St George’s Hospital told it requires ‘urgent’ improvement by CQC

The CQC found numerous issues with the maternity services at St George’s Hospital in its first stand-alone inspection, as it has previously been rated with gynaecology services as well.

The inspection took place in March 2023 and the current rating for St George’s University Hospitals NHS Foundation Trust remains as requires improvement.

Following this inspection, CQC issued a warning notice to focus the trust’s attention on rapidly making the necessary improvements to keep people safe at St George’s Hospital. 

Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said: “When we inspected maternity services at St George’s Hospital, it was concerning to see a deterioration in the standard of care being delivered.

“We saw areas where significant and urgent improvements are needed to ensure safe care is provided to women, people using this service, and their babies.    

“Both staff and people using the service were being let down by leaders who failed to respond quickly, resulting in care that was unsafe, and in the delivery suite, also chaotic. 

“When things went wrong, we saw staff were honest and supportive to people, but leaders were slow to respond and often logged incidents as causing less harm than they did.

“We saw some baby deaths weren’t investigated as serious incidents and investigations didn’t always take place in a timely way.

“This is unacceptable and put people at risk of avoidable harm from mistakes being repeated. 

“Staff told us care often felt unsafe because there weren’t enough of them, and we saw they’d reported numerous incidents in which people’s safety was at risk.

“Staff said managers told them nothing could be done, but we found opportunities to reduce risks had been missed or ignored.  

“We also found people were at risk of infection because ward environments were dirty and poorly maintained.

“Again, staff had raised many issues with the trust but some longstanding problems still hadn’t been fixed.

“Leaders must listen and act when staff tell them something isn’t right.  

“Following the inspection, we’ve issued a warning notice to focus the trust’s attention on how they’re managing risks to women and people using this service, as well as their babies, and we expect to see rapid and significant improvements.  

“The trust has submitted an action plan on how they plan to resolve the issues raised. 

“We’ll continue to monitor the service and the wider trust, including through future inspections, and won’t hesitate to take further action if we’re not assured it’s delivering safe and effective care.”  

Inspectors also found that leaders didn’t always act quickly to reduce risks to people’s safety from understaffing, didn’t always try to understand why many staff were leaving, and hadn’t mentioned issues in maternity during the trust’s annual staffing review.

While staffing challenges are affecting much of the NHS, the CQC reported that leaders must ensure this doesn’t undermine people’s safety. 

Inspectors also found that the delivery suite had no clear leadership to make sure women and people using the service received safe, consistent care. 

The service didn’t assess people’s risk in a consistent way when they arrived and didn’t always prioritise people according to their clinical need.

Inspectors saw some people wait without privacy or a way to call for help.

The CQC discovered incidents in which some people left before being seen because they’d waited so long.  

Medical staff didn’t always have enough training in resuscitation, caring for people with disabilities, or safeguarding children and young people.

Training days were often rescheduled because there weren’t enough staff. 

Staff even told inspectors that they felt opportunities weren't equal for all staff and inspectors saw that staff from ethnic minority groups were underrepresented in leadership roles and promotions. 

However, the CQC did also find that women and people using the service said most staff were friendly and explained their care to them. However, some people said staff were stressed. 

Most staff told the CQC that they knew how to care for parents with learning disabilities and used a ‘maternity passport’ to make sure they could communicate their needs and wishes. 

Inspectors found that a new maternity strategy had been implemented under the current director of midwifery, and staff said the workplace culture was improving. 

Jacqueline Totterdell Group Chief Executive said, “We take the findings of this report extremely seriously and accept that the standards on our maternity unit have fallen below what we expect.

“We have taken immediate action to address the concerns raised by the CQC and we remain committed to making improvements to ensure those providing and receiving care in our department have the best possible experience.

“I would like to reassure those due to give birth in our maternity unit that it continues to be a safe and positive environment to give birth in, which has been recognised by the CQC national patient experience maternity survey which rated St George’s as receiving the fourth highest patient satisfaction levels nationally in 2022 as well as being rated in the top three performing Trusts in London for antenatal care.

“We understand that people may be concerned, and I would encourage anyone who is to get in touch so we can listen to and answer questions directly.”