During the inspection we visited six surgery wards and an outpatient clinic in the older person’s assessment unit. We paid particular attention to the treatment and care of older people in these areas.

The majority of people we spoke with told us that they were happy with their care, treatment and communication during their stay at the hospital. They felt that staff took time to discuss and explain their diagnosis and treatment, involved them in decisions and offered them choices about their care. One person said, “Every member of staff involved in my care from the senior doctor to the person cleaning the ward are committed and friendly.” Another said, “I’ve been to a lot of hospitals and this is the best ward I’ve been on.”

We found that there were effective systems in place for the prevention and control of infection and wards were clean and tidy. One person told us, “The ward is kept clean and staff always wash their hands before seeing me.”

Most people felt that there were enough staff to meet their care and treatment needs. One person said, “The nurses are brilliant and they see to me quickly when I needed anything.” However, on one ward people and staff were concerned about staffing levels. We raised this with trust management who took action to resolve these concerns immediately following the inspection.

Guy’s Hospital is part of Guy's and St Thomas' NHS Foundation Trust. The trust provides local acute and community services for people living in the London Boroughs of Lambeth, Southwark and Lewisham; and specialist services for patients from further afield. Guy’s Hospital provides acute hospital services to an inner city population of around 975,885.

Guy's and St Thomas' NHS Foundation Trust employs around 12,586 whole time equivalent (WTE) members of staff with approximately 3,637 staff working at Guy’s Hospital.

We carried out an announced inspection of Guy’s Hospital between 7 and 10 September 2015. We also undertook unannounced visits to the hospital on 21 and 23 September 2015.

Overall, this hospital is rated as good. We found urgent and emergency care, medical care, surgery, critical care, outpatients and diagnostic services and end of life care care were good.

Our key findings were as follows:

Safe

• There was a positive culture of incident reporting. Incidents related to safeguarding were appropriately recorded and actions were taken to address them.

• Measures for the prevention and control of infection met national guidance and standards of hand washing and cleanliness were consistently high and regularly audited.

• In most areas, staff were aware of their role in relation to safeguarding children and adults living in vulnerable circumstances and knew how to access the safeguarding team for advice and guidance when required.

• There were sufficient doctors and registered nurses on duty and good retention of nursing staff.

• In most cases, patient records, including prescription charts were fully completed and medicines were stored and administered appropriately, including controlled drugs.

Effective

• Policies, procedures and protocols reflected best practice and guidelines from statutory and professional bodies.
• Multidisciplinary working functioned effectively.
• Staff were well supported with access to training, clinical supervision and development.
• Patients were offered sufficient qualities of fluids with a variety of hot and cold drinks available and drinks were left within easy reach.
• Most staff understood the basic principles of the Mental Capacity Act, 2005 and could explain how the principles worked in practice. However, in some areas, there was inconsistency in how staff recorded capacity assessments and there was no evidence to support that staff had received training in the Mental Capacity Act 2005 or DoLS.
• In critical care, fewer than the recommended 50% of staff had completed a post registration critical care nursing award.
• Understanding of Deprivation of Liberty Safeguards was variable between staff and practice was not embedded in this area.

Caring

• Patients received compassionate care and were treated with dignity, respect and privacy and involved in their care.
• Patients receiving end of life care received good care.
• Patients were happy with the standard of care they had received and they felt staff had a genuine interest in helping them.
• Patients and their relatives were positive about their experience of care and the kindness afforded them.
• Emotional support was provided by staff in their interactions with patients.

Responsive

• Complaints were taken seriously were investigated using a process that was evidence-based to ensure that learning took place.
• Discharge plans were commenced on admission and most patients had estimated dates of discharge documented in their records.
• In surgery, there were some challenges with referral to treatment waiting times due to demand outstripping capacity, but this was being addressed appropriately.
• Information leaflets were available in waiting areas and were provided to patients by staff.
• Outpatient and diagnostic imaging services were not always responsive as the trust was persistently failing to meet the national waiting time targets related to cancer treatment.

Well-led

• Most staff were aware of the trust vision and incorporated this as part of their daily work.
• Staff showed a positive attitude to their work and spoke well of the trust and their colleagues.
• Senior managers were supportive to their staff and were visible on the wards.
• Patients were engaged in service development.
• The surgery service was innovating in a number of areas to improve patient outcomes and build capacity within the service, including highly effective multi-disciplinary outreach services.
• There were effect governance processes in place and staff were able to provided examples of feedback and learning points.
• Most staff felt empowered to drive forward initiatives and improvements.

We saw several areas of outstanding practice including:

• The SPCT was effective and provided face to face support seven days per week with visits up till 9pm and calls till 11pm and a consultant providing out of hours cover

• The Amber care bundle and a range of training courses for staff in end of life care such as the Sage and Thyme training model, Simulation days and Schwartz rounds.
• The Guy’s Orthopaedic Outreach Team (GOOT): a fast track discharge and multi-disciplinary support service which improved patient outcomes and reduced length of stay. 
• Proactive Care of Older People Service (POPS): an award-winning service and the first of its kind in the UK. The POPS service looks after patients aged 65 years and above to improve their medical health before and after surgery by assessing them before surgery, following their care while in hospital and supporting consultants and ward staff.

• The use of 'Barbara's story' to engage with staff and enhance a compassionate approach to patient care.

• ​Supportive practice of the mortuary and bereavement team.

• Staff in the bereavement office had sourced funding to provide family members with sympathetically designed cloth bags so they had a more discreet way of taking home personal belongings of a deceased patient, rather than use a plastic hospital property bag.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Improve governance links between directorates with surgical activity to ensure learning and concerns are shared across these directorates in a timely way.

In addition, the trust should:

• Take steps to increase the number of day surgery cases to reduce bed demand and reduce length of stay. The trust should consider introducing a named day surgery clinical lead to improve coordination of day surgery and provide a single contact for surgical directorates.
• Take steps to improve the working culture within theatres to ensure that all theatre staff have fair access to learning and development opportunities.
• Continue embedding and monitoring use of the ‘five steps to safer surgery’ WHO surgical safety checklist, with a particular focus on pre-briefing and de-briefing.
• Ensure consent for surgery is clearly documented in patient records and patients are given adequate time and documentation to make decisions about their care in advance of their planned procedure date.
• Improve engagement with lifestyles teams in tertiary, secondary and primary care to help surgery patients with smoking cessation, weight loss or exercise programmes to improve local health outcomes.
• Review the process for completing DNACPR forms and determine a specific location where they are kept for end of life care patients .
• Improve the consistency of mental capacity assessments and the recording of them for patients receiving end of life care.
• Review the escalation process when delays occur with the completion of death certificates.
• Reduce delays in 31/62 days cancer waits (diagnosis and treatment) in Outpatients.
• In the outpatients department, ensure all staff are aware of protocols related to obtaining patients’ consent; including protocols for those who might lack capacity to make a decision”. 
• Ensure all incidents in the outpatients department are investigated promptly and outcomes of the investigations recorded and shared with team to prevent recurrence. 
• In the outpatients department, ensure all staff receive mandatory training and are appraised regularly as prescribed by trust’s policies related to staff training and development.
• On Samaritan Ward, review the provision of toilet facilities for patients.
• Improve mandatory training completion by staff on the medical wards/departments.
• Improve performance on the number of patients starting treatment within 62 days for upper and lower gastro-intestinal illnesses.
• Ensure all staff, including staff working in outpatients departments, are provided with basic life support training.

Professor Sir Mike Richards

Chief Inspector of Hospitals