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

Reports


Inspection carried out on 7-10 September 2015

During an inspection to make sure that the improvements required had been made

Guy's and St Thomas' NHS Foundation Trust is a large provider of acute and specialist services for residents of Lambeth and Southwark, across London, the South East and further afield. The trust operates from two acute sites; Guy's Hospital, St Thomas' Hospital and a range of community locations. The Evelina London Children's Hospital is part of St Thomas' Hospital. The boroughs of Lambeth and Southwark are particularly deprived

The trust has 1,277 beds including 1090 general and acute, 75 maternity and 112 critical care beds. 

There were 182,720 A&E attendances at the trust in 2014/15 and 79,700 inpatient admissions. Of the inpatient admissions, 28,084 were elective and 51,616 were non-elective. In 2014/15 there were 1,187, 182 (total attendances) outpatient appointments.

We carried out an announced inspection between 7 and 10 September 2015. We also undertook unannounced visits on 21st, 22nd, 23rd and 26th September.

This was the first inspection of Guy's and St Thomas' NHS Foundation Trust under the new methodology.  We have rated the trust as good overall with Guy's Hospital, St Thomas' Hospital and community services rated as good. In relation to core services most were rated good with services for children and young people and the Emergency Department at St Thomas' Hospital rated as outstanding. Community services for adults and medical care at Guy's Hospital were rated as requiring improvement.

.Our key findings were as follows:

  • During our inspection we found staff to be highly committed to the trust and delivering high quality patient care.  
  • We saw staff provided compassionate and patients were positive about the care they received and felt staff treated them with dignity and respect.
  • The trust had vacancies across all staff groups, but was recruiting staff and staffing levels were maintained in services through the use of bank and agency staff.
  • Staff were aware of how to recognise if a child or adult was being abused and received good support from the trust's safeguarding team. 
  • The trust had an incident reporting process and staff were reporting incidents and receiving feedback. More work was needed to complete investigations into serious incidents in a timely manner and share learning across directorates.
  • The trust had not fully implemented the five steps to safer surgery.
  • We observed effective infection prevention and control practices in the majority of areas we inspected. In some community services it required improvement and space between beds in some of the critical care units was limited.

  • Patient care was informed by national guidance and best practice guidelines and staff had access to polices and procedures.  
  • Patients had their nutritional needs met and received support with eating and drinking.
  • There was good team and multidisciplinary working across all staff groups and with clinical commissioning groups, voluntary organisations and social services to deliver effective patient care.
  • Staff had attended training on the Mental Capacity Act 2005, but some staff, in both inpatients and community services, were unsure how to translate the principles into practice.
  • Staff understood and responded to the needs of the different population groups the trust served and worked hard to meet the needs of individual patients. 
  • Patients were largely treated in timely manner with the trust meeting national access targets. However the trust had not met the 62 day cancer access target since 2013.
  • Patient movement through the hospital was well managed with systems to ensure delays in seeing patients in the Emergency Department and when patients were well enough to be discharged were minimised.  The number of cancelled operations was low.
  • The trust had a backlog of complaints, some with a significant delayed response times. Action had been taken to reduce the backlog and improve response times and the quality of responses.
  • Executive and non executive members of the trust were visible in most areas. Community staff knew who they were but, felt they were less visible with the exception of the Chief Nurse.  
  • The trust had a clear vision and strategy which staff were aware of and fully engaged in delivering.
  • The trust was committed to public engagement and national and individual service surveys indicated that patients had a positive experience when using the trust. The trust had a good working relationship with the Council of Governors who felt involved and able to fulfil their role.
  • Governance was devolved to the services/directorates and although there was oversight at trust level this needed to be strengthened.
  • Staff were positive about how their local and senior managers engaged with them. They were supported in their personal development and were empowered and supported to initiate improvements in services.
  • The trust was in the process of rolling out the electronic patient record and aligning the IT systems. In some community and acute inpatient services staff were using both handwritten and electronic records.
  • The trust was facing financial challenges for the first time along with increasing demands on services. Although some action had been taken robust plans were not in place to address the cost savings that needed to be delivered.    

We saw several areas of outstanding practice including:

trust wide

  • The use of 'Barbara's story' to engage with staff and enhance a compassionate approach to patient care.
  • The trust wide engagement of staff in a culture of improvement and compassionate care that lead to a proud and empowered workforce.

At St Thomas' Hospital

  • The use of 'Barbara's story' to engage with staff and enhance a compassionate approach to patient care.
  • The specialist support units active within the urgent and emergency department including alcohol, toxicology, homeless, youth support and play therapy for children.
  • The role of the security team in the emergency department was embedded into the day to day working of the department. The team was multi-lingual and trained in effective de-escalation techniques and demonstrated outstanding empathy to patients.
  • The provision of 'reflection time' to staff within the urgent and emergency department.
  • The approach to communication with and support of dementia and complex needs patients via well designed communication boxes and a specialing team.
  • The ward environment and signage afforded dementia patients.
  • The Proactive Older Patient service.
  • The multidisciplinary team support for families attending the neonatal unit.
  • The paediatric cardiology service had introduced a home monitoring programme for infants following single ventricle palliation surgery (Norwood 1 operation or hybrid procedure). This allowed these patients to safely live at home with their families while they recovered and prepared for the second stage of their treatment.

  • Supportive practice of the mortuary and bereavement team.
  • The SPCT was effective and provided face to face support seven days per week, up to 9pm, with calls taken until 11pm and a consultant providing out of hours cover.
  • The AMBER care bundle and a range of training courses for staff in end of life care such as the Sage and Thyme training model, simulation days and Schwartz rounds.
  • We saw staff in the bereavement office had sourced funding to provide family members with sympathetically designed cloth bags so they had a more discreet way of taking home personal belongings of a deceased patient, rather than use a plastic hospital property bag.
  • Staff in the emergency department had sourced funding and designed and produced a bereavement card that they sent to any families whose relative died in the department.

At Guy's Hospital

  • The specialist SPCT was effective and provided face to face support seven days per week, up to 9pm, with calls taken up to 11pm and a consultant providing out of hours cover.
  • The Amber care bundle and a range of training courses for staff in end of life care such as the Sage and Thyme training model, Simulation days and Schwartz rounds.
  • The Guy’s Orthopaedic Outreach Team (GOOT): a fast track discharge and multi-disciplinary support service which improved patient outcomes and reduced length of stay.
  • Proactive Care of Older People Service (POPS): an award-winning service and the first of its kind in the UK. The POPS service looks after patients aged 65 years and above to improve their medical health before and after surgery by assessing them before surgery, following their care while in hospital and supporting consultants and ward staff.
  • The use of 'Barbara's story' to engage with staff and enhance a compassionate approach to patient care.

  • ​Supportive practice of the mortuary and bereavement team.

  • Staff in the bereavement office had sourced funding to provide family members with sympathetically designed cloth bags so they had a more discreet way of taking home personal belongings of a deceased patient, rather than use a plastic hospital property bag.

In Community Services

  • The trust very recently introduced a specialist nurse for childhood obesity in Lambeth in response to an identified need.

  • The Looked After Children (LAC) nurse specialist introduced an opportunistic immunisations for looked after children, which had improved the uptake of immunisations by 22% in this group of children.

  • Community services had a dedicated end of life care (EOLC) team as well as a specialist palliative care team (SPCT).

  • In community services patient's families and people close to them were given a leaflet that provided clear information about the dying process to help them understand the signs of an actively dying person, why some interventions such as taking blood pressure were stopped and what to expect in the final stages of death.

  • The trust had a diabetes information and education service. Staff provided education to newly diagnosed adult diabetic patients and an open telephone service for staff or patients to access expert advice.

  • Patients on the Amputee Rehabilitation Unit had access to acupuncture as part of their pain management plans. Patients were complimentary about this service and felt that their pain was better managed as a result of the acupuncture service.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly the trust must:

At St Thomas' Hospital

  • Improve governance links between directorates with surgical activity to ensure learning and concerns are shared across these directorates in a timely way.

  • Ensure that all women attending the maternity department receive a venous thromboembolism risk assessment.
  • Ensure that appropriate levels of midwifery staffing are available in all areas so that women are cared for in the most appropriate environment.

At Guy's Hospital

  • Improve governance links between directorates with surgical activity to ensure learning and concerns are shared across these directorates in a timely way. 

     

In addition the trust should

At trust level

  • Continue to improve governance and assurance systems and reduce the backlog of complaints and investigations into serious incidents.
  • Continue to work implement the electronic paper record and align IT systems across the services

  • Continue to ensure staff attend all mandatory training

At St Thomas' Hospital

  • Review barrier nursing arrangements within HDU and ensure the environment meets infection prevention and control guidance.
  • Ensure that the full 'five steps to safer surgery' are embedded in operating theatre practice.
  • Continue reviewing and improving cancer performance.
  • Ensure consent is clearly documented and patients are given documentation of the process. Implement the recommendations from the consent audit 2014.
  • Ensure all complaints are responded to in a timely manner.
  • Where appropriate utilise day surgery more to reduce the length of stay.
  • Address areas of the national fracture neck of femur audit where the trust is performing below the national average.
  • Ensure that staff are familiar with the mental capacity assessment process and that this is followed where appropriate.
  • Ensure all staff are aware of safeguarding principles and triggers for making a referral
  • Continue to increase consultant cover in maternity services
  • Ensure that telephone advice given to women in maternity services is documented
  • Ensure there is a system in place to check that HSA4 notifications of termination of pregnancy for fetal abnormalities are submitted to the Department of Health.
  • Consider reviewing the tools staff use to assess pain and introduce a standard methodology that is consistently used and recorded.
  • Consider reviewing the process for completing DNACPR form, determine a specific location where they are kept and ensure staff are aware they can be used as an interim measure on discharge until the primary care team can complete a new one.
  • Consider reviewing the escalation process when delays occur with the completion of death certificates.
  • Ensure all incidents in the outpatients department are investigated promptly and outcomes of the investigations recorded and shared with team to prevent recurrence.
  • In the outpatients and clinical imaging departments ensure all staff are appraised regularly as prescribed by trust’s policies related to staff training and development
  • Ensure staff are aware how to arrange for an interpreter.
  • ​Ensure that consultants review the results of local audits and implement strategies to ensure results continue to improve towards meeting CEM guidelines.

At Guy's Hospital

  • Take steps to increase the number of day surgery cases to reduce bed demand and reduce length of stay. The trust should consider introducing a named day surgery clinical lead to improve coordination of day surgery and provide a single contact for surgical directorates.
  • Take steps to improve the working culture within theatres to ensure that all theatre staff have fair access to learning and development opportunities.
  • Continue embedding and monitoring use of the ‘five steps to safer surgery’ WHO surgical safety checklist, with a particular focus on pre-briefing and de-briefing.
  • Ensure consent for surgery is clearly documented in patient records and patients are given adequate time and documentation to make decisions about their care in advance of their planned procedure date.
  • Improve engagement with lifestyles teams in tertiary, secondary and primary care to help surgery patients with smoking cessation, weight loss or exercise programmes to improve local health outcomes.
  • Review the process for completing DNACPR forms and determine a specific location where they are kept for end of life care patients .
  • Improve the consistency of mental capacity assessments and the recording of them for patients receiving end of life care.
  • Review the escalation process when delays occur with the completion of death certificates.
  • Reduce delays in 31/62 days cancer waits (diagnosis and treatment) in Outpatients.
  • In the outpatients department, ensure all staff are aware of protocols related to obtaining patients’ consent; including protocols for those who might lack capacity to make a decision”.
  • Ensure all incidents in the outpatients department are investigated promptly and outcomes of the investigations recorded and shared with team to prevent recurrence.
  • In the outpatients department, ensure all staff receive mandatory training and are appraised regularly as prescribed by trust’s policies related to staff training and development.
  • On Samaritan Ward, review the provision of toilet facilities for patients.
  • Improve mandatory training completion by staff on the medical wards/departments.
  • Improve performance on the number of patients starting treatment within 62 days for upper and lower gastro-intestinal illnesses.
  • Ensure all staff, including staff working in outpatients departments, are provided with basic life support training.

In community services

  • Improve the amount of 'patient facing time' in the health visiting service.
  • Ensure the waiting area at Mawbey Brough provides an appropriate environment for children and families.
  • Review the use of wooden baby changing tables to promote improved infection control.
  • Review the school nursing provision to ensure the full core service can be delivered to schools.
  • Ensure that interpretation services are offered to people for whom English is not their first language.
  • Take action to reduce the rate of patients who ‘did not attend’ appointments (DNA) among children’s community services.

  • Take action to improve the rate of first and second child health reviews.

  • mustEnsure that consent for care and treatment is obtained in line with national guidance.

  • When patients (aged 16 and over) are unable to give consent because they lack the capacity to do so, the trust should ensure staff

    must act in accordance with the Mental Capacity Act 2005

  • Ensure that all staff undertake training in safeguarding children at the level relevant to their role.
  • Ensure that there are systems in place to identify the cleanliness of equipment.
  • Ensure that the environment at Dulwich Hospital is suitable for purpose.
  • Review the paper and electronic records to ensure that the recordings are complete, accurate and do not contain variances and discrepancies.
  • Consider training nurses in the palliative and end of life care to verify death. This would be beneficial to the bereaved as someone closely involved in their relative/friend's death would officially verify death in a timely and sensitive manner and allow the release of the patient's body to an undertakers within an appropriate timescale.

  • The trust should ensure that all staff have a clear understanding of Deprivation of Liberty Safeguards (DoLS); that mental capacity is always appropriately assessed and recorded for patients who may lack capacity; and all staff know who can consent on the patient’s behalf and how this information should be recorded in patients’ records.

  • Consider training the CNS and EOLC nurses to be independent prescribers and allow the nurses who are trained as independent prescribers to use the skills they have.

  • Explore ways to allow patients, who are assessed as able, to self-medicate at Pulross Intermediate Care Centre.
  • Ensure patients at Minnie Kidd House have access to specialist seating assessment.
  • Ensure that all staff are up to date with their mandatory training.
  • Standardise record keeping so that staff can have access to the full multidisciplinary team  documentation in chronological order.
  • The trust should ensure that robust arrangements are in place for the management of risk.

Professor Sir Mike Richards

Chief Inspector of Hospitals


CQC inspections of services

Service reports published 24 March 2016
Inspection carried out on 7-10 September 2015 During an inspection of Community health services for children, young people and families Download report PDF | 311.21 KB (opens in a new tab)
Inspection carried out on 7-10 September 2015 During an inspection of Community health inpatient services Download report PDF | 335.81 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Community health services for adults Download report PDF | 373.66 KB (opens in a new tab)
Inspection carried out on 7-10 September 2015 During an inspection of End of life care Download report PDF | 400.81 KB (opens in a new tab)
See more service reports published 24 March 2016

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