St George's University Hospitals NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation
• Environmental sustainability – sustainable development

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust had a vision and set of values with quality and sustainability as the top priorities. However, not all staff understood what the vision, values and strategy were and their role in achieving them. There was a 5 year strategy in place across the group. Whilst the strategy was aligned to local plans in the wider health and social care economy, there was a lack of pace in progressing some of the strategic objectives related to the group model and culture.

The trust vision was refreshed in May 2023 and a 5-year strategy was implemented across the group model.

The trusts corporate strategy. ‘Outstanding Care, together: Our strategy 2023 to 2028’ was published in May 2023. The strategy focused on providing outstanding care, digital technology, and environmental sustainability.

At the time of our inspection, the Group’s strategy had been in place for approaching two years. The Trust had taken steps to disseminate the strategy to staff and teams across the organisation and was taking steps to support teams in pursuing improvements using the CARE framework.

The strategy was developed with the voices of patients, staff and partners aiming to meet the needs of the community it serves.

Management oversight of the Group strategy was by the Group Executive Committee, chaired by the Group Chief Executive Officer. The Group Executive Committee received regular reports on strategy implementation and in relation to the progress of nine strategic initiatives. The Group Executive Committee’s oversight of progress in implementing the strategy was supported by the Group’s Project Management Office. Assurance on the delivery of the strategy was through the Group Board chaired by the Group Chairman. The Group Board received 6-monthly strategy implementation reports.

The trust has developed 6 enabling strategies to support the delivery of the overall strategy:

• Quality and safety.
• People.
• IT.
• Estates.
• Green plan.
• Research and innovation.

Senior leaders told us that despite a significant year-long engagement process involving 2000 individuals in its creation, the trust had not yet fully embedded its strategy within the organisation. Post assessment we were told that the trust recognised this and was taking steps to ensure that teams at all levels understood the strategy and their role in it, but this work was ongoing at the time of the inspection. Senior leaders acknowledged that the pace of embedding of the Group model, and Group-wide ways of working, had been slower than was originally planned when the Group was formed in February 2022. This was due to a number of factors, including operational pressures and the absence of external funding to facilitate Group-wide integration. Leaders also acknowledged that a significant factor in the lack of pace was bringing the two trusts together culturally with a shared purpose and vision which demonstrated clearly to staff the benefits of the Group. Many of the conversations we held at all levels described a dual culture across the organisation with staff referring to doing things the ‘St George’s way’. This lack of shared purpose and vision manifested in some silo working across divisions and missed opportunities to share best practice, collaborate and learn from patient safety incidents. Senior leaders told us the challenges of unifying across the group model and the impact on the delivery of the strategy were exacerbated by the identified lack of an inclusive culture (see quality statements related to Workforce, Equality and Freedom to Speak Up for more details).

The trust had launched a new set of values 15 years ago and was still in the process of embedding these values into the organisation. Our observations and interviews with staff at all levels confirmed this. Some operational teams at ward level reportedly used their own local values instead of consistently aligning with overarching trust values. Senior leaders recognised that there was more work needed to ensure that the values were embedded and were continuing to engage with staff and teams.

The trust was actively engaged in a process of self-improvement and culture change, largely in response to external reviews and internal staff feedback. They had recognised past issues and committed to embedding positive practices. However, despite these stated commitments and initial actions, a review of service reports, information of concern, and data sharing suggested that these intended changes were not yet deeply embedded within the Trust's culture and operations. Many recommendations remained in their early stages, with statuses recorded as 'not yet due' or 'ongoing review' against deadlines in late 2024. This indicated that while the Trust had identified areas for improvement and set out plans, the practical integration and consistent application of these cultural shifts were still in progress.

St. George's demonstrated commitment to cultural improvement, particularly in safety and learning, but faced ongoing challenges in fully embedding these changes and adopting staff trust in systemic follow-through, as evidenced by key survey data. SGUH significantly improved in staff feeling secure to raise concerns, but remained slightly below the Picker Average, indicating ongoing cultural reinforcement was needed for safety and responsiveness.

During and after the onsite trust-level assessment, the CQC received anonymous communications that described the culture as a blame culture, unprofessional, toxic, and lacking in accountability, with a reluctance to challenge.

The pharmacy strategy exhibited alignment in shared direction and culture with the other trust in the group model. However, some initiatives had limited resources and capability built in, to ensure that the quality and sustainably standard were maintained throughout the wider trust. The Chief Pharmacist had limited direct engagement with the board and we were told this led to dilution of critical information to the board. This further raised concerns about shared understanding and accountability at the highest levels of the organisation. Despite this, the pharmacy departments participation in an acute provider collaborative improved services like aseptic provision for patients in areas such as Kingston.

A significant development since the 2018 well-led inspection was the establishment of the GESH Group. The Trust had agreed to form a group model with Epsom and St Helier University Hospitals NHS Trust in June 2021, having shared a Chairman-in-Common since October 2019. A Group Chief Executive was appointed in August 2021 and a single Group-wide executive team was established on 1 February 2022. From April 2022, a number of Board Committees (Quality, Finance and People) had met as Committees in Common across the two trusts with shared agendas, and since April 2023 a Group Board has provided integrated Board-level leadership of the two trusts.

Most leaders had the skills, experience, knowledge and capacity to conduct their roles on appointment and on an on-going basis. However, some leaders displayed behaviours that were not inclusive and this had an impact on the organisational culture and the ability to deliver quality services.

Leaders generally understood the challenges to quality and sustainability and whilst they could identify the actions to address them, they did not always have the capability or capacity to ensure that actions were effectively implemented. During our assessment, we were told that some senior leaders displayed behaviours that were not inclusive and this had an impact on service delivery across the trust.

Interviews with leaders at all levels demonstrated that some lacked the capacity for strategic delivery. Concerns arose regarding the competency of some leaders to deliver the strategy, with specific questions directed at the board about its direction. Leadership capability across the group model, particularly in overseeing both trusts, was questioned despite available coaching and training. Bandwidth was also identified as potentially too large.

Senior leaders acknowledged that there was a need to strengthen the leadership development, talent management and succession planning strategies. Whilst there were priorities for ensuring sustainable, compassionate, inclusive and effective leadership, this was yet to be fully embedded. Those initiatives that were underway had limited assurances that they were addressing the risk associated with lack of inclusive leadership. Our review of the board assurance framework confirmed this. The trust had introduced some leadership initiatives and had plans to introduce other programmes aligned to their people strategy. Our interviews with senior leaders and review of documentation demonstrated that there were no clear measures to monitor success with those initiatives. We raised these concerns with senior leaders and after our inspection we received some reassurances of how the organisation intended to measure the effectiveness of these initiatives.

The Chief Pharmacist reported directly to the Divisional Director of Operations for the Children’s, Women’s Diagnostics and Therapies Division, with a professional reporting line to the Group Chief Medical Officer. The Chief Pharmacist attended site leadership meetings. They felt heard by the senior leadership team, but they identified a lack of pharmacy input in certain areas and committees, such as the Central Incident Review Group (CIRG). Reports from the pharmacy directorate was submitted to the Board’s Quality Committee. Pharmacy service sits in divisional directorate, and the chief pharmacist is managed by the group divisional Director of Operations, although, they have direct access to entire Senior Leadership Team (SLT) and attends the site leadership team. Having, said this, there were governance committees with responsibility to review and implement actions relating to medicine incidents that have no pharmacy input or oversite such as central incident review group (CIRP) resulting in significant incidents backlogs including the hospital thrombosis group (HTG).

Senior leaders failed to recognise or address an information governance issue. The Caldicott Guardian, despite being knowledgeable, was often kept out of the loop, we were provided with some examples where the Caldicott Guardian received critical information by chance and not via a formalised processes for sharing information from the information governance team. The Guardian wished to enhance staff education but was not well known across some services and had limited access to the board. IT systems hindering efficient role performance.

Interviews with some divisional teams demonstrated evidence of breakdowns in communications between service leads and divisional lead in some areas. While surgery, neuroscience, theatres, and cancer divisions experienced positive internal dynamics, their communication lacked consistent reference to broader strategic aims and trust values, indicating a potential misalignment. However, some divisional leaders demonstrated strong leadership relations between its unit, site leadership, and group leadership, with group executives having visited the service.

The 2024 annual NHS Staff Survey saw 4,757 staff members participate across the Trust, a 31% increase from 3,637 participants in the 2023 Staff Survey. The Trust was one of a small number of trusts nationally to see engagement in the staff survey increase in 2024 compared with 2023. NHS staff survey results showed responses to questions in relation to compassionate leadership have improved since 2021, though this remained lower than the Picker average (7.11 compared to 7.21).

Fit and proper person regulation (FPPR) is the regulation that requires NHS trusts to check all executive and non-executive directors (or equivalent roles) are suitable and fit to do the role. The service had implemented robust systems to ensure compliance with the FPPR. We reviewed the files of 5 Board members (both executive and non-executive directors), and found that they demonstrated the necessary suitability and fitness for their respective roles, as defined by the regulation.

People did not always feel they could speak up and that their voice would be heard.

Leaders were not always viewed as acting with openness, honesty, and transparency. Staff said leaders did not always address concerns, leading to some staff finding it difficult to speak up. We received feedback that described “toxic cultures,” highlighting “numerous incidents” and “distressing experiences personally endured” by staff. These included abusive behaviours and racism directed at staff from black and minority (BME) and white ethnic backgrounds. Staff had referred their concerns to external bodies. Leaders investigated concerns raised internally and engaged staff to improve the problems and records confirmed this. However, they needed to do more to ensure staff felt safe to report concerns.

The organisational culture did not always encourage staff to proactively raise concerns despite the systems, policies and procedures in place. The Freedom to Speak Up Guardian (FTSUG), FTSU champions and management teams provided staff space to raise concerns. However, some staff told us they feared reprisals or not being believed so reported concerns anonymously or not at all. Some staff told us that there was a lack of confidentiality and transparency when interacting with those in senior leadership roles. Staff told us that there was a lack of accountability when issues were raised with senior leaders. CQC received information of concern from staff who wished to remain anonymous, as they did not feel safe to raise concerns within the organisation.

Before and after our trust level assessment we received 23 contacts from members of staff who told us that they were afraid to raise concerns about patient safety for fear of retribution. A number of the concerns we received related to concerns that the trust did not understand the lived experiences of people from BME backgrounds, and did not support people equally. Staff from BME backgrounds are now the largest group within the trust’s workforce. There were issues raised about racial discrimination and bullying and harassment as well as there being a culture where the organisation was not seen as inclusive and that race and gender were barriers to being heard. Staff told us that some senior leaders were seen as either blocking things or being able to influence decisions.

We raised these significant concerns with senior leaders. Initially senior leaders failed to realise the significance of these concerns as they felt that the numbers of staff raising concerns externally was a small proportion of the total workforce. Senior leaders also felt that actions were already being taken to address these concerns in specific areas of the organisation where concerns had been raised internally. We were concerned that the trust was not doing enough to understand the extent of the issue across the organisation. This is because our review of documentation and interviews with staff at all levels demonstrated that there were limited assurances that staff were confident to speak up and raise concerns.

Strategies to promote staff empowerment and confidence in speaking up were not yet fully embedded. Since our last well-led assessment in 2019, the trust had now introduced a FTSU group model in May 2024. This consisted of a full time FTSU Guardian across the trust and 4 deputies across the locations. Improvements made since our last assessment included developing a FTSU vision and strategy. The trust had also taken actions to strengthen board and executive oversight of concerns raised by staff. There had been an increase in the number of people raising concerns through FTSU since 2019. Senior leaders told us that this was in part due to the mandatory training that had been introduced as part of the FTSU strategy. The trust also had a Raising Concerns Oversight and Triangulation Group, chaired by the Executive Lead for FTSU, and which brought together senior Executive and Site Directors to review concerns raised by staff. The purpose of the Raising Concerns Oversight and Triangulation Group was to support improvements in the pace of resolving concerns raised by staff, to escalate significant concerns, and to triangulate various sources of data relating to concern raising alongside patient safety, quality, workforce and operational performance data, as well as data from concerns raised externally to the trust. This group also reports directly into the Group Executive Committee which receives highlight reports after every meeting to ensure Executive oversight of concern raising by staff. In addition to this the FTSU Guardian provides reports to the People Committee, a Committee of the Board. Concerns raised by staff related to quality and safety are reported to the Quality Committee following discussion at the Raising Concerns Oversight and Triangulation Group.

The FTSUG produced a monthly report of current concerns to the Executive level Raising Concerns Oversight and Triangulation Group, as well as a 6 monthly report that was presented to the Group Executive Committee, People Committee and the Group Board. In the FTSU report covering the first two quarters of 2024/25, there were 78 concerns raised at St George’s University Hospital. The breakdown was as follows. administrative and clerical staff were the highest group of staff raising concerns, nursing and midwifery second. By division the highest was from children’s, women’s diagnostics and therapies. Medicines and cardiovascular second and corporate third. In terms of themes, bullying and harassment at 52.56% was the highest theme, Inappropriate attitudes and behaviours second at 43.58%, Worker safety was at 24.13% and then patient safety at 17.24%. These were similar to the concerns we heard during our assessments of the service groups and the trust level assessment.

Our interviews with some senior leaders after the on-site assessment demonstrated that there is a genuine commitment to drive the necessary improvements in the culture. There is an acknowledgement that this will take time as there has been little improvement in this area for a number of years based on the NHS staff survey results and other external reports.

Since this trust level assessment, the trust have supplied us with an action plan of how they will work with teams to improve the culture. We will continue to monitor these plans through our regular engagement with the trust.

Our interviews with staff at all levels and review of documentation demonstrated that the trust did not always value diversity in their workforce. Senior leaders failed to recognise and fully consider the impact of workforce inequality on service delivery and patient safety. However, leaders were committed to working towards an inclusive culture to promote equality and equity for people who work for them.

The trust’s commitment to continuously improve the organisation’s culture was not fully reflected in the staff’s experiences. At our last Well Led assessment in 2019 we identified that the Trust needed to improve in the following areas.

• Continuing work on addressing bullying and harassment within the trust.
• Embedding and ensuring that there were clear objectives for, and awareness of, equality and diversity networks.
• Promoting equality and diversity in staff’s day to day work and when looking at opportunities for career progression for BAME staff.

Our review of documentation and interviews with staff demonstrated that there was still work to do in these areas. Whilst there had been some developments with equality, diversity and inclusion (EDI) initiatives there was limited evidence to demonstrate overall improvement.

Processes to remove bias from practices were not always effective or fully embedded and some staff groups described experiences of structural discrimination. In addition, processes to monitor fairness in recruitment and career progression for staff in equality groups were not implemented effectively. EDI was monitored in line with the NHS Workforce Race Equality Standard (WRES). However, evidence showed a lack of progress in areas such as career progression for Black and minority ethnic (BME) staff, discrimination incidents (from managers and peers), and the treatment of disabled staff. There was limited diversity in non-clinical management grades at band 8b or above. The composition of the Board did not reflect the diversity of the local population and the staff group.

We received a range of mixed comments from staff about the culture and working environment at the trust. For example, we were told it was a pleasant and supportive place to work where people embraced the diversity and positive work completed. However, we also received a number of concerns from staff either during or after our Well Led site visits and at our previous site visits of Maternity, Urgent and Emergency Care and Surgery. Many of these were about concerns relating to bullying and harassment, racism, and perceived racism or unfair treatment. As such, they mirrored the Workforce Disability Equality Standards (WDES) and FTSU findings as well as indicating that there were parts of the trust where staff may be more likely to experience these issues. We were concerned that the trust was not currently triangulating this information with patient safety information to fully understand the impact of workforce inequality on patient safety.

Our review of the WRES and WDES demonstrated that whilst there were some improvements in the data, the trust still had work to do to ensure that staff are being treated equitably, particularly those with protected characteristics. The data highlighted that there are areas for improvement within this trust, particularly in relation to career progression and harassment, bullying and abuse within race equality metrics. Data indicated that experiences of white staff in relation to these areas was worse than the national average, and that Black and Minority Ethnic (BME) groups reported even worse experiences than their white colleagues, suggesting evidence of cultural issues within the trust. There were also disparities within experiences of disability equality.

Within the WRES 2022 metrics and ESR 2023 data, the three priority areas for improvement for this trust were board representation, career progression in non-clinical roles (middle to upper levels) and harassment, bullying or abuse from patients, relatives or the public in last 12 months against all staff. Career progression was also highlighted as an issue within the WRES 2023 metrics. Those from BME groups reported worse experiences than both white staff at this trust and when compared to BME staff experience nationally. Staff from BME groups also reported worse experiences of discrimination from a manager/ team leader or other colleagues compared to white staff, and harassment, bullying or abuse from colleagues when compared to BME staff experience nationally.

Staff with long-term conditions or illnesses at the trust reported worse experiences in all 7 of the Workforce Disability Equality Standard (WDES) metrics from the 2023 NHS Staff Survey, compared to those without (most notably in experiences of harassment, bullying and abuse, equal opportunities for progression, and feeling valued). They also reported worse experiences than the national average of staff with a long-term condition or illness in 7 of the 8 metrics. This indicates worse experiences for staff at the trust who have a long-term condition or illness, and worse experiences when these metrics are compared nationally.

Leaders took action and provided resources to prevent and address bullying and harassment, particularly for those with protected characteristics. However, some staff felt the mechanisms were not effective in stopping instances of bullying and harassment.

Staff networks had been formed to promote EDI but were not always impactful. The trust had 4 staff networks. All have an executive sponsor and a trust Senior Leadership Team sponsor. The Women’s Network had not had a chair for a period of 6 months following turnover in the role. The level of involvement of the executive sponsors in equality networks was inconsistent. Staff said they did not always have protected time to attend network events making it difficult for them to engage. The EDI team in the people function organised events in collaboration with Staff Network Chairs. Network leads said the events were well received by colleagues. There were efforts to strengthen networks.

The trust had introduced a new group diversity and inclusion action plan for 2025-2028. This included developing the equality networks and introducing a shadow board. These were yet to be implemented. Staff received training in EDI as part of the action plan. At the time of our assessment 95% of staff had completed EDI training. Senior leaders told us that there were benefits and some challenges with implementing an EDI plan across the group. One of the main challenges was being able to demonstrate improvements at the individual trust given the differences in staff demography and population. Senior leaders were committed to continuously reviewing the EDI action plan and identifying actions that were measurable to demonstrate achievements.

The new group diversity and inclusion action plan 2025-2028 sets out actions for the next 12-18 months. It builds on the trust’s existing culture and diversity and inclusion action plan and had six EDI workstreams. These have been mapped to NHS England’s EDI Improvement Plan and aligned to the trust’s people strategy 2024-2026. The six EDI workstreams are:

• Leadership commitment.
• Improving health and wellbeing.
• Inclusive recruitment and talent management.
• Eliminating pay gaps.
• Supporting internationally recruited staff.
• Safeguarding our workforce.

Executive leaders recognised that there was further work to do to create the right conditions for success. They told us that the people function, including human resources, needed improvement with the employee relations function being fragile. Senior leaders demonstrated a genuine commitment to tackle these systemic issues.

The Trust saw a small increase in staff declaring disabilities from 3.5% in 2023 to 3.7% in 2024. This was an improvement in staff declaring disabilities since 2021 when just 2.3% of staff had declared a disability. However, staff with disabilities were more likely to be in lower pay bands, and applicants without disabilities were 1.26 times more likely to be appointed, an increase from 1.15 in 2023. This data highlighted persistent disparities in career progression and recruitment for disabled staff. There has been a reduction in the percentage of staff experiencing harassment, bullying and abuse from patients/service users and from colleagues. However, 21.1% of staff with a disability reported harassment and bullying from managers. This is 5.8% above the national average (15.3%). Staff with a disability are 4.08 times more likely to enter the capability process compared to staff that do not have a disability. Although the WDES report notes that this high likelihood is due to the relatively low numbers of staff with a declared disability.

Whilst both staff groups reported an improvement in rates of feeling valued by the organisation, staff with a disability were still much less likely to feel that their work is valued. The staff survey results show that 31.3% of staff with a disability who responded to the staff survey said they felt the organisations valued their work - compared to 43.6% of staff without a disability. The gap between the two groups has declined in the past year – currently at 12.3% (increased from 10.6% in 2023). There was also a declined in terms of the percentage of staff with a disability who considered the trust offers equal opportunities for career progression and in terms of the numbers of staff with a disability being appointed from shortlisting.

There had been some improvements. For example, 68.9% of staff with a disability felt that reasonable adjustments had been made to enable them to carry out their work. This improved by 7.2% points compared to last year. Last year, St George’s was 10.7% behind the national average figure in this indicator. Progress in this area has reduced the gap to just 4.4% in the last 12 months, and the trust was now in line with the average for London trusts.

The WRES 2024 data demonstrated the Trust had improved in 8 of the 10 WRES indicators, with some indicators showing positive improvement over the past four years. On some indicators, the Trust was performing better than the London average. However, the WRES also demonstrated areas where there is a lack of equality and where improvements are needed. The percentage of BME staff in the organisation has risen to 53.6%. However, BME staff are over represented in the lower staffing bands, BME staff only making up 8.7% of the non-clinical VSM posts and BME staff are under represented at Executive level which remains at -41%, below national average. In addition, BME staff experiencing bullying and harassment from a manager or colleague remains is at 15.9%, although this has improved from previous years.

There were structures, processes and systems of accountability to support the delivery of the strategy. However, these were not always effective as not all levels of governance and management did not always function effectively and interact with each other appropriately.

The trust’s Board agreed to form a hospital group with Epsom and St Helier University Hospitals NHS Trust in June 2021. The two trusts had shared a Chairman-in-Common since October 2019. A Group Chief Executive Officer, who was the Accountable Officer of each trust within the Group, was appointed in August 2021, and a single Executive team across the Group was formed in February 2022. The Group had a Group Operating Model in April 2022 which set out how the different parts of the Group interacted. It had also established Group governance arrangements between 2022 and 2024 which involved Committees of the two trusts’ Boards coming together as Committees in Common for Quality, Finance, People, Infrastructure, Audit, and Remuneration. A Group Board, operating as a Committees in Common with delegated authority from the two trust Boards had also been established in April 2023. This means that there is a group executive team who have overall responsibility for achieving the shared strategic objectives for each trust in the group model. There is a group model governance and accountability framework which clearly identifies who is responsible for a particular area of governance at group level. For each trust in the group there is site level leadership who are responsible for ensuring that all aspects of governance, performance and operational delivery is appropriately escalated to group level. Our observations, review of documentation and interviews with staff at various levels demonstrated that the group and site leadership management and governance function did not always interact effectively to keep people safe from avoidable harm. For example, the issues in maternity, surgery and urgent and emergency care had been identified in previous inspections through incident data. Therefore, there should have been actions taken to address these and protect people from avoidable harm. The disconnect between senior leaders meant that there was a lack of governance and accountability in specific areas. This also had an impact on the level of assurance the Board received in relation to known risks affecting strategic objectives and the overall quality of care. This resulted in insufficient progress and a lack of pace in implementing improvements, particularly in relation to maternity. In these areas, there was a need for greater clarity about roles and responsibilities between the group and site leadership. A new Group Accountability Framework had been agreed by the Board in February 2025 and this provided greater clarity on roles and accountabilities.

Whilst there were assurance systems in place, our review of documentation and interviews with senior leaders demonstrated that assurance processes were not always effective. For example, the trust Board Assurance Framework (BAF) highlighted 14 strategic risks including improving safety and patient experience and tackling health inequalities. Eleven of the 14 risks were highlighted as having ‘limited assurance’ (January 2025). Our review of documentation and interviews with senior leaders confirmed that the lack of assurance was due to the on-going development of the group model and the need to strengthen and align policies, processes and systems. The trust had established Group governance arrangements following the establishment of the GESH Group in February 2022. This included the development and approval of a Group Operating Model in April 2022, the formation of Committees-in-Common for Board Committees from April 2022, the establishment of a Group Board in April 2023, the approval of a new Group Board Assurance Framework in 2024, and a new Group Accountability Framework in 2025. In addition, the trust had also taken a number of steps since our last inspection in 2019 to strengthen quality governance. This included an external 3-part quality governance review commissioned by the Board in 2019/20. This review identified areas of good practice and areas for improvement. The actions identified for strengthening quality governance were overseen by the Quality Committee and the Board. Following a CQC inspection of maternity services in 2023, the trust had commissioned an independent review of maternity services, the outcomes of which had been reported to the Board along with a set of improvement actions in June 2024. At the time of the inspection, the trust was in the process of reviewing its wider quality governance structures and processes in light of the learning from the review of maternity services.

Although there were systems in place to identify and manage risks, we were concerned that the developing assurance mechanisms were not always effective to ensure that actions taken were having the intended outcome of keeping people safe or taken in a timely manner. For example, in urgent and emergency care the impact of overcrowding in the emergency department had been identified as a risk on the departmental, divisional and corporate risk register and linked to the BAF on patient safety. Our review of documentation from April 2024 demonstrated that assurances were sought in relation to learning from patient safety incidents that occurred in February 2024. Actions identified to mitigate the risks included completion of risk assessments, this was still highlighted as a concern at our recent inspection of the emergency department.

Whilst there were systems in place to identify risks, senior leaders did not always identify actions to mitigate risks in a timely manner. The trust was slow to implement and embed a full capacity protocol to help manage the risks related to over-crowding in the emergency department in line with national guidance. This was introduced in September 2024 after ED staff raised patient safety concerns to external parties including CQC.

The group risk management strategy has been introduced in February 2025. Our review of documentation and interviews with senior leaders demonstrated that the risk management strategy once embedded should bring improvements to risk management processes.

Senior leaders were aware of the need to continue to strengthen governance processes at pace to ensure that people were safe and minimise the risk of avoidable harm. For example, the trust had recently introduced a group accountability framework that provides greater clarity on lines of responsibility between group and site leadership teams. This was yet to be fully embedded, however senior leaders told us this was already having a positive impact on assurance and oversight.

There were processes and systems to manage current and future performance. The trust worked hard to ensure that there was a holistic understanding of performance that sufficiently covered quality, patient experience, operations and finance from ward to board. This included an operational control centre which allowed staff to have a real time view of performance across the trust. The trust took actions to improve performance where needed. For example, the Trust introduced and ring-fenced an elective ward in 2020 to help address increasing waiting times for people. There was a plan in place to make this a permanent fixture to support patients being able to receive the right treatment at the right time. This had a positive impact on performance for people who were waiting 18 weeks plus for treatment. In addition, the trust performance against the 4 hour accident and emergency target was above the England average and regional average. The trust was also performing well against some of the cancer standards such as faster diagnosis standard (FDS – patients with suspected cancers have a diagnosis within 28 days). In performance areas where improvement was required such as length of time in ED and delayed discharges, we saw that there were plans in place to improve and the trust was on trajectory to achieve targets. Performance was discussed at various committees and at board level utilising the group Integrated Quality Performance Report.

There was a programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken. This included an internal audit of risk management, control and governance processes undertaken by the trust’s internal auditors. The most recent annual audit (2024) highlighted that the trust generally had adequate systems in place, and there were areas identified for improvement such as staff sickness rates and cyber security.

The trust had processes in place (including internal and external validation) to ensure the availability, integrity and confidentiality of identifiable records and data management systems in line with data security standards. However, our observations, review of documentation and feedback from staff at all levels demonstrated that processes to keep people’s information safe were not always followed. The trust was aware of the need to improve information governance and data quality and had a plan in place to address this.

Our review of documents and interviews with senior leaders demonstrated that the trust had effective financial governance arrangements. An external review conducted in November 2024 confirmed that the trust had effective financial controls in place. This meant that there were systems in place to ensure that quality of care was not compromised by financial constraints.

We reviewed the Trust’s arrangements for Emergency Preparedness, Resilience and Response. The Trust had arrangements in place for EPRR which had been externally reviewed and validated by NHS England as providing ‘substantial assurance’.

The trust and senior leaders understood their duty to collaborate and work in partnership, so services work seamlessly for people.

A core factor of the trust’s strategy was collaboration and working with others to develop services effectively and efficiently. This was highlighted in board papers and the trust vision and values. The purpose of entering into the group model with the other NHS trust was to make more efficient use of resources and improve quality of care. We saw that there was some development in these areas and senior leaders confirmed that whilst the benefits of the group model had not yet been fully realised, there were some positive indicators that this was starting to have an impact. For example, better utilisation of theatres across the group and cost savings in some administrative functions. The collaboration across the group model had resulted in positive outcomes in relation to the speciality of urology. This was particularly significant given the national challenges with long waits in urology.

There was a proactive Patient Partnership Experience Group (PPEG) which was led by patients and had been in place since 2016. The PPEG had direct access to executive leaders and worked collaboratively with teams to drive improvements and ensure that patients’ voices were being heard.

The trust was a key player in the south west London acute provider collaborative. Our review of documentation and interviews with senior leaders confirmed this. The trust had embarked on a number of ventures and initiatives to improve care for people in the communities they served. This included working with the other acute NHS trusts in the area to have an elective orthopaedic centre to address increased demand for trauma and orthopaedic services. Our review of data confirmed that treatment times for people using this service were better than the national average. For example, patients who needed a knee replacement that received treatment at the elective centre stayed in hospital an average of 1.9 days compared to the national average of 3.2 days. This meant that people spent less time in hospital and that the service could treat more people.

The trust collaborated with local boroughs and other partners in care to develop services for communities. For example, the trust collaborated with partners in the borough of Wandsworth and Merton to develop community services for frailty related conditions. The trust worked across the sectors of primary, community, mental health and voluntary, community and social enterprises (VCSE) to develop a programme of delivery for 2025/2026. The trust sought feedback from communities through engagement to further develop services.

Our observations, review of documentation and interviews with senior leaders confirmed that the trust was actively engaged in system wide collaboration and sharing of information with transparency. This was to address challenges that were external to the hospital but had a significant impact on people’s experience at St George’s hospital. This included working with partners to ensure that patients experiencing mental health illness received treatment in the right place at the right time. This issue is not unique to this organisation and staff at all levels were passionate about improving this for the community they serve.

There was a focus on continuous learning, innovation and improvement across most of the organisation. However, we found that processes for continuous learning and improvement were not consistently applied in all areas. Senior leaders were aware of this, our interviews with staff at all levels confirmed that actions were being taken to address this and the trust was committed to this.

St George’s Hospital is a major trauma receiving centre. It is 1 of 4 major trauma centres in London. The trust receives complex trauma cases from anywhere in the country as required. The trust is part of the major trauma network and shares learning and best practice through the network.

There was a strong focus on innovation and research. The trust had a dedicated research and innovation team that consisted of 2 senior clinical leaders. The research and innovation function was integral to the organisation’s status as a major teaching hospital. The team had been in place since 2023 and had built up the research capacity throughout the organisation to include nursing staff, allied health professionals (AHPs) and doctors in all specialities. This was a significant achievement to include staff from different professions particularly nursing staff and AHPs. The team had worked hard to promote the importance of research for improving patient care and there had introduced research champions across the trust in November 2024. The role of the research champions was to promote research and continuous improvement. At the time of the inspection, the research and innovation capacity at the trust was involved in over 300 clinical trials. This included pharmaceutical trials and paediatric cancer treatments.

The research and innovation team had developed strong working relationships with local educational institutions and in the local system.

The trust utilised technology to improve outcomes and service delivery. The trust had developed SMART theatres as part of a quality improvement project to increase efficiency and reduce energy consumption. The initial pilot of the project was trialled in 2 out of the trust’s 31 operating theatres and ended in January 2024. The pilot produced positive results to enable the trust to receive funding to rollout across all of the trust’s theatres and the trust would become one of the first trusts in the UK to have completely SMART operating theatres.

The site control room had been designed and developed with clinical teams. The control room featured innovative technology to enable teams to efficiently use data to manage flow. The control room had been introduced in February 2024 and was utilised by leaders at all levels to have transparency and detailed information to ensure that patients are cared for in the right place. The control room had been visited by other trusts and providers in London as its use has had a positive impact on access and flow in the organisation.

The Trust participated in a number of recognised accreditation schemes and was awarded a number of accreditations. This included Joint Advisory Group on gastrointestinal endoscopy (JAG) accreditation, Improving Quality in Liver Services and the trust was 1 of 3 national training centres for endoscopy. The trust had been accredited with the Veterans Aware Award in 2023 for their commitment to providing care to the armed forces. The trust was proud of their ward accreditation scheme which had been in place since 2019. The ward accreditation scheme was well embedded within the organisation.

The trust had also received accreditation under the Royal College of Anaesthetics ‘Anaesthetic Clinical Services Accreditation (ACSA)’ scheme. The ACSA accreditation award promotes quality improvement and high standards in anaesthetic services.

The trust had a system in place for learning from deaths and patient safety incidents. At the time of our assessment, the trust Standardised Hospital Mortality Indicator (SHMI) was at ‘expected’ and ‘lower than expected’ in some clinical groupings. This indicator helps providers to understand if the rates of mortality in their organisation are in line with expectations based on population health and trends.

The chief pharmacist actively invested in recruitment, implemented apprentice models, and prioritized staff well-being, career breaks, and work-life balance to address significant recruitment and retention challenges, especially among the trust's diverse staff, 53.6% of whom were from ethnic minority backgrounds

The trust divisional leaders held divisional incident review groups (DIRGs). The DIRG was held when a patient safety incident was identified as having the opportunity for learning to minimise the risk of avoidable harm. The DIRGs were held weekly and were attended by all specialties and services that had been involved in a patient’s care. Our observations and review of document confirmed that this was a multi-disciplinary meeting which was managed in an open and transparent manner. Teams worked together to understand what the issues were and to find solutions together. The Trust had implemented the first DIRG in 2023. The remaining Divisions implemented them in 2024. Whilst we observed a positive process, we were not assured this way of learning from patient safety incidents was fully embedded consistently across the organisation due to the concerns we found in maternity, surgery and urgent and emergency care services.

The trust had launched the Group Quality and Safety Strategy in December 2024. The strategy focuses on quality governance and learning from the experience of other services such as surgery and maternity. Senior leaders were committed to embedding continuous improvement and had implemented the ‘High Performing Teams’ initiative. This initiative sought to create an environment where teams had the tools and resources to improve their services. Our interviews with staff at all levels demonstrated that teams were keen to engage with continuous improvement activities for patient safety, however, they were sometimes constrained by operational demands and pressures. The trust has recognised this and had recently increased the capacity in the continuous improvement and project management teams.

The trust is one of a few trusts in the country that has a dedicated Fundamentals of Care team. This team are focused on ensuring that the basics of care are embedded throughout the organisation using internationally developed principles. The team was formed in 2024 and is part of a larger national network to share best practice and learning. However, we received information that demonstrated that the team did not function effectively and was not achieving the outcomes expected.

Senior leaders understood any negative impact of the organisation’s activities on the environment. The trust worked hard to making a positive contribution in reducing any negative impact and supporting people to do the same.

The trust first received an award for environmental sustainability in 2017. The trust developed a green plan and decarbonisation strategy from 2019 and it was first adopted in 2022. The trust had implemented the group’s ‘Green Plan’ in July 2024. The trust has made a public commitment to drive sustainable development to deliver their 5 year group strategy.

The trust’s estates decarbonisation strategy provides a road map to Net Zero by 2031 in line with national targets. The trust has introduced SMART theatres which has significantly reduced energy usage. As part of the estates strategy and Green Plan the trust was fitting LED lights throughout the organisation. This was due to be completed by October 2025. There was also a plan to develop a KPI scorecard to enable the trust to generate and have access to better data.