18 December 2019
St George’s University Hospitals NHS Foundation Trust is a teaching trust with two hospital locations; St George’s Hospital, Tooting, and Queen Mary’s Hospital, Roehampton.
The main acute site is St George’s Hospital, which provides general and specialist services including PPCI, HASU and Major Trauma Centre and has an emergency department. Queen Mary’s Hospital does not have an emergency department, but it does have a Minor Injuries Unit.
St George’s University Hospitals NHS Foundation Trust has 1,083 beds; 995 at St George's and 88 at Queen Mary's. The beds at St George's Hospital comprise of 871 general and acute, 67 maternity, 57 critical care. The beds at Queen Mary's Hospital comprise of 46 for people with limb amputations who require neurorehabilitation and 42 for sub-acute care, treatment and rehabilitation of older people. The hospitals are both in the London Borough of Wandsworth. The lead clinical commissioning group is Wandsworth, who co-ordinates the commissioning activities on behalf of the other local clinical commissioning groups such as Merton and Lambeth.
The trust serves a population of 1.3 million across south west London. Several services, such as cardiothoracic medicine and surgery, neurosciences and renal transplantation, also cover significant populations from Surrey and Sussex, totalling around 3.5 million people.
The number of staff employed by the trust as of May 2019 was 8,932 staff.
The trust was had been in Quality Special Measures since November 2016 and Financial Special Measures since April 2017.
18 December 2019
Our rating of the trust stayed the same. We rated it as requires improvement because:
- We rated safe, effective, responsive and well-led as requires improvement. We rated caring as good. We rated one of the trust’s 12 core services across two locations as outstanding, three as good, six as requires improvement and two were not rated. 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.
24 April 2014
Overall, we found that services provided to adults with long-term conditions were safe, effective, caring, responsive and well-led at a local level.
Staff were aware of adult protection and safeguarding. Staff reported serious incidents or concerns and the trust had good systems and processes in place for recording these. There was less clarity on how learning from safeguarding, incident reporting and complaints was disseminated down to an individual community team level. Processes for communicating with the clinical team leader level were in place.
The delivery of care and treatment was based on guidance issued by appropriate professional and expert bodies and a number of care pathways were in use. We saw that staff were involved in monitoring and assessing the quality of care, including the development of guidelines and protocols. We saw and heard evidence of innovation and a proactive approach to performance improvement at local level.
Staff demonstrated a caring approach. Patients and relatives spoke highly of the care they had received. We saw staff delivering care that was compassionate, planned according to people’s individual needs, and which focused on encouraging patients to maintain their independence.
We found the service was responsive to patients’ needs as well as to feedback from patients and relatives. Cascade of learning following review of feedback between teams was not conducted as a matter of routine.
The majority of staff understood the requirements of the Mental Capacity Act 2005, although there was little evidence of recently updated training. Staff were able to demonstrate an understanding of the care needs of a person living with dementia. Dementia training was not included in the provider’s mandatory training programme and we could find evidence of very few community staff having received such training.
The services provided to patients with long-term conditions are well-led at a local level, although escalation and reporting of risk above service level required further development. Staff had clearly defined roles and responsibilities and there was a sufficient skills mix to meet the care needs of people with long-term conditions. There was a mostly open culture locally where staff felt able to raise concerns and know that they would be acted on.
Some staff told us that they felt isolated from the acute hospital, while others felt well integrated. All staff we talked with expressed concerns about the lack of an integrated IT system and prompt support for IT issues in the community. While this did not impact on the care patients received it was frustrating for staff.
24 April 2014
We found the service provided by St George’s Healthcare NHS Trust, community health services for children, young people and families was good.
The safety of children and families was promoted through the proactive approach of the community teams and the staff having a clear understanding of their responsibilities in relation to safeguarding and child protection. There were good systems for ensuring that risks were responded to through partnership working with other agencies in order to protect children and ensure that concerns were dealt with through a multidisciplinary approach. Learning from incidents took place and actions were implemented to improve practice and the safety of the children and families.
The services were effective in working with partner agencies in the long-term care of children and families to ensure that children received the care and support they needed near to their home. The health centres were located throughout the borough and provided clinics at different times to allow people to access services at a time that suited them. Staff were supported in their work and followed best practice guidance. However, information relating to staff training was inconsistent and did not give an accurate record of the training received. Some staff within the family planning services were not aware of their responsibilities within the Mental Capacity Act 2005.
The children and families services were caring and people were involved in identifying their needs and the support they required from the service. People were treated with dignity and respect, and we observed that professionals confirmed people’s understanding of treatments offered and any risks involved. All staff conveyed a clear understanding of supporting the whole person, and taking into account their emotional and social situations, as well as physical and medical needs.
Specialist services had been developed in response to the needs of the local population, and to emerging needs that were specific to the area. Services across the health centres were accessible to all people living within Wandsworth, with efforts made to promote the services to specific groups that did not make use of the services available, or did not attend appointments. However, the trust did not routinely monitor the diversity of people who used the community services, and information in other formats or languages was not always available for people to access.
The children and families’ services were well-led. The governance arrangements of the trust ensured that monitoring of the community services took place. There were clear management structures in the community services and staff felt well supported by their local line management. However, the majority of staff we spoke with felt detached from the trust and that there was a lack of senior management presence in the community services. Similarly, the IT systems in use across the community services did not link up with to each other, which meant that important information about children and families could be missed. This did not impact on patients care but was frustrating for staff.
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.
- 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.
- 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.
- 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.
- 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.
- 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.
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.
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.
- 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.
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.
- 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.
24 April 2014
There were arrangements to enable safe practice across the outpatient services. There were clear arrangements in place for infection control.
Care and treatment was evidence-based and achieved good outcomes for people, enabling them to have a good quality of life. People were treated with kindness and respect and were supported to be make choices with regard to their care.
Overall the service was responsive to people’s needs but facilities for children should be improved in the orthotics clinic. The outpatients department was well-led with high levels of patient and staff satisfaction.
24 April 2014
There were arrangements to enable safe practice in day surgery services and for infection control.
The service was effective and their work based on evidence-based practice. The unit has achieved accreditation with the Joint Advisory Group on Gastrointestinal Endoscopy which assesses quality of practice in patient care, quality and safety and staff training.
Staff in the unit were caring and patients felt they had been well looked after. Management practices within the unit are good and staff felt supported. At a wider organisational level there is fewer acknowledgements of their achievements.
24 April 2014
We found that the minor injuries unit (MIU) at Queen Mary’s Hospital provided an efficient and effective walk-in service to patients who attended with minor injuries. The service had robust internal auditing procedures which ensured that the environment was clean and hygienic. Medication was stored appropriately and the service was run efficiently. However staff were unclear as to the
Patients attending the minor injury clinic were provided with information about their treatments and given comprehensive information verbally and in written form to take away with them. Patients who attended the unit told us they felt it was a good service and that they were treated with respect. The service was working to current National Institute for Health and Care Excellence (NICE) guidelines and had procedures in place to ensure that clinical information was current.
We found that services were well led and that the unit interacted well with the other services at Queen Mary’s Hospital. However we were told that here was less interaction of this service with the main A&E service at St George’s Hospital due to the location of the unit and the type of service which was provided. However this did not impact on the good service this unit provided to its patients.