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Provider: Guy's and St Thomas' NHS Foundation Trust Good

On 23 July 2019, we published a report on how well Guy's and St Thomas' NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Good  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Good

Updated 23 July 2019

Our rating of the trust stayed the same. We rated it as good because:

We rated safe as requires improvement, which was as we found at our previous inspection. Effective was rated as good, the same as our previous rating. Responsive remained as good and caring as outstanding. Well-led improved to an outstanding rating. We rated two of the trust’s 18 services as outstanding, 15 as good and one as requires improvement. In rating the trust, we considered the current ratings of the eight services not inspected this time.

Inspection areas

Safe

Requires improvement

Updated 23 July 2019

Our rating of safe stayed the same. We rated it as requires improvement because:

  • Although mandatory training was provided in a range of subjects not all staff had completed this as expected.
  • Patient records including the use of risk assessments were not always completed to the expected standard in the Guy’s outpatient services. Early warning observational risk scores in maternity services were not always completed consistently.
  • The administration of medicines in the outpatient department at Guy’s Hospital did not always meet professional standards.
  • Outpatient records were not always available in advance of clinics and community staff reported not being able to access information because of differing IT systems.
  • The Guy’s outpatient environment was not always suitable for its use and equipment was not always fit for use.

However:

  • There were enough staff with the right skills and experience to keep people safe and to deliver the required treatment and care. Staff knew their responsibilities to keep people protected from avoidable harm. Risk assessment and monitoring tools were available to help staff recognise and responded to patients whose needs changed. There was access to staff with additional skills and technical equipment in emergency situations.
  • Infection prevention and control practices followed by staff helped to minimise the risk of people getting a hospital acquired infection. The environment in which people received care was visibly clean and equipment was cleaned before patient use.
  • Medicines optimisation was met in most of the areas we inspected.
  • There was a well-established system to report, investigate and learn from incidents, which all staff understood and felt confident to use.

Effective

Good

Updated 23 July 2019

Our rating of effective stayed the same. We rated it as good because:

  • Treatment and care provided to people who used the services were based on national and professional guidance. The trust benchmarked the effectiveness of its services through participation in national and local audits.
  • Staff ensured the nutritional needs of patients were assessed and responded to and made sure pain relief medicines were provided in accordance with their prescription.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Multidisciplinary and cooperative working was very well established in all the services we inspected. Staff worked very well together to ensure patients received the right treatment and care from appropriately skilled staff.
  • Services were delivered by staff with the right skills and experiences. Staff in some areas had additional skills and expertise enabling them to deliver a highly effective service. Clinical nurse specialists provided a range of nurse-led outpatient clinics at St Thomas’, and there was a wide range of clinical services available to meet the needs of patients.
  • The competence of staff was reviewed and monitored by staff with the right skills and experience to do so. The trust actively promoted training and development, and regular supervision and performance reviews provided opportunities to identify new learning needs and additional training.

However:

  • The trust’s consent policy was not consistently followed in Guy’s outpatient department.
  • Outpatient services were not fully developed across the seven day week.
  • There were delays in making urgent deprivation of liberty safeguard applications at times when the service was not covered, which meant patients may have been detained unlawfully.
  • Appraisal targets in some areas had not met the trust’s required level.

Caring

Outstanding

Updated 23 July 2019

Our rating of caring stayed the same. We rated it as outstanding because:

  • There was a strong and visible culture of person-centred care which enabled staff to provide outstanding levels of compassionate care to patients.
  • Staff demonstrated kindness and empathy when communicating with patients and their loved ones. People were treated with dignity and respect and were listened to.
  • Staff gave information to people using the services in a manner which enabled them to raise questions, discuss opportunities and make choices about their health needs.
  • The individual physical, spiritual and emotional needs of people were considered when discussing and agreeing their care. Staff were respectful and polite when providing care and they recognised the importance of involving family and loved ones where able.

Responsive

Good

Updated 23 July 2019

Our rating of responsive stayed the same. We rated it as good because:

  • The services inspected were generally planned around the needs of the local population. There was a strong focus on ensuring patients had access to the right care at the right time, and where possible this aimed at preventing avoidable admissions to hospital.
  • Community service had innovative methods and established pathways to enable people to receive care closer to home. The newly developed Integrated Care, Strategic Business Unit provided a model which centred around early interventions to avoid hospital admissions, and better support for those people with long term conditions.
  • There was a good system for receiving, reviewing and responding to complaints overseen by a suitably skilled team. Duty of candour was understood by staff and followed when it applied. Learning from the outcome of the complaints process was welcomed as an opportunity to improve service delivery.
  • There was good provision for people who required specialist equipment or support with language and disability needs.

However:

  • Key access and treatment targets were not being met for reasons sometimes outside of the trust’s control. This included referral to treatment and the operational standard for patients receiving their first treatment within 62 days of an urgent GP referral in relation to cancer waiting times.
  • From November 2017 to October 2018, the ‘did not attend’ rate in outpatients was higher than the England average.
  • Patients could not always get an appointment at their preferred time and outpatient clinics often started late or ran behind time. Not all patients were made aware of delays in clinics.
  • The privacy of patients attending Guy’s outpatients was not always met, and the bereavement facilities in the maternity services required attention to make them more suitable for use.

Well-led

Outstanding

Updated 23 July 2019

Our rating of well-led improved. We rated it as outstanding because:

  • The leadership capabilities, qualities and experiences at executive and service level enabled staff to respond to the needs of people who used the service in a purposeful way.
  • The trust had invested in its leaders and had provided development opportunities and supportive mechanisms to enable them to flourish and deliver the requirements of their roles and respective services.
  • Department leaders made sure their staff were aware of the trusts vision and strategic aims, and they worked hard to make these happen. They were aware of the local service level challenges and risks and took actions to minimise the impact on people who used the services.
  • Leaders at service level contributed to the collection of performance data and communicated this to the relevant governance committees. Where required, leaders attended such meetings and presented reports, including those arising from serious incident reviews. They were open to challenge and valued this as an improvement opportunity.
  • Staff valued the opportunity to learn from incidents and saw this as essential to improving services for their patients. They felt able to raise concerns in a constructive manner and that these would be considered in a fair way.
  • Opportunities to make quality improvements, be creative and innovative were actively encouraged and supported by line managers and above. Staff were encouraged to develop and be involved in research programmes.
  • There was a proactive approach to engagement with patients, the public, staff and local organisations. This helped in the planning and management of services to the benefit of those who used the trust.
Assessment of the use of resources

Use of resources summary

Good

Updated 23 July 2019

Combined rating
Checks on specific services

Community end of life care

Good

Updated 24 March 2016

We rated the community end of life care services at Guy’s and St Thomas’ NHS Foundation Trust (GSTFT) as ‘good’ overall. We found the end of life care (EOLC) team, specialist palliative care team (SPCT) and community nurses were passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner.

During our inspection we asked the trust to gain consent from patients or bereaved relatives to speak with us about the care and support they had received from the community nursing, EOLC and/or the SPCT. We were advised that none of the five patients who were receiving care at this time were suitable to visit due to complex social circumstances and/or communication barriers; it was felt our visit would cause further distress to families and patients at a sensitive time. We were not provided with any contact details for bereaved relatives. 

At the time of our unannounced inspection we followed the request up again. We were told  that the trust had made a decision not to contact bereaved relatives to seek permission to provide us with contact details, therefore we were unable to evidence the views and opinions of people who had recently used the end of life care services. However we reviewed thank you cards and we witnessed staff talking about patients in a compassionate and considerate way during interactions with each other and in their description to us of how they cared for and supported patients and their families. They included patients and their families in discussions about their care and end of life plans; they considered social needs and family dynamics. Staff took conversations about prognosis, death and dying as far as was comfortable for the patient and their family; they displayed patience and understanding about how hard this dialogue could be. We were impressed that staff used other indicators to gain an understanding about the level of acceptance the patient may have. For example we observed one member of staff telling their colleagues at the weekly multidisciplinary (MDT) meeting that one of their patients was starting to accept they were dying as they noticed funeral directors information at their recent visit.

The trust responded to the independent review of the use of the Liverpool Care Pathway (LCP) for the dying patient and the subsequent announcement of phasing out the use of the LCP in July 2014. They created a document called ‘priorities of care’. Holistic assessments looked at the whole picture – the patient’s physical, emotional, spiritual, psychological and social needs were assessed and their carers’ views were taken into consideration. It was an open document so the whole MDT wrote about their interactions with the patient, any changes and the care and treatment provided, such as pain relief, symptom management and nutrition and hydration needs. Patient records/care plans were regularly updated, matched the needs of the patient at the time and were relevant to EOLC.

Staff were able to explain their understanding of the Mental Capacity Act (MCA) 2005 and Deprivations of Liberty Safeguards (DoLS). They told us they would always act in the patient's best interests should they assess the patient lacked the mental capacity to make decisions for themselves. However there was little understanding as to which forms were required to be completed and who could legally provide consent for best interest decisions on behalf of the patient.

There were regular MDT meetings to review all end of life patients who had or were being cared for using the trust’s ‘priorities of care’ or receiving palliative care services. If there was a clinically urgent case then joint visits or ad hoc meeting were organised as necessary. Incidents, complaints and concerns were also discussed at regular meetings and across the trust-wide meetings where appropriate.

Palliative and EOLC was provided by competent staff with a range of clinical and non-clinical skill mix. For example GPs, social workers and psychologists were employed by the trust as part of the team. We observed a flattened hierarchy amongst the teams. They were highly supportive of one another and open to challenge and advice on how to approach patient care and treatment. The EOLC and SPCT were highly trained and received continual consultant, doctor and pharmacy support.

The community nurses were given the confidence to care for palliative and end of life patients through training and support from the EOLC and SPCT. They were able to express their concerns if they felt out of their depth or uncomfortable supporting patients at the end of their life. However some of the community nurses expressed a concern that sometimes there was no time for them to reflect and ‘gather themselves’ after someone dying prior to going to their next patient. Whilst most of the nurses told us it was not always necessary to take time out after a patient’s death there were occasions when “it gets to you.” The senior leaders expressed surprise that staff did not feel they could take time if they required it and assured us they would address this with local managers and team leaders.

We found the end of life care service was well led. Staff in the EOLC and SPCT spoke highly of their managers and valued their experience and the support they gave. All the staff, including those who worked part-time or had been newly recruited, told us they felt part of their team and appreciated by their colleagues. All the community staff said they felt very much part of the wider GSTFT team, one of them told us this was a positive change as they used to feel “like the poor relative” to the acute hospitals.

End of life care was a clear priority for the trust, including services provided within the community. A draft strategy to provide seamless good quality care was due to be presented to the board. The strategy had been developed in conjunction with the clinical commissioning groups (CCGs), local hospices, other hospital trusts and other organisations such as Macmillan Cancer and Marie Curie.

Community health services for adults

Outstanding

Updated 23 July 2019

Our rating of this service improved. We rated it as outstanding because:

  • There was an overall common purpose and shared vision amongst staff and managers to drive improvement through integration, innovation and sustainability.
  • Staff consistently delivered patient-centred treatment and took a holistic approach to meet the needs of people at each stage of their care journey.
  • The strategic business unit, Integrated Care, demonstrated strong collaborative working with internal and external partners. Staff had found innovative and efficient ways to deliver more joined-up care to people who use services.
  • We saw many examples where staff demonstrated outstanding compassionate care and emotional support to patients and those close to them. Staff were passionate about the care they provided.
  • There was an embedded open and transparent non-blame culture when things went wrong. Staff were consistently competent and confident to assess, manage and mitigate risk.
  • Staff reported a non-hierarchical culture where staff development and education were at the heart of the service.
  • Staff were empowered to lead, manage and make key decisions to facilitate good patient outcomes.
  • Leaders put a strong emphasis on staff wellbeing. They listened to staff and were willing to make changes because of staff feedback. Staff safety was given high priority.

Community health inpatient services

Good

Updated 24 March 2016

We rated community inpatient services at Guy’s and St Thomas’ NHS Foundation Trust as ‘good’ overall. We found that the services were organised with patient safety as a priority. The rehabilitation services were patient centred and involved them and people important to them. Feedback from patients and relatives was very positive and we observed staff to be caring and compassionate in their approach. A recent successful recruitment campaign meant that the services were adequately staffed, and there was low use of bank and agency staff. Staff were engaged in improving the service and received regular appraisals, supervision and were supported to develop their skills further. There was a robust governance and risk management structure in place and staff were supported to report and learn from incidents.

Staff followed infection prevention and control procedures, all areas we inspected were clean and the environment and equipment was well maintained. Patients had their meals together in the dining area and most patients told us they enjoyed the food provided and were supported if necessary.

Patients were given sufficient information about their environment and what to expect during their admission. Their opinions were sought and listened to. Patients and those close to them were part of the decision making process and they agreed clear and realistic goals to work towards. Staff told us there was a commitment to successful rehabilitation and we saw evidence of good multi-disciplinary working across nursing, therapy and medical teams.

We observed patient records were well managed however nursing, medical and therapy staff recorded their interventions in different formats. This meant that staff supporting patients did not always have access to each other’s notes and there was a potential risk of the healthcare professionals not being aware of a patient’s progress or changes in treatment or care. Medicines were managed appropriately, although not all patients were given the opportunity to self-medicate, if appropriate for them to do so.

Admissions and discharges were well managed although some discharges were delayed due to difficulties in organising ongoing care.

Community health services for children, young people and families

Good

Updated 24 March 2016

People using the trust’s community health services for children, young people and families were protected from avoidable harm and abuse.

Staff were encouraged to raise concerns and to report incidents and near misses. Learning from incidents was shared with staff through regular meetings and newsletters.

There were robust safeguarding policies and procedures in place. Staff received regular safeguarding supervision and were knowledgeable about their responsibilities regarding safeguarding vulnerable people.

There was sufficient serviced and maintained equipment to meet the needs of patients and staff. Most environments were clean, tidy, suitable and safe.

There were generally enough staff to meet the needs of the people using the service, although school nurses were struggling to deliver a full core service because of having to attend meetings.

There was a high rate of compliance with statutory and mandatory training amongst staff.

The trust’s community health services for children, young people and families provided effective care and treatment so patients had good outcomes.

Staff followed accepted national and local guidelines for clinical practice. A number of pathways had been developed to ensure that patients received treatment focused on their needs. The trust participated in national and local audits so that they could benchmark their practice and performance against best practice.

There was a multidisciplinary, collaborative approach to care and treatment that involved a range of health and social care professionals. Staff had regular supervision meetings and access to learning opportunities to promote their development.

Appropriate handover arrangements were in place for those children and young people moving between services

People using the trust’s community health services for children, young people and families were treated with dignity and respect and were involved as partners in their care. People felt they were listened to by health professionals and were involved in their treatment and care. People using the service told us that they felt well-informed and involved in the decisions and plans of care. Staff respected the choices and preferences of people using the service and were supportive of their cultures, faith and background.

The service was responsive to the needs of people using it and had adapted to meet the diverse needs of the community it served. Complaints from people using the service were learned from and used to improve the service. The health visiting service needed to further improve the amount of patient facing time spent.

The trust’s community health services for children, young people and families was well-led. The integration of children’s community services to become part of Evelina London Children’s healthcare in 2014 has had a positive impact and promotes the ability of the trust to provide a truly integrated model of health care to children across the trust’s acute and community services.

The service actively sought and responded to the views of people using the service.

There was a robust governance framework and reporting structure. Staff had confidence in their immediate line managers and leadership at board level. Staff were proud of their achievements and input into a wider health agenda at local, regional and national level.