St George's Hospital (Tooting)

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We carried out a very focused, unannounced assessment of Urgent and Emergency Services on the 6th March during business hours, and 8th March, 2024 out of hours. This assessment was prompted in part by notification of two separate incidents, following which the service users died. The incidents are subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this assessment did not examine the circumstances of the incidents. However, the information shared with CQC about the incidents indicated potential concerns about the management of risk of falls from height. This assessment examined those risks. For this assessment we only viewed parts of safe. We found that the service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices. We found the service mostly control potential risks in the care environment. However we found that not all patient's who met the criteria to have fall risk assessments completed had these undertaken. This meant staff may not be aware of all patients that are at risk of falling and therefore could not take action to prevent falls from occurring. The service had enough nursing staff to keep patients safe however not all staff had received training specific to their role. We found that not all staff had undertaken falls prevention training, and some staff were trained 13 years ago meaning they may not be up to date with current practices.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at people's experiences in this part of the assessment.

Staff told us they knew how to access and use the trust’s incident reporting systems. There was an open and honest learning culture where staff felt safe to raise issues and concerns.

Managers told us they used incidents and near misses as an opportunity to learn and improve care. Managers shared learning from incidents at daily safety huddles, handover, team meetings and by email. All staff we spoke with, including agency staff, were aware of the two incidents relating to falls that had occurred, and what actions had been taken in response. At provider level, incidents were shared across sites to ensure cross service learning. Staff were aware of who the trust’s Freedom to Speak Up guardians were and how to contact them.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Feedback from leaders is detailed in the section 'processes'

The design, maintenance and use of facilities, premises and equipment kept people safe. All areas were clutter free and facilities and equipment were maintained regularly to keep patients safe. Cohorting areas had been fire risk assessed and safe for use. Emergency alarms were available on the wall in cohorted areas. Staff carried out daily safety checks of equipment in each cubicle. This included checking trolleys were fit for use, emergency alarms were active, and that call bells were working. Patients could reach call bells and staff responded quickly when called. Patients who were unable to use call bells were regularly checked by staff to ensure their needs were met. Trolleys were at an appropriate height for individual patients, and bed rails were used appropriately as required. Electronic assessments were completed to identify which patients were at risk of falls, and what equipment and measures were needed to keep them safe. However we saw that only 74% of patients who needed risk assessments had them completed, meaning staff may not always identify patients at risk of falls.

The trust did not complete any audits to check the compliance with completing falls risk assessments prior to December 2023. Audit results from December have been below the trust’s target of 90%. Results showed that for patients who met the criteria to have falls risk assessments completed, only 67% were completed in December 2023, 23% in January 2024, and 33% in February 2024. This meant that staff may not know who was at risk of falling meaning they may not use the correct equipment or processes to keep people safe. Leaders told us that as a result of the poor audit results, the daily safety huddles in the emergency department focus on the completion of falls risk assessments. The emergency department team is also working with the Trust Falls Coordinator and Head of Nursing Quality to develop an action plan to improve falls education and the clinical assessment and management of patients who may be at risk of falling.

People we spoke with felt well cared for, but did not feel there was always enough staff on duty.

Please refer to 'Observation'

The service had enough nursing staff to keep patients safe however not all staff had received training specific to their role. The emergency department had a nursing vacancy rate of 5%, which was below the Trust target of 10%, and a sickness rate of 5%, which was above the Trust target of 3.2%. They had a nursing staff turnover rate of 14%, which was above the Trust target of 13%. Leaders told us that the trust had implemented a recruitment lead to understand why staff are leaving, and a QR code has been made available for staff to complete questionnaires and feedback. For the 12 months prior to the assessment, shift fill rates averaged 95% for qualified staff, and 89% for unqualified with the worst months being March 2023 when 91% of qualified and 81% of unqualified shifts had been filled. Leaders told us that to address any shortfalls the team proactively manages rosters to book temporary staffing in advance and review skill mix accordingly. The emergency department participates in the Trust daily staffing meeting where mitigations for any staffing shortfalls are agreed on the day, with staff moved as appropriate from other services areas to support the emergency department. During the site visits we found the department to be fully staffed, with any shortfalls filled with bank and agency staff. Staff told us they were able to request additional staff for patients who may require one to one care, including patients who were at high risk of falling, and that these requests were mostly filled. During the site visits we saw that all patients requiring one to one care had an additional member of staff with them.

Not all staff had up to date training in falls prevention. 91% of eligible staff had completed the training of falls prevention. 89% of staff working in the adult’s emergency department had completed their training in falls prevention against the Trust target of 90%. . Leaders told us that staff completed their falls prevention training as part of their trust induction. We saw some staff had completed their training in 2011 which was 13 years prior to the assessment, meaning they may not be up to date with current guidance. The trust did not provide falls prevention training for medical staff or agency staff. Leaders told us that agency staff would receive their training through their employers. Leaders told us that staff received training on completing the falls risk assessments when they completed their training for using electronic patients notes. Training records showed that 86% of staff had completed the section covering risk assessments, meaning 13% of eligible staff had not been trained in how to input patient information related to falls risk assessments. Since the inspection the trust has told CQC that 91% of eligible staff had received training in completing falls risk assessments.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.