St George's Hospital (Tooting)

St George’s Hospital in Tooting, London, is the main hospital site of St George’s University Hospitals NHS Foundation Trust. The trust serves a population of 1.3 million across Southwest London. A large number of services, such as cardiothoracic medicine and surgery, neurosciences and renal transplantation are provided and the trust also covers significant populations from Surrey and Sussex, totalling around 3.5 million people.

As well as acute services, the trust also provides a full range of community services to patients of all ages following integration with community services in Wandsworth in 2010.

St George’s Hospital provides acute hospital services and specialist care for the most complex of injuries and illnesses, including trauma, neurology, cardiac care, renal transplantation, cancer care and stroke.

St George’s University Hospitals NHS Foundation Trust employs around 8,536 whole time equivalent (WTE) members of staff with approximately 3,259 working at St George’s Hospital. We carried out an announced inspection of St George’s Hospital between 21 and 23 June 2016. We also undertook unannounced visits to the hospital on 2, 7 and 11 July 2016.

Overall, this hospital is rated as require improvement. We rated  outpatients and diagnostic imaging as inadequate. We rated the emergency department, medical care, surgery, services for children and young people and end of life care as requires improvement. We rated critical care and maternity and gynaecology as good.

We rated safe as inadequate. We rated effective, responsive and well led as requires improvement. We rated caring as good.

Our key findings were as follows:

Safe

• Several areas of the hospital’s estate that was in a state of disrepair. There was water ingress during heavy rain to several clinical areas we visited. Work had commenced to repair some of the affected areas, but the significant maintenance huge backlog, meant that this would take some time.
• Heating and power failures which had previously affected one medical ward remained on the risk register and had not been fully addressed.

• Some theatres were not fit for purpose. Theatres were sometimes closed due to electrical faults or unsafe temperatures. Sixteen of the 51 theatres needed to be completely refurbished. Since the inspection, we have been told by the trust, that the refurbishment of theatres 5 and 6 had been completed.

•  The ED environment was aged 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.
• 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, which had a high impact on infection prevention and control.
• Medicines were largely stored and managed appropriately, save for a few exceptions. For example, there were several examinations where radiographers gave contrast to patients despite PGDs not being in place.
• Mandatory training completion by staff was low in many areas.
• Records were well documented with fully completed care plans and legible entries that had been signed by the relevant staff member. However, there were instances where care records were not stored securely, increasing the risk of unauthorised access.
• 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 of making themselves.

• 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 emergency department.
• Information technology issues impacted on staff’s timely access to information and as a result records were fragmented in some areas.
• Evidence based guidance was available and care was provided in line with the guidance.

• We saw multiple examples of effective multi-disciplinary team working however there were shortfalls in some areas including MDT working for those at end of life or where patients required in out from both medicinal and surgical practitioners.   ​ .
• All 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 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.
• There had been improvements in the appraisal process for nursing staff, but there were limited opportunities for training and development.

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 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.
• Children shared ward areas with other children of a different gender or age group. Parents were asked to sign a disclaimer confirming their acceptance that their child could share an area with children of a different age or gender.

• 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.
• The ED was not large enough for the current throughput of patients and did not meet modern standards, which meant that in some areas, privacy and dignity of patients was compromised.
• 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 in waiting times had been achieved over the previous three months by running extra clinics.
• curtains used to screen the beds on at least four of the medical wards did not preserve people’s privacy.
• Some patients were unhappy with having to use of disposable utensils and plastic beakers.
• Parents were informed via text, when the 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.
• Whilst there were named executive and non-executive directors, staff working within the palliative care team considered ttere was lack of executive strategic direction for the provision of palliative care. for the top of the organisation. 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 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 no evidence that a vision and strategy for maternity was being jointly developed with midwives and obstetricians.
• 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.

• 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 some of 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:

• 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 Improve all its governance processes, so that patients receive safe and effective care.
• Ensure the 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 staff radiographers only administer medication (contrast media) where appropriately authorised Patient Group Directions (PGDs) or valid prescriptions are in place.
• Ensure the fit and proper persons’ requirement regulations for directors is 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 always 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 the equipment stored on Pinckney Ward is cleaned and 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 there are robust arrangements in place, which staff are conversant with, in relation to the recognition and escalation of deteriorating patients.
• 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 furniture in patient/clinical 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 is sufficient diagnostic equipment (including cystoscopes) to supply day surgery, main theatres and endoscopy.
• Ensure staff are appropriately inducted to the clinical areas to which they are employed to work. 

Professor Sir Mike Richards

Chief Inspector of Hospitals