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

On 18 December 2019, we published a report on how well St George’s University Hospital NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Requires improvement

Updated 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.
Inspection areas

Safe

Requires improvement

Updated 18 December 2019

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

  • Medical care and children and young people services did not always have enough staff with the right qualifications, skills, training and experience. However, there were mitigations in place to keep patients safe from avoidable harm.
  • Records were not always stored securely. In the emergency department, casualty cards were unsecured in the cubicles in majors. In surgery at St George’s Hospital, some patient identifiable information and do not resuscitate forms were in folders that were not marked as confidential. In the day care unit at Queen Mary’s Hospital, some records were left in persons unlocked cabinets during the day. This meant records were accessible to unauthorised persons.

  • Services provided mandatory training in key skills to all staff, however, not all staff had completed them.
  • Services did not always control infection risk well. We saw examples of staff not washing their hands between patient contact.

  • Services were dealing with an ageing estate which at times was a risk to patient safety. The trust had taken some actions to control the risk, such as filters on taps to prevent legionnaires disease and the pipework was flushed regularly to prevent leaks, but this was an ongoing challenge.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • Staff completed risk assessments for each patient swiftly. They removed or minimised risks and updated the assessments. Staff identified and quickly acted upon patients at risk of deterioration.

  • Services managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave people who used services and their families honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.

Effective

Requires improvement

Updated 18 December 2019

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

  • Some policies were out of date. This meant that staff did not have access to the most up to date evidence-based practice.

  • The number of staff who received an annual appraisal was below the trust target in many wards and departments.
  • Staff did not always monitor the effectiveness of care and treatment and did not always use audit findings to make improvements and achieve good outcomes for patients. For example, on the medical care wards, not all patients had a pain score recorded in their records, which meant staff were not able to see whether a patient’s pain score had changed after administering analgesia. However, wards used the results of their accreditation scheme to drive improvement.

  • Staff did not always record consent in patients’ records. We saw some examples in surgery at Queen Mary’s Hospital, of forms not completed in full and inconsistent recording which meant staff were not sure correct consent for treatment had been obtained.

  • Not all patients had a pain score recorded in their records. Some staff told us they did not use a pain score tool for patients and no score was recorded in their records. This meant staff were not able to see whether a patient’s pain score had changed.

However:

  • Services provided care and treatment based on national guidance and evidence-based practice. For example, they followed guidance from the National Institute for Health and Care Excellence (NICE) and Royal College of Surgeons

  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. Services made adjustments for patients’ religious, cultural and other needs.

  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.

  • Staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They used agreed personalised measures that limited patients' liberty.

Caring

Good

Updated 18 December 2019

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

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.

Responsive

Requires improvement

Updated 18 December 2019

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

  • People were not able to access services in a timely way. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.

  • Referral to treatment (RTT) data for non-admitted pathways was worse than the England overall performance. However, the trust only returned to reporting on referral to treatment data for St George’s Hospital in January 2019.

  • The trust was not meeting the emergency department national standard to admit, treat or discharge patients within four-hours.
  • The trust did not always meet their threshold for ‘did not attend’ rates. However, leaders discussed ‘did not attend’ rates at meetings and measures to improve them were considered, including texting and making phone calls to patients, prior to their appointment. .

  • The average length of stay for medical elective patients was higher than the England average.
  • Facilities and premises were designed for the services delivered. However, there were limitations on space within clinics and waiting areas, in the outpatients’ department at St George’s Hospital.

However:

  • Services planned and provided care in a way that met the needs of local people and the communities served. They also worked with others in the wider system and local organisations to plan care.

  • Services were inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.

  • Services treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. However, there was a lack of patient information displayed in some areas, on how to raise a concern.

Well-led

Requires improvement

Updated 18 December 2019

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • Most leaders had the skills and abilities to run their services. However, we had concerns that there was insufficient oversight and management of issues in surgery at Queen Mary’s Hospital, and the outpatient department at St George’s Hospital.

  • Some frontline clinical and non-clinical OPD staff were unaware of their services strategy document and were not involved in the development of the services strategy.
  • Some black, Asian and minority ethnic (BAME) were not aware of the equality network they could join.
  • Some leaders did not operate effective governance processes and n

    ot all staff at all levels were clear about their roles and accountabilities. For example, there was no clarity of who had overall responsibility and oversight of surgery at Queen Mary’s Hospital, and some senior staff in the outpatient department at St George’s Hospital, could not tell us their responsibility for the development of the service.

  • Some staff and middle grade managers were not aware of what was on their department’s risk register and arrangements for managing risks were not always clear.

However:

  • Leaders collaborated with partner organisations to help improve services for patients.
  • Staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

  • Leaders were visible and approachable in services for patients and staff.
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.

Community 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.