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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

Reports


Inspection carried out on 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.


CQC inspections of services

Service reports published 19 July 2018
Inspection carried out on 6 Mar to 18 Apr 2018 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Service reports published 1 November 2016
Inspection carried out on 21 - 23 June 2016 During an inspection of Community end of life care Download report PDF (opens in a new tab)
Inspection carried out on Announced visit, 21-23 June 2016. Unannounced visit, 6 July 2016. During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Inspection carried out on 21 June 2016 - 23 June 2016 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 21-23 June 2016 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
See more service reports published 1 November 2016
Inspection carried out on 6 Mar to 18 Apr 2018

During a routine inspection

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

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

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

Inspection carried out on 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

Inspection carried out on Announced visit between 21 and 23 June 2016. Unannounced visits on 2, 7 and 11 July 2016.

During a routine inspection

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

Inspection carried out on 10-13 and 22 February 2014

During a routine inspection

St George's Healthcare NHS Trust is one of the largest hospital and community health service providers in the UK. With nearly 8,000 staff and around 1,000 beds, the trust serves a population of 1.3 million across South West London. The trust provides healthcare services, including specialist and community services, at two hospitals – St George’s Hospital in Tooting and Queen Mary’s Hospital in Roehampton –therapy services at St John’s Therapy Centre, healthcare at Wandsworth Prison and various health centres. During this inspection, we visited both hospitals, St John’s Therapy centre and a selection of health centres, looking in detail at both acute and community services.

Key findings from this inspection include:

Staffing

This trust (like many others) experiences difficulty in recruiting enough nurses to cope with the increasing demands on the service and the complexity of patients admitted to the ward areas. We held a number of staff focus groups where staff stated that they had actively chosen to work at St George’s hospital as they enjoyed the culture of the organisation and felt that they were able to deliver a good service to their patients. However, we noted on some wards and areas that there were significant issues with shortages of staff which impacted on patients and the care they received.

Cleanliness and infection control

Overall, the hospital was found to be clean and good infection prevention and control systems were in place. We noted that there were some issues of cleanliness within the mortuary and the day assessment unit. However, most ward areas and departments were clean and clutter-free. The chief nurse and director of operations was the lead for infection prevention and control and this ensured that this issue has board-level commitment.

Mental Capacity Act

We found that the trust staff were unsure of the processes to follow when they identified someone who may have limited or no capacity to make decisions about their care. We have asked that the trust take action to address this and will follow up to ensure action has been taken.

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.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Other types of report

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.