The inspection team comprised three Care Quality Commission (CQC) inspectors joined by a specialist CQC inspector with experience in care of the elderly nursing. During the inspection we visited the hospital’s Elderly Care Unit and spent time on all three wards on the unit.

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, “Staff always talk to me and explain things as they go.”

People told us that if they had any concerns they knew who to ask and they were provided with information and support if they wish to pursue their concerns further.

Most people felt that although staff were always very busy, there were enough staff to meet their needs and there was never a time when they did not do things properly or did not provide the treatment they needed. One person said, “I think there are plenty of staff, I am happy with them and I have no complaints about the care they provide.” Another person told us, “The staff are always there to help me when I need it.”

The mostly positive comments were supported by our observations and the evidence we examined. We found that the trust was meeting the standards we inspected.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Overall, we found that the majority of patients were happy with the care they were receiving and that staff were kind, caring and dedicated. Patients said that they felt involved in discussions about their care and treatment and their privacy and dignity was respected. Patients felt that night staff were less supportive than day staff. We also found that staff sometimes talked over patients and their relatives.

The majority of patients said that they liked the food on offer, had a choice of food and were supported to eat and drink. They said that their food and drink intake was monitored and that they could get something to eat if they missed a meal. We did, however, hear from one patient who needed their food mashed and that instead it arrived whole on their plate.

St Thomas' Hospital is part of the Guys and St Thomas' NHS Foundation Trust (GSTT) which provides acute services to the population in the London boroughs of Southwark and Lambeth generating over 2 million patient contacts per year. The hospital has 920 beds and also acts as a tertiary referral centre in a number of specialties across the south of England including cancer services, cardiothoracic services and orthopaedics. The hospital also includes the Evelina London Children's Hospital.

GSTT employs approximately 12,586 staff of which 5560 are employed at St Thomas' Hospital.

We carried out an unannounced inspection of St Thomas' Hospital between 7th and 10th September 2015. We also undertook unannounced visits to the hospital on 21st,22nd,23rd and 26th September.

Overall this hospital is rated as good. Urgent and emergency services and services for children and young persons were rated as outstanding. Medical care, surgery, end of life care,outpatients and imaging, critical care and maternity and gynaecology were rated as good.

The compassionate and supportive nature of the care provided was rated outstanding as was the quality of leadership provided. Services were rated as good in terms of effectiveness and responsiveness, however the overall provision of safe care requires improvement.

Our key findings were as follows:

Safe

• There was an open and transparent approach to incident reporting that was supported by processes for reporting and the learning from incident investigations largely embedded.
• Both nursing and medical staffing levels and skill mix supported the provision of safe care and was well supported by a programme of mandatory training. Staffing levels in maternity services were reviewed annually and although there had been an increase in the antenatal day assessment unit  staff found it hard to keep up with demand at times.
• Their were effective arrangements in place to minimise the risks of infection to patients and staff.
• Medicines and medical records were managed in an appropriately secure and monitored manner.
• Access to equipment and the quality of the physical environment were good with the exception of parts of the critical care service which was cramped with beds close together.
• Patient risk was well assessed across the trust, however the full five steps to safer surgery had not been fully embedded in operating theatre practice.

Effective

• Staff had ready access to and followed policies and protocols driven by accepted national guidelines and best practice.
• Multi-disciplinary teams were very well developed with a full range of health and social care professionals. In some areas, notably the urgent and emergency care department, the multi disciplinary teams were supplemented by further specialist teams including alcohol and toxicology support.
• Staff received appropriate appraisal and supervision and worked within a competency framework. Learning and development opportunities were provided for and specialist roles well developed in nursing.
• Patients were largely given timely pain relief following the application of appropriate pain scoring tools although we did identify some inconsistent documentation.
• Meal times were protected and well supported to ensure nutrition of patients. Similarly fluid intake was monitored to protect patients from dehydration.
• Consent processes and the documentation of mental capacity was largely good, however review of consent forms in surgery identified illegible recording.

Caring

• Our observations and feedback from patients and carers indicated a kind, compassionate caring approach to the delivery of care. This was of particular note in children's services, critical care and end of life care where exceptional practice was identified.
• Patients reported that they treated with dignity and felt fully involved in their treatment and care.
• Services were well designed to provide emotional support to patients, carers and colleagues with access to counselling and spiritual support. Post bereavement support was of an exceptional standard in a number of services.

Responsive

• Services were well planned to meet the needs of the local population and co-ordinated with community and primary care services with the homeless team and the proactive older patients service examples of excellence.
• Patients were largely treated in timely manner meeting national access targets. However the trust had not attained the 62 day cancer access target since 2013.
• Services were designed to meet individual needs with the development of communication support for dementia and other complex patients very well developed. This was enhanced by the patient experience tale 'Barbara's story' which had clearly impacted on all staff and was extensively understood.
• Patient flow was well managed leading to minimal movement of patients between wards and a low numbers of surgical cancellations. Proactive discharge planning was well supported by the hospital at home team.
• The processes for the management of complaints and dissemination of learning from complaints were well developed although one surgical department had a significant number of complaints remaining unresolved.

Well-led

• The culture of organisation was highly positive, open and proud and was fully reflected in the high degree of engagement and empowerment of staff in service provision and improvement.
• Leadership within the trust was visible, supportive and collegiate and this, along with the organisational culture, contributed to the stability of the workforce in terms of recruitment, retention and low sickness levels.
• Robust governance arrangements were in place to monitor, evaluate and report performance and risk back to staff and upwards to the trust board.
• The trust vision and strategy was well communicated and understood and as a consequence directorate plans were fully aligned.
• The organisation encouraged and rewarded innovative practice and service development.

We saw several areas of outstanding practice including:

• The use of 'Barbara's story' to engage with staff and enhance a compassionate approach to patient care. 
• The specialist support units active within the urgent and emergency department including alcohol, toxicology, homeless, youth support and play therapy for children.
• The role of the security team in the emergency department was embedded into the day to day working of the department. The team was multi-lingual and trained in effective de-escalation techniques and demonstrated outstanding empathy to patients.
• The provision of 'reflection time' to staff within the urgent and emergency department.
• The approach to communication with and support of dementia and complex needs patients via well designed communication boxes and a specialing team.
• The ward environment and signage afforded dementia patients.
• The Proactive Older Patient (POP) service.
• The multidisciplinary team support for families attending the neonatal unit.

• The paediatric cardiology service had introduced a home monitoring programme for infants following single ventricle palliation surgery (Norwood 1 operation or hybrid procedure). This allowed these patients to safely live at home with their families while they recovered and prepared for the second stage of their treatment.

• Supportive practice of the mortuary and bereavement team.
• The SPCT was effective and provided face to face support seven days per week up to 9pm, with calls taken until 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.
• We saw 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.
• Staff in the emergency department had sourced funding and designed and produced a bereavement card that they sent to any families whose relative died in the department.

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

Importantly, the trust must:

• Ensure the quality and safety team coordinate and have oversight of all governance issues to improve learning and sharing across directorates.
• Ensure that all women attending maternity department receive a venous thromboembolism risk assessment.
• Ensure that appropriate levels of midwifery staffing are available in all areas so that women are cared for in the most appropriate environment.

In addition the trust should:

• Review barrier nursing arrangements within HDU and ensure the environment meets infection prevention and control guidance
• Ensure that the full 'five steps to safer surgery' are embedded in operating theatre practice.
• Continue reviewing and improving cancer performance.
• Ensure consent is clearly documented and patients are given documentation of the process. Implement the recommendations from the consent audit 2014.
• Ensure all complaints are responded to in a timely manner.
• Where appropriate utilise day surgery more to reduce the length of stay.
• Address areas of the national fracture neck of femur audit where the trust is performing below the national average.
• The hospital should ensure that staff are familiar with the mental capacity assessment process and that this is followed where appropriate.
• Ensure all staff are aware of safeguarding principles and triggers for making a referral
• Continue to increase consultant cover in maternity services.
• Ensure that telephone advice given to women in maternity services is documented
• Ensure there is a system in place to check that HSA4 notifications of termination of pregnancy for fetal abnormalities are submitted to the Department of Health.
• The hospital should consider reviewing the tools staff use to assess pain and introduce a standard methodology that is consistently used and recorded.
• The hospital should consider reviewing the process for completing DNACPR form, determine a specific location where they are kept and ensure staff are aware they can be used as an interim measure on discharge until the primary care team can complete a new one.
• The hospital should consider reviewing the escalation process when delays occur with the completion of death certificates. 
• 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 and clinical imaging departments ensure all staff are appraised regularly as prescribed by trust’s policies related to staff training and development
• The hospital should ensure staff are aware how to arrange for an interpreter.

• ​The hospital should ensure that consultants review the results of local audits and implement strategies to ensure results continue to improve towards meeting CEM guidelines.

Professor Sir Mike Richards

Chief Inspector of Hospitals