St George's University Hospitals NHS Foundation Trust

St George's University Hospitals NHS Foundation Trust is a combined health care service. The trust provides secondary and tertiary acute hospital services and community services to the local population. The trust employs around 8,500 WTE staff and serves a population of 1.3 million across Southwest London.

Change in rating

• This trust had been rated good overall in a 2014 CQC comprehensive inspection. This most recent inadequate rating reflects a marked deterioration in the safety and quality of some of the trust services as well as to its overall governance and leadership.
• It is important to note that at the time of the inspection, the trust had introduced a range of supportive and recovery mechanisms as a means of stabilising the organisation. An interim chair and chief executive had been appointed to offer the organisation direction and to develop a robust and deliverable recovery plan. A number of interim appointments had been made to ensure there was a leadership which was able of delivering on the organisations' recovery plan. The executive team were clear about the challenges they and the trust faced and acknowledged the need for significant improvement across the board. Key substantive appointments had been amde to the non-executive board which included the appointment of individuals with significant experience in regards to improving patient safety.
• Whilst we have rated the trust as inadequate overall, we noted good care in several areas and some outstanding practice in maternity for which clinical and support teams should be commended. 
• We issued a letter of intent proposing to take urgent enforcement action under Section 31 of the Health and Social Care Act, 2008 due to the state of disrepair of some buildings at St George’s Hospital. In response, the trust took appropriate action and therefore no enforcement action was pursued in that instance. We did however issue a Section 29A Warning Notice to the trust for breaches in regulations related to safe and fit premises at St George’s Hospital, obtaining consent under the Mental Capacity Act, 2005, good governance and the fit and proper person requirement.

• Contributing factors for the deterioration in the trust’s overall rating include, neglect of maintenance of its buildings; failure to ensure the requirements of the fit and proper persons regulation had been implemented; and a leadership culture which was weighted towards trying to achieve financial stability which inadvertently impacted on the quality of services being provided.
• Members of the executive and non-executive recognised that an attitude of ‘learnt helplessness’ existed across the organisation. Both the Chairman and Chief Executive recognised the need to improve staff engagement, to develop a long term sustainable vision and strategy for the organisation and to re-introduce accountability and strong leadership across all divisions within the trust.

Safe

• Several areas of the hospital’s estate were in a state of disrepair. There was water ingress during heavy rain to several areas we visited. Work had commenced to repair some of the affected areas, but the huge backlog, meant that this would take a significant level of investment and time to resolve.
• Heating and power failures which had previously affected one medical ward remained on the risk register and had not been fully resolved however some mitigating action was in place.
• A number of operating theatres were not fit for purpose. Staff implemented contingency plans which included the elective closure of operating theatres when electrical faults or unsafe temperatures posed risks. Sixteen of the 31 theatres needed to be completely refurbished. Since the inspection, we have been told by the trust that the refurbishment of theatres 5 and 6 has been completed.
• There were poor fire detection systems and poor fire separation provision in Lanesborough Wing, St George’s Hospital. Following the inspection, St George’s Hospital was inspected by the Fire Safety Regulation Department and issued with a compliance level 1 with ‘verbal action’. 
• Due to ageing infrastructure, there was a risk of water contamination, specifically legionellosis. The risk of contamination was increased because of insufficient flushing of low-use water outlets. Ward staff were not routinely submitting evidence to demonstrate they had flushed water outlets as was required by trust policy. There was limited evidence to suggest that individuals or divisions were being held to account for this omission. The trust took action following the inspection to ensure that routine flushing of water outlets took place.
• The ED was not large enough for the current throughput of patients and modern standards, which meant that in some areas, privacy and dignity of patients was compromised. The environment was old and this meant that some areas looked dirty, despite regular cleaning. Many parts of the department were extremely hot and uncomfortable.
• Children and young people with mental health conditions were cared for on Frederick Hewitt Ward, but an environmental risk assessment had not been carried out to identify ligature points and other risks to their safety.
• The storage of equipment and fluids in the ED within the major incident cupboard was unclear and created confusion about what was training equipment and what was ‘live’ equipment.
• Mandatory training completion by staff was low in many areas.
• Many staff were trained in safeguarding adults and children and there were policies and processes in place for them to follow. However, 53% of medical staff working with children and young people had not completed level three safeguarding training, which is a requirement for all staff working with children. Safeguarding training was identified as a risk on the services risk register. Access to training was a problem; there was no dedicated trainer and no safeguarding supervision for staff.
• There was variable adherence to infection control procedures and some medical and surgical staff ignored challenges from colleagues.
• There were several examinations where radiographers gave contrast to patients despite PGDs not being in place. Also, the serial numbers of prescriptions (FP10’s) for prescribers were not always monitored for use in some outpatient clinics. Apart from these, medicines were largely stored and managed appropriately.
• There were instances where care records were not stored securely, increasing the risk of unauthorised access. Otherwise, records were well documented with fully completed care plans and legible entries that had been signed by the relevant staff member.
• Medical and nursing cover across the hospital was generally good, apart from in the paediatric wards.
• Most staff knew how to report incidents and there was evidence of learning from incidents being shared as well as changes to improve practice being made.

Effective

• There was a lack of formal mental capacity assessments and best interest decision making as required under the Mental Capacity Act, 2005 and some patients had decisions made for them that they were capable making themselves. This existed both at St George’s (acute) and Queen Mary’s (community) Hospitals. For example, on some medical wards, bed rails to prevent falling out of bed and mittens to prevent pulling out of nasogastric tubes, were used on patients, who had not given their consent, nor had mental capacity assessments.
• 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. Moreover, there were no audits or quality monitoring of patient outcomes in the community end of life care services.
• There was no replacement of the Liverpool Care Pathway (LCP) following its removal from use in June 2013 and the community end of life care team was not consistently delivering effective care in accordance with national guidelines or evidence based care. There was however, treatment based on evidence-based guidance in several other areas.
• The Nursing Daily Evaluation Last Hour and Days of life document was a prompt sheet that was not backed up by either assessment or evaluation tools.
• Pain was assessed and patients told us their pain was managed well. However, pain relief was not always documented in records and there could be a delay to administration of analgesia when patients arrived within the department.
• Information technology issues impacted on staff’s timely access to information and as a result records were fragmented in some areas.
• There had been improvements in the appraisal process for nursing staff, but there were limited opportunities for training and development.
• Most areas participated in national clinical audits and patient outcomes were measured. Many clinical areas showed positive results, particularly maternity and surgery.
• Outcomes for renal patients in relation to survival rates and transplantation were excellent and were amongst some of the best in the country.
• A strong obstetric team focused on effective intrapartum care and staff used innovative and pioneering approaches to care with excellent outcomes. The maternity service was achieving year on year reductions in emergency caesarean sections.
• The maternity unit was strong in fetal medicine and had done pioneering work in non-invasive testing.

Caring

• Staff delivered care in a kind and professional manner.
• Although we observed and received some very positive reports of staff’s kindness and caring attitude to patients, we also received some reports from patients about a lack of empathy from staff and poor communication.
• Patients were largely treated with dignity and respect.
• Most patients were positive about the care that they had received from staff and the way they had their treatment explained to them.
• Feedback from survey results showed high levels of satisfaction by patients and relatives with most of the services provided.
• There was sensitive support in place for bereaved parents of children.

Responsive

• The service had consistently failed to meet the ED four hour target for the last year and had only recently made changes involving all departments to reduce the time in the department and improve adherence with the target. There had begun to be some improvement in performance against the four hour target.
• The trust had to temporarily cease national reporting of the RTT data. This was because, they could not guarantee the data they were reporting was robust and accurate.
• People were not able to access services for assessment, diagnosis or treatment when they needed to. The trust was not meeting national waiting times for diagnostic imaging within six weeks and outpatient appointments within 18 weeks for the incomplete pathways.
• The trust was not meeting the urgent two week referral target for patients with suspected cancer and cancer waiting times on the whole were variable across the targets.
• Follow up appointments were not always made in a timely manner and ‘Did Not Attend’ rates were higher than the England average.
• Theatres were unable to meet demand. Cancellation of operations were frequent and some of these were not rebooked within 28 days.
• Bed occupancy levels in surgical wards were higher than the England average, with a steady increase over 2015.
• Patients sometimes had to wait for tests because of demand on ultrasound and MRI scanners.
• There were a significant number of patient moves at night, between the hours of 10pm and 6am, which caused disruption and anxiety to some patients.
• Although a hospital passport had been completed for patients with a learning disability, their care plans were not adapted to take account of their individual needs.
• Care of people living with dementia was variable. The butterfly scheme existed but the Dalby Ward environment had not adapted to meet the needs of people living with dementia.
• There was not always a systematic approach to the management of actions and learning from complaints.
• Interpreters were sometimes used when patients were consenting to treatment and did not understand English, but at other times staff relied on relatives to interpret.
• Not all women currently received continuity of midwife care.
• There had been delays in access to some gynaecology clinics and procedures, although reductions had been achieved over the previous three months by running extra clinics.
• The curtains used to screen the beds on at least four of the medical wards did not always preserve people’s privacy.
• Some patients were unhappy with having to use of disposable utensils and plastic beakers.
• Parents were informed via text, when their child came out of theatre following surgery.

Well-led

• Leadership across several departments was weak, with many longstanding problems failing to be addressed within a timely manner. There was a lack of strategic direction for some of the services from the top of the organisation.
• We found a reactive rather than proactive approach to risk and environmental safety.
• The lack of multidisciplinary team meetings (MDT) with colleagues from medical and surgical departments and other allied health professionals was an area of concern.
• An external review of Referral To Treatment (RTT) data quality at St George’s University Hospitals NHS Trust (June 2016) found that due to a high number of unknown start times of a patient’s referral journey, patients were prevented from being treated in chronological order. The trust was also inconsistent in achieving their two week targets for patients with suspected cancer. 
• Following the inspection, the trust wrote to NHS Improvement and NHS England, to confirm their intention to temporarily cease national reporting of our RTT data. This was because, they could not guarantee the data they were reporting was robust and accurate. The trust was taking action to proactively resolve the issue and was seen to be working with commissioners and external agencies in a collaborative way to ensure timely and robust resolution.
• The risk register in several divisions, did not fully document all risks identified across the departments and mitigating actions were not always sufficient to address risks. Actions taken to mitigate the risks were insufficient and timescales to fully address the risks were unclear.
• Some staff felt able to approach their senior management team and felt well supported by their senior clinical staff. However, staff working with children and young people did not receive feedback from their appraisals and felt support was inconsistent.
• There was low morale among theatre staff and consultant surgeons. Some consultant surgeons were not working with a multidisciplinary approach and were not engaged in the divisional objectives.
• Black and minority ethnic staff felt that they were not given the opportunities that less experienced white staff had in some areas.
• There was ineffective senior leadership and high levels of staff stress on Gwynne Holford Ward, Queen Mary’s Hospital (community).
• There was no overall vision and a lack of strategic direction for community end of life care services from the top of the organisation.
• Systems and 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.
• Fit and proper persons, which is a legal requirement for trusts to undertake, was not fully embedded in the trust.
• Junior doctors reported that there was no formal channel through which concerns and suggestions could be raised.
• The trust performed worse than other trusts in 24 questions, in the NHS staff survey in 2015.
• Trust compliance with the workforce race equality standards was poor. Staff from black and minority ethnic backgrounds reported poor opportunities for career progression or promotion. Governance and board oversight of the workforce race equality standards was poor.
• Both the interim chair and chief executive had acknowledged the significant challenges faced by the trust and spoke candidly of them. Interim appointments were being made to address deficits in the leadership.
• Engagement of patients and the public in the improvement of services was evident.
• There were examples of the development of services and the introduction of new practices to take the service forward.
• We saw innovation across some areas, including participation in research, journal publication and use of social media to disseminate key information to staff.

We saw several areas of outstanding practice including:

• Outcomes for renal patients in relation to survival rates and transplantation were excellent and were amongst the best in the country.
• The outcomes achieved by the specialist medical and surgical services provided by the hospital.
• The effectiveness of maternity care delivered by the hospital.
• The responsiveness of the neonatal unit to parents whilst their baby was on the unit and the support provided by the outreach nurse.
• The involvement of children of varying ages on the interview panel as part of the recruitment process for ED paediatric nurses.

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

Importantly, the trust must:

• Develop a long term strategy and vision
• Move towards having a stable, substantive leadership team.
• Ensure all premises and facilities are safe, well-maintained and fit for purpose.
• Ensure all care is delivered in accordance with the Mental Capacity Act, 2005, when appropriate.
• Review and implement robust governance processes, so that patients receive safe and effective care.
• Ensure RTT data is robust and accurate so that patients are given appointments and treatment based on their needs and within national targets.
• Ensure serial numbers of prescriptions (FP10s) for prescribers are always monitored for use.
• Ensure radiographers only administer medication (contrast media) where appropriately authorised Patient Group Directions (PGDs) are in place.
• Ensure the fit and proper persons’ requirement regulations for directors are always complied with.
• Ensure the paediatric ward environment, staffing and training requirements are suitable for treating and caring for children and young people with mental health conditions.
• Ensure medicines are stored in an appropriate manner, by keeping cupboards locked when not in use.
• Ensure the process for decontamination of nasoendoscopes is compliant with guidance.

In addition, the trust should:

• Maintain patient privacy, dignity and confidentiality at all times.
• Review the fluid storage within the ED major incident cupboard to ensure that training equipment is not stored with ‘live’ equipment.
• Ensure staff consistently follow guidance related to the prevention of healthcare associated infections with specific regard to hand hygiene.
• Ensure medical equipment across the trust stored on is cleaned and that there are systems in place for monitoring the cleanliness of equipment returned to the ward.
• Ensure all staff caring for children receive level 3 safeguarding training.
• Ensure the process for investigating serious incidents is timely and undertaken by people trained in investigation so they understand the root causes of an incident and identify measurable action.
• Minimise the cancellation of operations and when this cannot be avoided, they are rescheduled within 28 days.
• Reduce the moves of patients to wards that are not appropriate.
• Ensure staff use the early warning scoring system effectively, including the timely escalation of deteriorating patients to relevant personnel. 
• Ensure divisional and trust priorities are shared by personnel of all grades and professions who work together to promote the quality and safety of patient care.
• Address the low morale among theatre staff and consultant surgeons.
• Replace damaged chairs and furniture within patient areas so that they can be thoroughly cleaned.
• Ensure that all patients within the ED ‘streaming’ area are assessed within a private area.
• Ensure staff can observe the patients whilst they are waiting in their outpatient departments.
• Ensure patient electronic records are not easily visible or their paper records are not easily accessible by the public.
• Improve the percentage of telephone calls answered by staff in the outpatient department are within the service level agreement targets.
• Communicate effectively with patients when outpatient clinics overrun.
• Ensure there are sufficient cystoscopes (to examine the inside of the bladder) to supply day surgery, main theatres and endoscopy.
• Ensure all relevant staff are appropriately inducted to the trust and within clinical environments to which they are allocated to work.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.

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.

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.

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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.

We rated this service as inadequate because:

• Changes had been made to Gwynne Holford Ward since our last inspection without due regard for the impact on people’s safety. The premises were not appropriate for the service provided and the layout had contributed to fragmented care. The care was not delivered in a way that focused on people’s holistic needs.
• There were critical shortages of staff on Gwynne Holford Ward and not all of the staff on the ward had the right skills and knowledge to do their job. Staff told us that patients were being admitted with more complex needs and they found this challenging.

• Bedrails were used for many patients, without it being discussed and there being any clear indication for their use. There had been no consideration by staff that the use of bedrails was a form of restraint and was possibly depriving patients of their liberty.
• There was a lack of urgency by nursing staff to get the deteriorating patient medically assessed.
• Although we saw some good areas of practice, there was variable implementation of evidence-based care. Processes in documentation, administration of medicines, infection control and prevention and responding to the deteriorating patient were weak areas on Gwynne Holford Ward.
• Incidents were not consistently reported or acted upon on Gwynne Holford Ward and opportunities to learn from these and improve care were missed.

However:

• Staff felt valued by their peers, matrons and ward managers. Staff had a strong focus on providing compassionate care.
• There was excellent multidisciplinary team working and there were clear referral processes. Both wards aimed in their rehabilitation programmes to maximise the functional and physical ability of the patient.