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The Care Quality Commission checks whether hospitals, care homes and care services are meeting government standards. Visit our website at www.cqc.org.uk.

Royal Surrey County Hospital

  • Egerton Road, Guildford, Surrey, GU2 7XX

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Type of service
Hospital

Specialisms/services
Assessment or medical treatment for persons detained under the Mental Health Act 1983, Diagnostic and/or screening services, Family Planning services, Maternity and midwifery services, Services for everyone, Surgical procedures, Termination of pregnancy, Treatment of disease, disorder or injury

Local Authority Area
Surrey

These checks were made using our new inspection model for NHS hospitals. If we are taking enforcement action, we highlight it below.
The ratings below are the result of a pilot undertaken to help us confirm how we will to rate at different levels of an organisation.

Click on each area to read a summary

Summary of inspection on 17-18 and 23 October 2013

The Royal Surrey County Hospitals NHS Foundation Trust is based at the Royal Surrey County Hospital. It is a leading general hospital and specialist tertiary centre for cancer, oral and maxillofacial surgery and pathology. The trust also has a very strong reputation for minimally invasive and laparoscopic surgery, which are used widely across the surgical specialties. It runs outpatient clinics at Cranleigh, Haslemere and Woking hospitals.

The trust has over 520 beds, 14 operating theatres, two MRI scanners, four CT scanners, interventional radiology equipment and a gamma camera.

It serves a population of 320,000 for emergency and general hospital services and employs 3,100 staff, making it the second largest employer in Guildford. Every year, the trust sees 240,000 outpatients, 58,000 inpatients, and 72,000 patients in accident and emergency. It delivers more than 3,200 babies every year.

Overall, the trust was providing services that were safe, effective, responsive, caring and well-led. However, there were some areas for improvement.

The culture throughout the trust was very open, and staff were very enthusiastic, positive and knowledgeable about the trust’s overall vision and strategy.

The Board structure is relatively new and there is still some embedding required. The CEO is well respected and popular with the staff and he and board members were visible throughout the trust. There was evidence of good leadership at the majority of department levels and a lot of innovation by staff to continually improve the patient’s experience. There are a number of processes for communication flow from and to the Board and departments. However, priorities at the departmental level had not been captured at trust level, and there is a lack of connection to the Board. This led to the executive team being unclear on its understanding of issues in departments, and there was a general perception throughout the trust that the executive team and local teams are progressing at different paces and priorities were not always aligned.

The quality strategy focused on national targets and future developments without defining key quality and safety priorities of the organisation. Thus members of the Board were not able to articulate all of the quality strategy for some basic quality issues specific to the trust.

Operational management was not fully connected from Board to departmental level and not all middle management had a clear understanding of the range of risks across the trust. There is a risk register that looks at risks highlighted by the specialist business units, but it was not evident that the Board reflects a trust-wide perspective.

The trust was working to full capacity in most departments with cancellations of elective surgery on one of the days of the visit, and this was providing a challenge for them. The trust recognised this problem, and it had a number of plans to improve the capacity of the hospital in the long term. The full alignment of capacity issues and the impact of patient experience could not be fully articulated by the trust. Although capacity was being created within theatres and critical care to support cancer services, the impact of this in pressure on ward beds could not be evidenced within the business planning. The trust had paid less attention to how it would manage the current capacity issues, and the impact they were having on the experience of patients, until it implemented the long-term plans. These capacity issues included:

  • Staffing levels for support/administration staff.
  • Staffing on some wards, particularly care of the elderly.
  • Managing capacity issues in outpatients, particularly in ophthalmology.
  • Managing issues such as discharge letters and GP correspondence.

The trust had plans for the development of its cancer services to meet the needs of patients. This will inevitably put further challenges on capacity and staffing requirements. The trust will need to address these before it puts its plans to expand cancer services into action.

Patients were generally very positive about the care they received at the hospital. They were very supportive of the trust and keen to be involved in the improvement at the hospital. The vast majority of patients that contacted us and those we spoke with commended the care they received at the trust. However some patients we spoke to at the listening event and who had contacted us directly had not had good experiences and some reported delays in their complaints being dealt with a timely fashion. They had little opportunity to engage with the trust other than through the complaints system. The trust was developing more ways to engage with patients and the community, but it had not fully implemented its ideas. However, there was some innovative work taking place at departmental level.

Cancer services were safe, effective, responsive and well-led. They were at full capacity, and staffing in some areas left little allowance for contingency planning and unplanned absences. On occasions this did impact on the effectiveness of services and their ability to be caring. The staff themselves were caring, but not all patients had their expectations met, and the cancer patients experience survey identified a number of areas where the trust needs to make improvements.

Staff were positive and engaged, and nursing staff levels were being managed well at departmental level, despite staff shortages in some areas.

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Background information for inspection on 17-18 and 23 October 2013

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Checks on specific services

Summary of inspection on 17-18 and 23 October 2013

The A&E department was safe, caring, responsive and well-led. However, we found that the department’s effectiveness could be improved. Some clinical pathways were not being followed (for example management of Neutropenic sepsis) and the management of people’s pain needed improvement as patients presenting with pain were not always given or offered pain relief in a timely manner.

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Summary of inspection on 17-18 and 23 October 2013

Overall, medical care was caring, effective, responsive, well-led and effective but improvements were required in safety. We had concerns about Merrow, Wisley, Eashing and Albury wards we visited, where staffing levels were low and there was a risk that patients may not receive safe care. The trust had acknowledged that Eashing and Wisley do not have a sufficient number of staff to provide the care needed by acute patients, and it was taking action to address the problem but had not identified shortages on Merrow and Albury. We saw that staff were busy and that patients’ basic care needs were attended to. However, sometimes staff were not always able to update bedside documentation to reflect patients’ present care needs, or attend to patients in a timely manner.

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Summary of inspection on 17-18 and 23 October 2013

Over all we found surgery to be safe, caring, effective, responsive and well-led. We found that staff assessed patients’ needs and planned care to meet those needs. Staffing levels were acceptable on all wards except Ewhurst, where there had been no senior sister for eight weeks. Since the recent appointment of a senior sister on this ward, we were told that things had improved.

Practices and procedures within theatres were safe. The trust had recently revised the World Health Organisation Surgical Safety Checklist. Most patients we spoke with told us that their treatment had been effective at each stage, from admission as an emergency or referral by the GP to successful surgery and recovery. The surgical wards had an ‘early warning score’ that detected deterioration of patients’ conditions and called for urgent medical help. We saw that all wards had safety performance heat maps.

Patients were satisfied with their care. Some patients said that they had quick personal care when they needed it, but a few said that staff did not answer call bells as quickly as possible by members of staff. Overall, we found that staff kept patients informed about their treatment. However, there were a few instances when patients had not been kept adequately informed. This resulted in patients feeling isolated. Patients told us that the overall service was good and the wards were well run. They told us that members of staff worked well with each other. We found that staff had completed training in a number of areas including dementia awareness, infection control, and health and safety.

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Summary of inspection on 17-18 and 23 October 2013

Over all we found intensive/critical care to be safe, caring, effective, responsive and well-led. Staff assessed patients’ needs and planned care to meet those needs. There were sufficient numbers of suitably qualified nursing staff to meet patients’ needs and provide safe care. Intensive Care National Audit & Research Centre (ICNARC) data shows that the trust were performing well within expected nationally, though there were significant delays in discharging their medically well to the wards. The department recognised that the number of beds in the unit was not adequate. It had plans for expansion for an additional 12 beds. However, we are concerned that the trust has not clearly thought through the requirement for additional nursing, other staff and beds in other wards to accommodate the increased amount of patients requiring discharge from ICU, or how it will manage discharge of medically well patients.

Staff respected patients’ privacy and dignity. Family members told us that the care in ITU was “first class”. The department had carried out a survey of the views of patients’ families. Responding to the feedback, it was going to put in place accommodation for relatives. We found there was multi-professional team working across the unit and with other hospital providers in the area. This meant the service was well-led.

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Summary of inspection on 17-18 and 23 October 2013

Overall, medical care was caring, effective, responsive, well led and effective but improvements were required in safety. We had concerns about Merrow, Wisley, Eashing and Albury wards we visited, where staffing levels were low and there was a risk that patients may not receive safe care. The trust had acknowledged that Eashing and Wisley do not have a sufficient number of staff to provide the care needed by acute patients, and it was taking action to address the problem but had not identified shortages on Merrow and Albury. We saw that staff were busy and that patients’ basic care needs were attended to. However, sometimes staff were not always able to update bedside documentation to reflect patients’ present care needs, or attend to patients in a timely manner.

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Summary of inspection on 17-18 and 23 October 2013

Over all we found children’s services to be safe, caring, effective, responsive and well-led. The children’s unit is modern and well equipped and reflects the ideas and contributions of children and young adults who use the service. The unit is a testament to how the organisation has used staff and patient suggestions to develop a state-of-the-art environment that provided high levels of care in a calm and relaxed atmosphere. Parents told us that the facilities were outstanding and that staff paid great care and attention to the needs of the children and their families.

The children’s service has good and effective leadership within an open and supportive culture. The staff reported that there was a close and integrated team spirit in the unit that worked closely with maternity services.

There was a dedicated children’s outpatient department that provided a service within the children’s unit and offered a range of general paediatric and specialist clinics. A&E facilities were functional and provided a high level of care and support. However, the environment for children and young people attending the A&E department did not reflect the care and attention to detail of the design of the main paediatric area.

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Summary of inspection on 17-18 and 23 October 2013

Over all we found end of life care to be safe, caring, effective, responsive and well-led. Patients and relatives were positive about the quality of end of life care. None of the people we spoke to had any concerns about the way staff maintained patients’ privacy and dignity. We found that staff were caring and services responded to patient’s needs. Services were well-led.

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Summary of inspection on 17-18 and 23 October 2013

Over all we found outpatients to be safe and caring. Improvements are needed in effective, responsive and well-led domains. We found out-patient departments that did not always have the capacity to meet demand.

The eye outpatient service was especially overcrowded. Patients said they had been waiting for up to four hours, and data that we received before and during the inspection confirmed that this was a regular occurrence. The trust was aware of this and had plans to expand the service to address its capacity issue. However, it had not taken sufficient action to minimise the impact of this issue on patients while the service was expanded.

Problems in accessing medical records also made delays worse and put extra demands on the nursing staff to cope with the capacity levels. We had concerns that eye testing was being performed in a busy corridor and that there were significant delays in communicating with patients’ GPs, which had the potential to disrupt patients’ treatment.

The hospital made arrangements for people to attend appointments at a time that was convenient for them. However, the long waiting meant that appointments did not take place at the time planned, and patients expressed concern about that a lack of available parking spaces made it difficult to be on time for appointments.

We observed that staff were kind, caring and courteous in their dealings with patients. Staff were familiar with and understood the hospital’s vision and strategy.

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Inspection areas

Summary of inspection on 17-18 and 23 October 2013

Overall services were safe, but some improvements were needed in medical services.

  • Patients’ needs were assessed and staff provided care to meet those needs.
  • Systems were in place to minimise risks to patients. Including the safety thermometer (to measure patient safety).
  • Although services were safe, in some wards and outpatient departments we found that the level and mix of staffing might create a risk to the safety of patient care, particularly in areas of care for frail elderly patients and administration support services.
  • Analysis of falls in the Wisley ward had indicated that they had all occurred at night, and three had occurred when a staff member had been removed to provide cover elsewhere. This meant the ward was unable to operate the night time protocol safely due to staff shortages.
  • Not all the equipment in accident and emergency had proof of having been tested, so the trust could not be sure that all equipment was safe.
  • Trust priorities not clearly articulated within a robust quality strategy.
  • Root cause analysis of pressure ulcers were undertaken locally at grade 2 and corporately at grade 3, but there was no evidence of a connection between them.

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Summary of inspection on 17-18 and 23 October 2013

Overall the trust is effective, but the trust needs to make some improvements to ensure that all services are effective at all times particularly in outpatients and A&E.

  • Some clinical pathways needed improvement, for example the management of neutrosepsisin A&E was not always being followed.
  • The management of people’s pain in A&E needed improvement as patients presenting with pain were not always given or offered pain relief in a timely manner.
  • In some areas, the trust had not been consistent in making changes identified in its action plans in response to complaints and incidents.
  • Staffing levels were impacting on the effectiveness of some services. Current management of staffing levels, processes and patient numbers made effectiveness inconsistent.

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Summary of inspection on 17-18 and 23 October 2013

Overall, services were caring, but there were some areas for improvement.

  • Overall staff treated people with compassion, respect and dignity. The time given to care depended on patients’ specific needs. Patients felt cared for and listened to by staff, though some patients we spoke to at the listening event and who had contacted us directly had not had good experiences.
  • Staff generally maintained people’s privacy and dignity.
  • The vast majority of patients commended the trust on the care provided by the nurses and doctors.
  • Patients told us that, despite delays for appointments and long waits in outpatients, when they were seen the staff were very caring. However, there were a number of people who had not had this experience and reported a poor attitude in the way they were spoken to by some nursing staff, doctors and consultants.
  • The majority of patients and their relatives said that staff kept them informed about treatment.
  • Patient records reflected where staff had sought consent to deliver care and treatment, and discussions regarding treatment decisions had been recorded.
  • Staff involved patients and their families in the planning of care, and there was effective communication.
  • A ‘dementia passport’ was used to identify patients with dementia and ensure they got the support they needed when in hospital.
  • A ‘communication passport’ was used for adults with learning disabilities.
  • The cancer patients’ survey had identified some areas that required improvement. Overall, services were caring, but there were some areas for improvement

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application/pdf icon Quality report published 18 December 2013 782.1KB

Summary of inspection on 17-18 and 23 October 2013

Overall, services were responsive, although there were some areas for improvement particularly in outpatients

  • Maternity services were particularly good at responding to patients’ needs.
  • The children’s ward responded well to patients’ needs, though the department could make further improvements to the children’s environment in A&E.
  • Surgery services had responded well to patients’ needs, although patients did tell us that there were some delays at times due to staff shortages.
  • Records showed that A&E was now reaching the national target of seeing, discharging or admitting 95% of patients within four hours. Evidence showed that on arrival patients were seen by the triage nurse within 30 minutes.
  • Some medical wards (particularly the frail and elderly and outpatients) were not always able to respond to patients’ needs in a timely manner when there were staff shortages or overcapacity.
  • The trust now faces the challenge of how to meet people’s needs effectively until it can put more staff in place.
  • Overcapacity issues had led to delayed appointments and long waits in some outpatient departments, particularly ophthalmology.

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application/pdf icon Quality report published 18 December 2013 782.1KB

Summary of inspection on 17-18 and 23 October 2013

Overall there were some areas for improvement.

  • The trust was well-led at departmental level, with the exception of outpatients and there was a transparent, open, supportive culture. Everyone was clear on trust priorities, but priorities at departmental level had not been captured at trust level.
  • Current operational structures had a lack of connection to Board level, which led to the executive team being unclear on its understanding of issues at a department level.
  • The trust’s quality strategy focused on national targets and future developments. The Board was not able to articulate the quality strategy for some basic quality issues specific to the trust.
  • Not all middle management had a clear understanding of the spread of risk across the trust.
  • The risk register highlighted risks by the specialist business units, but it was not evident that there was a trust-wide perspective.
  • Consultants told us that they needed more leadership training, and that there was no provision for their leadership roles within their current job plans.
  • We were told that there was currently no leadership development plan.
  • There were clear lines of accountability within the maternity department.
  • Staff were confident about their roles and responsibilities.
  • Staff within the maternity unit trained together and operated as an efficient and cohesive team.

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application/pdf icon Quality report published 18 December 2013 782.1KB

Latest Inspection

The latest check of this hospital was carried out on 17-18 and 23 October 2013 using our new inspection model.

application/pdf icon Quality report published 18 December 2013 782.1KB

Inspection Reports

Carried out on 24 May 2013 during a routine inspection
Download report:  
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Carried out on 16 August 2012 during a routine inspection
Carried out on 22 and 23 March 2012 during a themed inspection
Carried out on 24 March 2011 during a themed inspection

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What our icons mean

All standards were being met when we inspected the service. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.
At least one standard in this area was not being met when we inspected the service and we required improvements.
At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.


What does a grey cross mean

At least one standard in this area was not being met when we inspected the service and we required improvements.

What happens next
The service will tell us how it is making improvements. Once we are happy that the improvements have been made, we will update our judgement to show a green tick. Other times, we may have to carry out a 'follow-up' inspection to check improvements.


How can I get more information
Our inspector's report will give you more information about why the service received a grey cross. You can also contact the service directly or visit its website for more details on any improvements it has made.



What does a red cross mean

At least one standard was not being met when we inspected the service and we took enforcement action.

What happens next
The type of enforcement action we take depends on the seriousness of our inspector's findings, and the service must make improvements before we update the judgement on our website.


How can I get more information
Our inspector's report will give you more information about why the service received a red cross. You can also contact the service directly or visit its website for more details on any improvements it has made.