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Provider: St George's University Hospitals NHS Foundation Trust Requires improvement

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 19 July 2018

Our rating of the trust improved. We rated it as requires improvement because:

  • We rated safe, effective, responsive and well-led as requires improvement and caring as good. We rated three of the trust’s 13 services as good and ten as requires improvement. In rating the trust, we took into account the current ratings of the five services not inspected this time.
  • We rated well-led for the trust overall as requires improvement.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website .

Inspection areas

Safe

Requires improvement

Updated 19 July 2018

Our rating of safe improved. We rated it as requires improvement because:

  • There was variable adherence by staff to infection prevention and control procedures.
  • Patient records were not always accurately recorded or stored securely and separate recording systems meant there could be difficulty in accessing records when patients moved between wards.
  • Several clinical areas on the St George’s Hospital site were in need of significant improvement and maintenance.
  • Equipment was not always available for use and there were delays in equipment being repaired.
  • Safeguarding assessments for children and adults in accident and emergency were not always completed.
  • Proving holistic care to patients living with mental illness was in need of improvement.

However:

  • Managers investigated incidents and shared lessons learned to their respective teams to prevent them happening again.
  • Staff were managing the risks to patients well. Staff monitored changes in the patients’ conditions using nationally recognised systems and escalated deteriorating patients. The majority of patients had risk assessments completed and reviewed regularly from admission to discharge.
  • Staff were aware of Duty of candour and were able to give examples of when they had displayed this with patients and relatives.
  • Medicines were stored securely and staff followed appropriate procedures for controlled drugs.
  • At St George’s Hospital, progress had been made to ensure outpatient records were tracked and could be located for clinicians.

Effective

Requires improvement

Updated 19 July 2018

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

  • Staff had limited knowledge of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) in many areas and we found staff did not always complete the required documentation fully or consistently. This was similar to what we found at the previous comprehensive inspection.
  • Staff appraisal rates were below the trust’s target in many areas.
  • The trust preformed worse than the national average in respect of the proportion of patients receiving surgery on the day of or day after admission.
  • St George’s Hospital was in the bottom 25% of trusts in terms of the proportion of patients not developing pressure ulcers.
  • St George’s Hospital performed worse than the national average of Patient Reported Outcomes Measures (PROMS) in respect of groin hernias, varicose veins, hip replacements and knee replacements.
  • Pain scores tools were not consistently completed and records demonstrated that timely pain relief was not always administered. We found this was similar at the last inspection.
  • There was a lack of local clinical audits and information on patient outcomes in some areas.

However:

  • Multidisciplinary team (MDT) working was well established in the organisation and formed an integral part of patient care.
  • Many areas provided care and treatment based on national guidance. There was strong evidence of a good education and research culture within the cardiac investigation unit and the therapies department.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.
  • Most patients received clear explanations before and after procedures.

Patients were cared for by appropriately qualified staff. Nurses had gone through an induction and achieved specific competencies before being able to care for patients independently. Medical staff received regular training as well as support from consultants.

Caring

Good

Updated 19 July 2018

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

  • Staff were observed to be caring, compassionate and attentive in their interactions with patients.
  • Feedback from patients was overwhelmingly positive and confirmed staff treated them with dignity and compassion.
  • Patients told us staff respected their needs and most patients felt involved in their care.
  • Staff took time to ensure patients and their families understood the treatment.
  • Children and young people, as well as their families had access to counselling services and psychological support.
  • Staff communicated with patients and those close to them in a way they could understand and took time to answer their questions.

However:

  • There were instances where patients’ privacy and dignity were compromised within the emergency department, the infusion suite in the outpatients department at St George’s Hospital and the Frederick Hewitt paediatric ward.

Responsive

Requires improvement

Updated 19 July 2018

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

  • Referral to treatment data was still not being reported to NHS England. An external review of the data quality in June 2016 identified that patients were not being treated in chronological order, as a result of a high number of unknown start times of a patient’s referral journey. In addition, the trust’s Elective Care Recovery Programme (ECRP) identified a large number of patients where the trust cannot say with certainty that they had been treated or were at the correct stage of their pathway.
  • There were increasing numbers of medical patients being cared for on surgical wards and this continued to be a challenge for the trust.
  • The Department of Health and Social Care accident and emergency standard for 95% of patients to be admitted, transferred or discharged within four hours, was consistently not met between January 2017 and December 2017.
  • The trust consistently failed to meet the Royal College of Emergency Medicine recommendation that the time patients should wait from time of arrival to receiving treatment was no more than one hour.
  • The monthly median of the percentage of patients leaving the trust’s urgent and emergency care services before being seen for treatment between January to November 2017 was worse than the England average in five out of 11 months.
  • The trust performed consistently worse than the England average in terms of the percentage of patients who were not treated within 28 days after a cancelled operation. Whilst there had been an improvement in the first quarter of 2017/18 (April to June 2017), there was a deterioration in the second quarter.
  • Most clinics in the outpatients department at St George’s Hospital overran due to the high demand for clinic slots, meaning patients waited longer than they needed to for their appointment. Waiting times were not always displayed in a way that was accessible to less mobile patients.
  • The system for booking appointments varied and caused confusion amongst patients.
  • The system for blood testing in Lanesborough Wing at St George’s Hospital was unclear meaning most patients queued for the reception desk to report for their blood test. This caused long queues.

However:

  • The trust had made changes designed to improve patient flow since our last inspection.
  • Translation services were available when needed. A patient we spoke with told us he had been supported with his diet and prayer needs.
  • From January 2017 to December 2017, only three of the trust’s patients waited more than four hours from the decision to admit until being admitted. The trust’s performance for this metric was much better than the England average.
  • The service ran ad hoc clinics to try and meet breach dates and ran clinics on Saturdays when there was a high demand.
  • The specialist seating service provided extra equipment such as adding a box for a patient with a complex posture to put a bottle of water and their mobile phone inside without the patient asking for it.
  • Children and young people had access to same day and next day clinics. GPs could obtain advice from paediatricians via a hotline.
  • Children and young people had access to interpreting services so that they could make decisions about their care.
  • The hospital school was rated as ‘outstanding’ by Ofsted and teachers at the school provided educational and learning support to children and young people across the hospital.
  • There was a discharge co-ordinator nursing team within the directorate who worked with local authority and community nursing colleagues for complex discharges.
  • There were a range of support teams available including dementia, learning disability and mental health liaison to meet patients’ individual needs.
  • There was access to face to face and telephone translation services and patient information leaflets could be accessed in languages other than English upon request.
  • The trust had introduced an automatic text or phone reminder system which had reduced the Did Not Attend rate by approximately 7%.

Well-led

Requires improvement

Updated 19 July 2018

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

  • The trust had an Elective Care Recovery Programme as well as a Clinical Harm Reduction Programme which were progressing. However, as RTT was still not being reported, the trust was not assured about the identification and treatment of patients referred to them.
  • In the ED at St George’s Hospital, staff lacked an understanding of mental health and did not know how to care for patients who were experiencing psychotic symptoms.
  • Some risks were not being dealt with in a timely way and not had associated actions. The risk register for community services did not fully reflect the risks on the ward’s risk register and some of the ward risks lacked suitable assurances in place.
  • The Queen Mary’s Hospital site required greater oversight of the quality and safety of care provided on some areas.
  • There remained no overall strategy for the services for children and young people.

However:

  • Some areas had clear leadership structures and vision for their services.
  • There was a governance structure to support the delivery of care and treatment and staff at different levels were clear about their roles and responsibilities.
  • Managers could articulate some of the challenges caused by the continuing operational pressures, and the impact this had on the quality and delivery of sustainable services; however, they had plans in place to mitigate risks or address challenges.
  • Staff morale was generally good across in many services.
  • Staff had access to the relevant information systems such as the incident reporting system and policies available through the intranet. Information was shared with staff through newsletters, email and ward meetings.
  • Children and young people were engaged thorough surveys and feedback forms. Children were also engaged in various projects to design logos and to raise money for charities. Paediatric ED nursing staff were interviewed by a children’s interview panel as well as going through a normal recruitment process.
  • A Queen Mary’s Hospital Clinical Partnership Meeting ensured all clinical staff involved with the hospital could meet to discuss quality and development.
Checks on specific services

Community health services for children, young people and families

Requires improvement

Updated 1 November 2016

Overall we rated services for children, young people and families (CYP) as ‘Requires Improvement’.

We rated safe as requires improvement because:

  • Staff were not consistently given feedback from managers about incidents, and learning from incidents was not disseminated.
  • We found a drug cupboard unlocked which contained oral contraception. Staff told us this had happened before and there was no spare key to lock the cupboard at the time.
  • Staff were referring to out of date safeguarding policies and safeguarding provision was on the care group risk register due to staff shortages.
  • Records were not always available to staff in a timely way due to significant IT issues.
  • We found a number of sharps bins that were not stored correctly.
  • However, staff had a good awareness of safeguarding concerns and there were good escalation processes in place.
  • Staff worked with a number of high risk groups and followed a robust lone working process.

We rated effective as good because:

  • Peoples’ care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. A number of audits monitored compliance against guidelines.
  • There were good examples of inter-professional and multi-agency working.
  • Staff reported good access to supervision on a regular basis. For example, staff within the family nurse practitioner service had weekly supervision.
  • Staff followed Gillick competence and Fraser

    guidelines to ensure people who used services were appropriately protected. Staff had a good understanding of consent. People using services told us staff asked for consent before carrying out any treatment.

  • There were some good examples where technology had helped improve services. However access to information in a timely way was affected by IT issues.
  • Access to training for professional development was limited due to financial constraints.

We rated caring as good because:

  • Staff across services for children, young people and families were professional, compassionate and caring.
  • We observed staff communicating with children, young people and families in polite and courteous ways.
  • Patient feedback about staff was very positive. People we spoke with said staff were caring, respectful, understanding and supportive.
  • Staff treated children, young people and their families with dignity, respect and in age appropriate ways.
  • Those using services received information about their care. They felt involved in their care and treatment.

We rated responsive as good because:

  • We found services were responsive to the needs of the local population.
  • There was good access to provision across the different locations.
  • Staff communicated with children and young people in ways that met their needs and involved them in making decisions about their care. For example, staff used a pictorial exchange communication system for children with communication difficulties.
  • There was a good understanding of different cultural needs of patients and access to interpreter services in a range of different languages.
  • However, some mothers told us there was no private space to breastfeed in some clinics.
  • Some parents told us staff did not provide them with information on how to make a complaint and were unsure of the process.

We rated well led as requires improvement because:

  • There was a trust wide strategy in place but staff were unable to tell us the strategy for children and young people’s services.
  • Issues with the electronic patient records system in the community and been raised a number of times and there was no action plan to address this. Some staff told us the trust had mentioned providing laptops. At the time of our inspection none had been provided to staff.
  • Staff said that executive managers were not visible within community services and community staff felt very separate from the trust.
  • Staff said that in their opinion, the acute services were the main focus of the trust and they were forgotten in community services.
  • However, there were some good examples of service development, such as the transgender sexual health service, perinatal mental health champions and breast feeding champions.
  • Staff felt well supported at a local level and by community services managers.

Community health inpatient services

Requires improvement

Updated 19 July 2018

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

  • Nursing staffing shortages on Mary Seacole Ward were having an impact on patient care. Staff were unable to meet the needs of patients, particularly patients requiring one to one care.
  • There were a number of vacancies in the nursing management on Mary Seacole Ward and there was a lack of leadership for the staff. While cover arrangements were in place, leadership arrangements lacked stability and clarity and shortages meant there was limited time for senior staff to cover managerial duties.
  • Patient records on Mary Seacole Ward were inconsistent. Fluid balance charts were incomplete and hydration recording was incomplete meaning patients were at greater risk of dehydration and urinary tract infections.
  • Services were not meeting the trust target for basic or intermediate life support training. This meant that there was a risk that not all staff had the skills needed to respond to patients requiring life support.
  • Medicines on Mary Seacole Ward were not always managed in line with best practice. Some controlled drugs had their labels obliterated by a pen and the medicines resource folder in the room contained out of date policies which could increase the risk of incorrect medication or staff not following correct trust guidelines.
  • Overall appraisal completion rates were low and below the trust target of 90% for Mary Seacole Ward. This meant that managers were not supporting all staff to deliver effective care and treatment or giving staff opportunities to discuss development.
  • Best practice guidance was not always being followed. Inconsistency of patient records on Mary Seacole Ward meant that patient needs were not being accurately recorded and best practice guidelines not followed.
  • Morale on Mary Seacole Ward was low among some staff groups. Staff described feeling a lack of acknowledgement of the pressures on the ward and did not feel their concerns were being addressed.
  • The risk register for community services did not fully reflect the risks on the ward’s risk register and some of the ward risks lacked suitable assurances in place.

However:

  • Improvements had been made on Gwynne Holford Ward since the previous inspection. Leadership had stabilised and staff felt supported. Staff were engaged and there was a clear management support structure in place.
  • Multidisciplinary team (MDT) working was well established on both wards and formed an integral part of patient care. Both wards had comprehensive multidisciplinary assessments for patients, care was patient centred and there was a holistic approach to treatment.
  • There was a strong ethos of continuous learning and improvement on Gwynne Holford Ward. Staff were engaged and supported to contribute to service improvement and we saw several examples of innovative approaches and practices.
  • Staff actively involved patients and their family in their treatment. Patients spoke positively of the staff and the care which was provided and described staff as supportive, friendly and compassionate.
  • Staff understood how to report incidents and feedback was shared with staff. Safety performance was regularly reported on and clearly displayed on both wards.

End of life care

Inadequate

Updated 1 November 2016

We rated community end of life care services as inadequate because;

  • The trust did not have a strategy for the delivery of community end of life care services. The lack of such a strategy could have a negative impact on the quality of end of life care and future service improvements.

  • There was no end of life care strategy that described the priorities for the trust as an integrated organisation. There was no trust-wide community and acute multi-disciplinary meeting.

  • There was no overall vision for community end of life care services.

  • Systems or processes were not sufficiently established or operated effectively to ensure the trust was able to assess, monitor and improve the quality and safety of community end of life care services or to identify and manage risk.

  • There was no embedded replacement for the Liverpool Care Pathway (LCP) that had been discontinued in July 2014 following national guidance from June 2013.

  • Community nursing staff did not always feel included in decisions about service changes and felt disconnected from the acute trust. However, they felt supported by their local team leaders.

  • There was inconsistent end of life care training for community nursing staff with some staff having received training in end of life care while others had not.

However;

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

  • Patients were treated with dignity, kindness and compassion and there was consistently positive feedback from patients and their relatives about the service.

  • Staff worked hard to ensure that patients at the end of life were given the support that they needed, including staying beyond the end of their shift to make sure patients had in place what they needed.

We rated safe as requires improvement because;

  • The community nursing staff did not always have the end of life care knowledge, skills or experience for their roles caring for end of life patients in the community.

  • There was insufficient IT equipment available to meet the needs of the service.

  • Community nursing staff told us they could visit patients with two staff if a risk had been identified. However, they did not always have sufficient numbers of nursing staff available to undertake such visits.
  • Patients’ level of dependency was not measured as there was no analysis of the types and details of care the community end of life patients received from the community nursing team.
  • Staffing levels and skills mix were not reviewed regularly to ensure patients received safe care and treatment at all times.

We rated effective as inadequate because;

  • The community end of life care was not consistently provided in accordance with national guidelines. There were no individualised plans of care specifically for community end of life care patients in the last phase of life that were based on national guidance or evidence based care and treatment.
  • There was no replacement of the Liverpool care Pathway (LCP) following its removal from use in June 2013. Moreover, there were no audits or quality monitoring of patient outcomes in the community end of life care services.
  • Community nursing team responsible for end of life care had not fully implemented the five core recommendations for care of patients in the last few days and hours of life as set out in the Department of Health’s End of Life Care Strategy 2008. The community nursing team had not implemented recommendations of ‘One chance to Get it Right’ document published by the Leadership Alliance for Care of the Dying People 2014.
  • There was no involvement of the physiotherapy, occupational therapy, dietitian, counsellor or chaplaincy services in provision of community end of life care services.
  • A training needs analysis for core end of life training had not been carried out in 2015 to identify the training needs for community nursing staff working in the community.

We rated caring as good because;

  • We observed community nursing staff caring for end of life care patients in their own homes with dignity, respect and compassion. Community nurses treated patients gently and checked their comfort at various stages of care and treatment. Families and relatives we spoke with told us staff were caring and had provided them with emotional support and kept them informed about their loved one’s care and treatment.
  • Community end of life care patients we spoke with and those close to them told us they were encouraged to be involved in their care. They told us they were routinely involved in decision-making and felt they had sufficient information to understand their treatment choices.

We rated responsive as requires improvement because;

  • Due to the shortage of experienced and skilled community nursing staff, the community end of life services were planned simply to get round those patients that needed basic nursing care using newly qualified and agency nurses.
  • There was no engagement between the acute end of life care team and community nursing team to plan and deliver an integrated end of life care service for patients. There was no equality and diversity champion within community nursing services to support staff.

We rated well-led as inadequate because;

  • There was no overall vision for community end of life care services. The corporate management was not effectively managing and monitoring the community end of life care service.
  • Community end of life care had no influence within the acute management structure and there was a lack of both strategy and resources which compromised the service’s sustainability.
  • Systems or processes were not sufficiently established or operated effectively to ensure the trust was able to assess, monitor and improve the quality and safety of community end of life care services. There was no governance structure which supported community end of life care services.
  • All community nursing staff felt confident about speaking up and raising concerns with their line managers. However community frontline managers felt their voice was not heard by senior management in the trust. Most of the staff we spoke with in different roles, although committed to their patients felt disconnected and undervalued by the trust.

Community health services for adults

Good

Updated 1 November 2016

We rated this service as good because:

  • There were appropriate risk assessment and monitoring process to ensure that patients were safe when using the service.
  • Treatment was planned and delivered in line with national guidelines and the outcomes of this were monitored.
  • Staff were kind and caring towards patients and made sure that people understood the care and treatment they were receiving. The patients and their relatives that we spoke to confirmed this.
  • There were innovations being planned and underway to improve the quality of services people received through better team work and greater integration of services.
  • Local teams worked well internally and with each other and there was a culture of staff providing safe, high quality healthcare to patients.

However:

  • Improvements were needed to the record keeping systems to ensure that all staff had access to the right systems and at the right time – and remote access should also be considered.
  • Staff vacancy rates meant that adjustments to when patients were seen were often needed, staff had to actively manage these risks and the service was heavily reliant on bank and agency staff.
  • Staff within the service did not feel connected to the Trust as a whole and there was limited leadership or strategic direction from the senior Trust team.

We rated this service as good for safety because:

  • People underwent appropriate risk assessments when they first started using the service and their safety was monitored throughout.
  • Staff knew how to keep people safe from abuse and what to do if they had any concerns about patients.
  • Staff received appropriate mandatory training in a range of topics.

However:

  • Not all lessons learnt from incidents were shared across different teams.
  • Multiple record systems were used and access was not always available to all, meaning important information might not always be available to relevant staff.
  • Staff vacancy rates meant the service was heavily reliant on bank and agency staff in some areas and the service had to regularly rearrange its programme of work to adjust to staff absences and manage patient risk.

We rated this service as good for effective because:

  • Staff followed up-to-date national guidance when providing care and treatment and monitored the outcomes of treatment.
  • The multi-disciplinary teams worked well together involving a full range of professionals in people’s care and treatment.
  • Staff had a good knowledge of the Mental Capacity Act as well as what actions to take if they were concerned about someone’s capacity to make a decision.

However:

  • Staff’s access to patient information was limited at times and a lack of remote working technology had a significant impact on the efficiency of the service.
  • Workload pressures and a lack of suitably trained staff could result in clinical supervisions not taking place or being delayed.

We rated this service as good for caring because:

  • We observed staff providing care and treatment in a kind, considerate and caring fashion.
  • The people we spoke with and their families described staff as “friendly”, and “very nice”.
  • All of the patients that we spoke with said they understood their care and treatment and we observed staff providing these explanations.
  • In written feedback patients rated the service highly in terms of the way they were treated by staff as well as understanding their care and treatment.

We rated this service as good for responsive because:

  • There were numerous initiatives underway to alter and redesign the model of care being provided to better support the needs of people using the service and provide better outcomes.
  • Arrangements were made so that people whose first language was not English or who had communication difficulties were supported when in contact with the service.
  • Complaints were responded to appropriately within set time scales.

However:

  • Whilst staff actively worked to minimise patient risk, the staff vacancy levels meant that low risk patient appointments were often rescheduled and at previous time significant waiting lists had built up for some services.

We rated this service as requires improvement for well-led because:

  • Whilst there were examples of local leadership there was limited evidence for any overall strategy for the service from a trust level.
  • There were concerns expressed by staff over recent changes to working patterns, duties and rising workloads. These concerns were expressed across several teams and were having a significant effect on staff morale in certain areas.
  • Staff in general did not feel connected to the Trust as a whole and felt that the community services in general did not receive appropriate focus or consideration on a senior trust level.

However:

  • There were numerous local initiatives in place and being planned to improve the quality of the service which were in line with NHS Strategic priorities to further integrate services and achieve efficiencies.
  • Service level staff and teams were dedicated to providing high quality, safe, compassionate care for patients, as well as working as a team and helping each other where needed.