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St George's University Hospitals NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

17 July to 5 September 2019

During a routine inspection

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.

6 Mar to 18 Apr 2018

During an inspection of Community health inpatient services

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 Some controlled drugs had their labels obliterated by a pen and the medicines resource folder in the room contained out of date policies which could increase the risk of incorrect medication or staff not following correct trust guidelines.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.

Unannounced visits on 10, 11 and 22 May 2017.

During an inspection looking at part of the service

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.

This is a report on the focused inspection we undertook on 10, 11 and 22 May 2017. The purpose of this inspection was to follow up on a Section 29A Warning Notice, which we issued in August 2016, following a comprehensive inspection of the trust in June 2016.

We checked whether the trust was meeting the requirements of the Warning Notice. As a result, there is no rating of this inspection. The Warning Notice required the trust to make significant improvements in certain areas because:

  • There were unsafe and unfit premises where healthcare was provided and accommodated staff.
  • There was a lack of formal mental capacity assessments and best interest decision-making and some patients had decisions made for them that they were capable making themselves.
  • The design and operation of the governance arrangements were not effective in identifying and mitigating significant risks to patients.
  • Risks to the delivery of high quality care were not being systematically identified, analysed and mitigated.
  • Staff were not being held to account for the management of specific risks.
  • There was a lack of processes in place to provide systematic assurance that high quality care was being delivered; priorities for assurance had not been agreed and were not kept under review. Effective action had not been taken when risks were not mitigated.
  • The data used in reporting, performance management and delivering high quality care was not robust and valid.
  • There were not suitable arrangements in place for ensuring directors were fit and proper.

We found that the trust had partially met the requirements of the Section 29A Warning Notice. The trust had made significant improvements regarding; mental capacity act assessments/best interest decisions /deprivation of liberty safeguards, some elements of premises and equipment, medicines management and managing incidents. However, the trust is still required to make further improvements with regards to the fit and proper persons’ requirement, estates maintenance, accuracy of the referral to treatment data and governance.

Over key findings were as follows:

  • Systems and processes that operate effectively in accordance with good governance remain weak.
  • The head of internal audit only had limited assurance on the trust’s annual report.
  • Eleven Priority 1 recommendations remained outstanding beyond the agreed deadlines, and several deadlines had been put back.
  • The trust had made significant progress with regards to addressing legionella/pseudomonas risks in the water system.
  • There had been improvements in monitoring FP10 prescriptions and the risk of these going missing had been reduced.
  • Authorised Patient Group Directions were in place in the radiography department and most radiographers had appropriately signed them, following our prompting during the visit.
  • Renal services had been relocated, so patients were no longer in an unsafe environment. Operating theatres 5 and 6 had been refurbished since the previous inspection.
  • The water leaks to the maternity staff room had been resolved.
  • The Wandle Unit had been demolished and building work had commenced on the construction of a new building.
  • Fixed wire testing had been carried out by the trust in accordance with BS7671.
  • Planned preventative maintenance and work programs had been developed and introduced to help reduce the thermo-regulation problems of Lanesborough theatre 1 occurring in the future.
  • Governance around estates management had improved and there were annual reports for all services.
  • Replacement box filters that prevent contamination of the theatre air handling units, were stacked in the plant room by the side of theatres 5 and 6 vent plant, allowing for possible contamination of the “new filters” Theatre plant rooms we visited were untidy and cluttered with numerous water leaks.
  • There were still gaps in assurance with regards to estates maintenance, but the trust had plans within a reasonable timetable to mitigate these.
  • New transformer units, which are used to increase or decrease the alternating voltages in electric power applications, were needed to meet power demands. This was because there was a risk of power failure at St George's Hospital.
  • Serious incidents were now being reported within internal and external KPI deadlines.
  • Mental Capacity Act and Deprivation of Liberty Safeguards training, understanding and application had improved on the areas where we had concerns.
  • Referral to treatment data was still inaccurate and still not being reported to NHS England. A recovery programme and Clinical Harm Review Group was making progress, but it could take up to two years to be fixed. So far, two cases of serious harm to patients had been identified, as a result of delays in making their follow up appointments.
  • On some risk registers, there were no ‘action due date’ and there should be. Also, the concerns identified as part of the Workforce Race Equality Standard (WRES) was not on the Human Resources corporate risk register.
  • There was a WRES reporting template and action plan on the trust’s website dated July 2016, which was in the process of being updated. We saw the new action plan, but this was a work in progress and still had to go through a number of checks before it could be uploaded on the website.
  • There were mechanisms in place to ensure that staff delivering end of life care services in the acute hospitals and community services worked closely together.
  • The trust was continuing to fail meet the Fit and Proper Person Requirement Regulation (Regulation 5, HSCA, 2014).

Importantly, the trust must:

  • Ensure that it has systems and processes that operate effectively in accordance with good governance.
  • Strengthen governance and reporting arrangements, so as to provide the board with increased oversight of Elective Care Recovery Programme delivery.
  • Continue to address the gaps in assurance with regards to estates maintenance.
  • Continue with the recovery programme and Clinical Harm Review Group with regards to RTT data.
  • Ensure it meets the Fit and Proper Person Requirement Regulation.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Announced visit, 21-23 June 2016. Unannounced visit, 6 July 2016.

During an inspection of Community health inpatient services

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.

10-13 February 2014

During a routine inspection

St John’s Therapy Centre is a registered location for St George’s Healthcare NHS Trust community services. Since 2010 the trust has provided a range of community services within the London Borough of Wandsworth from Bridge Lane Health Centre, Doddington Health Centre, Eileen Lecky Clinic, Stormont Health Centre, Tudor Lodge Health Centre, Brocklebank Health Centre, Westmoor Community Clinic, Balham Health Centre, Joan Bicknell Centre and Tooting Health Centre as well as St John’s Therapy Centre. The trust serves a population of approximately 1.3 million across South West London and provides services for older people, adults with long-term conditions, people with learning disabilities, families and children.

Continuing care

Community services aim to provide a service for adults over the age of 16 years with physical health needs, including:

  • Diabetes specialist nursing
  • Heart failure specialist nursing
  • Integrated falls and bone health service
  • Intermediate care
  • Nutrition and dietetics
  • Occupational therapy
  • Podiatry (including podiatric surgery)
  • Respiratory specialist nursing
  • Speech and language therapy
  • Tissue viability specialist nursing
  • Hemoglobinopathies
  • Neuro-rehabilitation
  • Wandsworth integrated community equipment service

The service is designed to promote healthier lifestyles, physical, psychological and social wellbeing, and supports and encourages people with disability and long-term conditions to live independent lives. Services work with other healthcare professionals (such as GPs, continence service, Macmillan cancer support team, practice nurses, therapy services, tissue viability nurses) to deliver comprehensive and effective care to clients. Specialist services are available for people with diabetes, epilepsy, neurological conditions, physical ailments, cardiac conditions, and so on.

The trust also has four community wards within the London Borough of Wandsworth. Each of the four wards support current systems and have a GP, social worker, pharmacist, ward clerk and advanced nurse practitioners. Other key staff include community matrons, community (district) nurses and healthcare support workers and therapists. One ward has a mental health nurse on a pilot basis. The four community wards are – Central Wandsworth (Wandle), North Wandsworth (Battersea), West Wandsworth (Roehampton/Putney) and South Wandsworth (Balham/Tooting/Furzedown). The aim of these wards is to proactively manage patients in the community with long-term/chronic conditions to reduce the number of unplanned admissions to secondary care. They provide a rapid response to urgent requests for community services to enable patients to be managed in an acute phase at home, thus avoiding admission to hospital. They are also able to provide assistance in the safe, early discharge of patients from secondary care back into the community.

Community learning disability

The Wandsworth community learning disability team is a specialist multidisciplinary team offering a community service to adults over the age of 18 with a learning disability living in the London Borough of Wandsworth. The overall aim is to improve the physical and mental health and wellbeing for service users. The multidisciplinary team comprises community nursing, dietetics, dysphagia service, occupational therapy, physiotherapy, psychology and speech and language therapy, supported by an administration service and an access and referral management service. They work in close collaboration with learning disability social workers.

The community learning disability team offers a range of assessments and interventions for:

  • Communication
  • Challenging needs
  • Coordination and facilitation of health needs
  • Dysphagia (swallowing difficulties)
  • Mobility/exercise/postural management
  • Physical health issues
  • Activities of daily living (such as dressing and bathing)
  • Support in hospital/medical appointments
  • Significant emotional and relationship difficulties.

Family and children’s services

Services are provided from a number of clinics and include well-baby checks, as well as family planning and Sure Start programmes. The services are well integrated into the local authority and include:

  • Health visiting services
  • School nursing
  • Midwifery clinics
  • Children’s continuing care
  • Sexual health
  • Children’s therapies
  • Childhood immunisation
  • Child health records
  • Homeless, refugee and asylum-seekers service
  • Special schools nursing
  • Children’s speech and language therapy.

This is the first inspection of St George’s Community Services. Overall, we found that St George’s Community Services were meeting the core questions.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.