Guy's Hospital

Updated 23 July 2019

Guy’s Hospital is part of Guy’s and St Thomas’ NHS Foundation Trust and is situated near London Bridge in the borough of Southwark in central London. Guy’s Hospital provides a range of medical and surgical services for inpatients, as a day-case and outpatients.

Guy’s is a major elective centre for south London and provides specialities including; urology, orthopaedics, ear, nose and throat and cancer services, including radiotherapy and breast and lung surgery. It has the largest dental school in Europe and since the previous inspection has opened a dedicated cancer centre. The hospital also has an Urgent Care Centre and provides community services within the local borough.

The hospital has 400 beds.

Updated 23 July 2019

In rating the location, we took into account the previous ratings of services which were not inspected on this occasion.

Our rating of services stayed the same. We rated it them as good because:

• The hospital always had enough staff with the right qualifications, skills, experience and training to keep patients safe from avoidable harm and abuse, and to provide them with the care and treatment they needed. Staffing levels were matched to patient need and clinic activities. All staff understood their responsibilities to safeguard patients from abuse and neglect and had appropriate training and support.
• There was a well-embedded incident process and learning from the investigative process was valued by staff.
• Departmental leaders had the knowledge and experience to lead and support staff. They promoted a positive culture, which valued and respected staff. There was a commitment to the improvement of waiting times, patient access and the whole patient experience.
• Staff engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborate with partner organisations effectively. Feedback from patients was used to develop services.

However:

• Some of the expected service delivery targets were not being met. This included the referral to treatment (RTT) targets for all the specialities and in cancer services patients receiving their first treatment within 62 days of an urgent GP referral.
• A significant number of patients had overdue follow up appointments, which posed a risk to some. Patients had long waits in some clinics and were not always offered a choice of appointments times.
• Medicine administration was not always in line with trust policy.
• Mandatory training in key skills was available to all staff but expected completion rates for this was not being met.
• The premises were not always suitable for the intended use and patients’ privacy and dignity could not always be maintained. Equipment was not always safely managed.
• Staff did not always complete patient records to professional standards.

Updated 24 March 2016

Between April 2014 and March 2015, Guy's Hospital did not meet the Referral to Treatment target (admitted) of 90 % but did so in 88.9% of cases.

There was a positive culture of incident reporting. Staff understood and fulfilled their responsibilities to raise concerns and report incidents. Measures for the prevention and control of infection met national guidance and standards of hand washing and cleanliness were consistently high and regularly audited. There were sufficient doctors and registered nurses on duty, staffing levels were tracked four times a day across the hospital. Patients who were deteriorating were seen by advanced nurse practitioner and had their care re-assessed.

Staff were well supported with access to training, clinical supervision and development. National Institute for Health and Care Excellence guidance was used across a range of conditions. Patients’ nutritional needs were assessed with scores recorded and risks identified. Consultants covering oncology and haematology were available seven days per week. Patients were asked for verbal consent to be treated and we saw consent forms to treatment forms had been signed by the patients prior to medical procedures.

Patients received compassionate care and were treated with dignity and respect. Patients and relatives and their relatives were positive about their experience of care and the kindness afforded them. Patients told us they were involved in decisions about their care and treatment and were given the right amount of information. The trust had a higher response rate to the Friends and Family test (FFT) than the England average.

We found evidence of  monitoring of patient outcomes through a range of audits and national guidance was used to inform patient care and treatment.  

The hospital proactively managed patients discharge. Where a patients discharge was delayed this was escalated to the discharge team to progress. 74% (3,444) of patients experienced no ward move and were treated in the correct speciality bed for the entirety of their stay. Patients had their needs assessed and fundamental care rounds were undertaken at different times of the day. Formal complaints were managed through the Patient Advice and Liaison Service (PALS), they were investigated with learning points identified and fed back to staff.

Staff were aware of the trust's vision and incorporated this as part of their daily work. The culture within the division was of openness and honesty. Ward managers were provided with regular reports on incidents, complaints, survey results and staffing data. Trends could be readily identified and learning was disseminated to staff. Staff reported they were supported by their managers and department heads. We found that staff and patients were engaged with the development of medical care services, and saw examples of innovative practice.

Updated 24 March 2016

Patients achieved positive outcomes, including good safety thermometer results and a better mortality rate than other similar units. This was due evidence-based care delivered by safe numbers of competent staff. Patients could access the service without delay and there was suitable patient flow through the unit.

There was positive safety reporting culture within critical care and investigations completed as a result highlighted learning points which were clearly communicated to ward staff. Patient records including medicines administration charts were fully completed and medicines were appropriately managed.

Staff were caring and maintained patient privacy and dignity during their admission to the unit. We observed staff treating patients with respect and obtaining consent from patients prior to performing care tasks. Patient and relative feedback about the care they received was positive and there were good facilities for relatives. There were few formal complaints received by the unit and we noted the actions taken in response to informal feedback.

Staff were comfortable approaching the leadership team with any issues and were encouraged to develop professionally. The management team had good oversight of the unit however, vision for improvements to Guy’s Critical Care Unit was minimal and the primary goal for developing critical care within the trust was focused at St Thomas’ Hospital.

Staff knowledge of safeguarding principles and Deprivation of Liberty Safeguards was limited and appropriate practice in these areas was not embedded. Staff appraisal rates were low and less than the recommended 50% of nursing staff had a post registration award in critical care nursing. We saw no immediate action in place to ensure sufficient stock of some medicines over weekends which meant some patients missed doses of certain medicines for three weekends in a row.

Updated 24 March 2016

We saw that patients benefited from a multi-disciplinary approach to care. Generalist nurses and medical staff worked alongside the specialist palliative care team (SPCT) to deliver a cohesive plan of care.

Staff at Guy’s Hospital provided skilled and compassionate end of life care to patients. The SPCT was effective and provided face to face support seven days per week including 24/7 community visiting. Due to staff shortage at the time of the visit on call was restricted to visits until 9pm and calls taken until 11pm. The Consultant rota remained unchanged during this period. 

There was good leadership of the SPCT. Staff felt senior managers were willing to help, offered support and guidance, were often seen on the wards and were very approachable. We found many examples of innovative practice, including 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. 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.

The hospital had a long term vision and strategy plan around end of life care. This had been drafted by external advisors and staff commented that it was not, in its current form, wholly achievable but it was under review. Staff were clear their focus was on providing individualised care, with quality outcomes and multi-disciplinary input. The SPCT encompassed national guidance into its end of life care protocols and practice such as the NHS guidance – Priorities for the Care of the Dying Person and One Chance to get it Right - developed by the Leadership Alliance for the Care of Dying People (LACDP). It also referenced to the NICE quality standards for end of life care.

Bereavement support was available from a number of sources – staff in the bereavement office, the social workers attached to the SPCT and the chaplaincy. We visited a number of wards and observed patients being cared for with dignity and respect. Staff facilitated rapid discharge of patients to their preferred place of death. Medicines were provided in line with guidelines for end of life care. Feedback from patients and relatives, both in person during the inspection and gathered by the hospital in its own bereaved carer survey, was overwhelmingly positive.

The hospital was in the process of moving to wholly electronic based records. We found that during this process staff needed to use three different software systems as well as paper records, which led to some confusion and uncertainty around where to find key information. This was particularly noticeable with regard to 'do not attempt cardiopulmonary resuscitation' (DNACPR) forms. We found there was no consistency in the recording of mental capacity assessments.

From January to December 2014 there had been 971 deaths at the Trust.

Updated 23 July 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated outpatients as requires improvement because:

• Medicine administration was not always in line with trust policy.

• The service was not meeting the referral to treatment (RTT) targets for all the specialities. For cancer services, the trust is performing worse than the operational standard for patients receiving their first treatment within 62 days of an urgent GP referral.

• The service provided mandatory training in key skills to all staff and but did not ensure everyone completed it to meet the trust targets.

• The service did not always have suitable premises or equipment and did not always look after them well.

• Documentation in paper records and medicine administration was not always in line with trust and professional standards.

• The trust had many patients with overdue follow up appointments and it was unclear how the trust was managing the risks to these patients.

• Patients’ privacy and dignity was not always maintained due to the layout of some the clinical areas.

• Patients told us they regularly experienced long waits in clinic and they were not always offered a choice of appointments times.

However:

• The service had enough staff, with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

• There were effective systems to protect people from avoidable harm. Learning from incidents were discussed in departmental and governance meetings and action was taken to follow up on the results of investigations.

• Leaders were very knowledgeable about their services and were committed to develop the service to improve waiting times, patient access and patient experience.

• The services engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborate with partner organisations effectively. The views of patients were sought in several different ways and senior leaders engaged with staff to keep them informed of important changes.

• Managers promoted a positive culture that supported and valued staff.

Updated 24 March 2016

The trust mandated staff to use all five stepsof the World Health Organisation (WHO) Surgical Safety Checklist in theatres, including team briefing and de-briefing components, in May 2015. Prior to this, staff were primarily expected to use the three central steps (sign in, time out, sign out) only. We witnessed some surgeons completing the five steps of the WHO checklist thoroughly and in full. However, we also found some inconsistencies in the application of briefings and de-briefings by some surgeons.

We found good levels of cleanliness, infection control and hygiene across surgery wards and in theatres. Staffing in wards and theatres was good with very low use of bank and agency staff, and there was good retention and management of nursing turnover. There was good completion of mandatory training and effective systems in place to report incidents. However, we found that the sharing of learning from incidents could be improved.

Surgical patients received effective care and treatment that met their needs and there was evidence of positive feedback from patients. Their care and treatment was planned and delivered in line with national and local guidelines. Patients were treated with compassion, dignity and respect. All of the patients we spoke with praised the staff for the care they provided and said that they would recommend the hospital and its surgery services.

We found very effective multidisciplinary team working between doctors, nurses, physiotherapists and other allied health professionals. Information was shared proactively between staff groups to ensure good coordination of patient care on wards and to help discharge patients more rapidly. However, this effective team working was sometimes impacted by delays elsewhere in the hospital, particularly in obtaining prescription drugs from the pharmacy.

The leadership and culture of surgery services promoted the delivery of high quality, person-centred care. The service had a clear vision and values. There was high morale amongst staff, particularly on the wards. Staff were supported by their managers and there was a culture of openness to learn and develop services. Performance information was shared within each of the directorates delivering surgical services, but we found limited formal structures for governance information to be shared between the directorates delivering surgical activity. Staff were given opportunities to provide feedback and inform service development. They were also supported by managers to develop their knowledge and skills to improve the quality of care provided to patients.

Updated 24 March 2016

The trust had only recently taken over responsibility for the service prior to the inspection and has not supplied any patient outcome data provided that was specific to the UCC. Therefore, we did not know whether the UCC was performing better or worse than similar units.

The team working in the department were dedicated to providing a safe and efficient service that took into account the needs of the local population. Staff were skilled at caring and treating for patients with complex needs and those who needed a referral to a more appropriate service. Staff had been trained to ensure that patients who could not communicate verbally could be assessed and treated effectively.

Our interviews with staff and review of documentary evidence in the department showed us that management and leadership structures were conducive to a department that operated with openness and transparency. This was evident in the way staff approached incident reporting and investigations and the handling of complaints. Learning from such instances was embedded into service planning and detailed root cause analyses ensured that investigations were fair and thorough.

The streaming processes in the department were well established and meant that ENPs consistently met the target of seeing each patient within 15 minutes of their registration. Patient attendance rates were monitored on a monthly basis and were used to plan staffing levels to effectively meet times of high demand. The interactions we observed between patients and staff were positive and the patients we spoke with told us they were happy with the service they had received.

The environment was clean and tidy and staff complied with trust infection prevention and control policies. Equipment was maintained to an appropriate standard and had been checked regularly. Medicine storage met the requirements of the National Institute for Health and Care Excellence and staff were appropriately trained for the administration of medicines.