review of staffing data from the previous 12 months showed that 100% of streaming shifts had been filled, with no staffing gaps.

Senior leaders told us streaming wait times were reviewed 3 times daily during hospital‑wide capacity meetings to maintain oversight and escalate concerns when required. We saw evidence that waiting times and queue numbers were routinely discussed at these meetings.

The service routinely monitored the effectiveness of the actions taken since the last inspection. Recent audit results showed significant improvement, with average streaming wait times reducing from 27 minutes to 5 minutes, which was better than the national 15 minute target.

Following the last inspection, the service developed written documentation standards for staff to adhere to and introduced a documentation template. Leaders told us daily documentation checks were carried out by the nurse in charge, with immediate feedback provided to staff where required. We reviewed 10 patient records and found all contained detailed nursing and medical documentation, including for patients who had been in the department for over 24 hours.

We reviewed documentation audits from the previous 12 months. These showed 97.3% compliance with triage documentation and 98.2% compliance with nursing evaluation notes, both of which were above the trust target of 90%. However, not all patient risk assessments had been fully completed. While 91.3% of patients had an initial falls risk assessment completed, only 68.2% of patients who required a multifactorial risk assessment had one completed, which was below the trust target of 90%. In addition, only 88.4% of patients had pressure ulcer checks documented, and 85.4% had pain scores recorded within one hour of admission or triage.

There had been improvement in the completion of the National Early Warning Scores (NEWS2) since our last inspection. Recent audit results showed improved compliance at 98.5%. During this assessment, we found all risk assessments had been completed in the 10 records we reviewed.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Medicines were readily available across the ED. Following the previous inspection, the service had undertaken a month‑long review of medication use to ensure that all frequently used and time‑critical medicines were consistently accessible, and that items not routinely required were removed from stock.

We reviewed the records of 10 patients and found that time‑critical medicines had been administered as prescribed and within the correct timeframes. In response to our earlier findings, the service had updated its list of time‑critical medicines, delivered targeted education to staff, and displayed posters in all treatment rooms setting out which medicines were time‑critical, how to access them, and the expected administration times. Medicines requiring the most urgent administration were highlighted in red within a red‑amber‑yellow colour‑coding system.

Staff told us they were able to access time‑critical medicines easily and that these were consistently available. When a medicine was not immediately accessible, staff reported that the increased presence of pharmacy personnel meant supplies could be obtained more quickly and efficiently.

There had been improvement in the use of the electronic prescribing system since our last inspection. We reviewed 10 sets of patient records and found that the electronic prescribing system had been completed in all cases, with weights consistently recorded. Pharmacists told us that weight documentation was routinely completed and that this had contributed to a reduction in prescribing errors. Audit results from the 12 months prior to the assessment showed that 89% of patients had a recorded weight, which was slightly below the trust target of 90%.

The electronic medication chart generated alerts when a medicine had not been administered at the prescribed time. For example, we saw that a slow‑release analgesic patch had not been applied because it was not available in the ED. This omission had been clearly flagged on the system. The record also showed that the patch had been ordered from the pharmacy and was awaiting delivery, and that alternative analgesia had been prescribed to ensure the patient received adequate pain relief while awaiting its arrival.

The trust updated its medicines management policy in May 2025. However, alerts identifying overdue medicines or overdue assessments were still not referenced within the policy, meaning it did not fully reflect national guidance.

Since the previous inspection, the service had implemented a twice‑daily drug round. The nurse in charge announced the start of the round via a public address system at 8am and 6pm to ensure it was completed reliably. Leaders told us this had contributed to a reduction in missed medications. Staff also reported that the system was helpful and effective, as the scheduled announcements provided a clear prompt and supported them in administering prescribed medicines in a timely manner.

Since our last inspection, the pharmacy team had delivered training to staff in the ED on the management and administration of controlled medications. We saw the ‘Dos and Don’ts’ associated with controlled drugs reinforced through a poster for staff which was displayed throughout the department. The service reported they had seen a reduction in medication incidents relating to controlled drugs.

During this inspection, we reviewed the controlled drugs stored and the controlled drugs record books across all areas of the department and found no discrepancies. When errors had occurred, these had been corrected using brackets in line with national guidance. However, audits from the previous 12 months showed that controlled drug errors were not being consistently recorded correctly, indicating that improvements were not yet fully embedded.

Since our last inspection, the service told us that it had risk‑assessed the self-administration of medicines policy and suspended self‑administration in the ED, with all medicines now administered by staff. However, not all staff were aware of this change, with some staff reporting that they allowed patients to take their own medications.

The service had increased pharmacy staffing in the department, with the most recent recruitment taking place 6 months before our inspection. Two Band 8a pharmacists, one Band 7 pharmacist and a pharmacy technician were in post to provide dedicated support to the ED. This additional capacity had improved the timeliness of medication reviews, and patients who remained in the ED for more than 24 hours received a pharmacist review to ensure their regular medicines were prescribed.

However, pharmacy cover in the ED was only available on Monday to Friday, with weekend provision limited to an on‑call pharmacist. This arrangement was not compliant with Royal College of Emergency Medicine (RCEM guidance), which stipulates that pharmacy support to the ED should be provided 7 days per week.

Following the inspection the service told us that pharmacy provision is available to the ED on both Saturday and Sunday between 8am and 4pm, with a pharmacist supporting both the Acute Medical Unit and the ED, and an on-call pharmacist available outside these hours. However, this still falls short of RCEM guidance, which states the emergency department pharmacy service should be present 7 days per week.

Leaders told us they were aware that the required changes were still embedding into practice and that progress was being monitored through monthly quality improvement meetings. We reviewed the minutes of these meetings, which confirmed that this oversight was taking place.