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

This was a focused follow‑up assessment for this service. During this assessment, the rating improved to requires improvement. We specifically looked for evidence that the breach relating to General Data Protection Regulation (GDPR) compliance 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.

We assessed elements of one quality statement for the well led domain - governance, management and sustainability.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles, systems of accountability and good governance in relation to General Data Protection Regulations (GDPR).

Improvements had been made in systems and processes to support the confidentiality of people using the service. The automatic lock‑out time for computers had been reduced from 10 minutes to 3 minutes, meaning sensitive information was no longer visible after a short period of inactivity. Staff were also reminded during twice‑daily safety huddles of the importance of manually locking their computer screens when stepping away, rather than relying solely on the automatic lock.

If Smart Cards were left in a computer, the system automatically locked after 3 minutes, and users were required to enter their personal identification number (PIN) to regain access even if the card remained inserted. This reduced the risk of unauthorised access using another person’s Smart Card. This mitigated the risk of anyone accessing the system using another person’s Smart Card.

The service had recently introduced a “tap‑and‑go” login system, which required staff to tap their Smart Card on a device reader and enter their PIN to access the system. Leaders told us this had already reduced the number of Smart Cards left in computers; however, as implementation was still ongoing, the system was not yet fully embedded in practice.

Information governance was part of the standard agenda for staff meetings, and we reviewed minutes from the previous 12 months confirming this. It was also included in the ED clinical governance newsletter, which was shared electronically with all staff.

The service had an up‑to‑date Information Governance policy, and staff we spoke with were aware of it. Training records showed that 94% of ED staff were up to date with information governance training, which exceeded the trust target of 90%.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.