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Epsom General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 27 May 2016

Epsom General Hospital is part of Epsom and St Helier University Hospitals NHS Trust. The trust provides local acute services for people living in the southwest London and northeast Surrey. Epsom General Hospital provides acute hospital services to population of around 180,000.

Epsom General Hospital is home to the South West Elective Orthopaedic Centre (SWLEOC), which is one of the largest hip and knee joint replacement centers in the UK. Most of the trust’s elective surgery is undertaken at Epsom General Hospital and the majority of emergency surgery is carried at the trust’s other location, St Helier Hospital and Queen Mary's Hospital for Children.

Epsom and St Helier University Hospitals NHS Trust employs around 5024.8 whole time equivalent (WTE) members of staff with approximately 705 staff working at Epsom General Hospital. We carried out an announced inspection of Epsom General Hospital between 10 and 13 November 2015.

We also undertook unannounced visits to the hospital on 21, 23, 25 and 27 November 2015. Overall, this hospital is rated as requires improvement. We found urgent and emergency care, surgery, critical care, maternity and gynaecology, services for children and young people required improvement. We found medical care, outpatients and diagnostic services and end of life care were good. We have rated the South a West London Elective Orthopaedic Centre as outstanding.

We found the care of patients was good, but the safety, effectiveness, responsiveness and leadership and management required improvement.

Our key findings were as follows:

Safe

  • Systems and processes were in place for reporting and investigating incidents but learning from incidents and complaints was inconsistent.
  • Low nurse staffing levels on some surgical and children wards meant there was a risk to the quality of patient care. There was also a large number of vacant medical staff posts and high use of locum doctors in paediatrics. However, the hospital had recently undergone a recruitment drive which had enabled it to fill some of its nursing and medical vacancies.
  • Cardiac monitors used in the majors area in ED were not fit for use and this had been an ongoing risk for over a year, without an adequate solution. Major incident equipment we observed was out of date and not ready for use in the event of a major incident.
  • Mandatory training completion rates were low.

  • The hospital was visibly clean. However data supplied by the trust indicated that wards repeatedly fell short of the infection prevention control compliance threshold. Staff reviewing patients on the unit did not always comply with infection control practices such as being bare below the elbow and hand washing.

  • Appropriate procedures and staffing were in place to prevent harm.

  • We identified gaps in record keeping and safe storage of medicines management in some areas.

Effective

  • Patient outcomes were good across most specialties and the trust performed well in national surgical audits. In the SWLEOC, patient outcomes and patient satisfaction consistently exceeded national averages.
  • We found staff appraisal completion rates were low.
  • There was a lack of clarity amongst some staff with regard to how the Deprivation of Liberty Safeguards should be used
  • There was a lack of agreed guidelines specific to the critical care unit and no system to ensure consistency of care, even though three different consultants cared for patients in one day. The unit had a larger number of delayed discharges compared to similar units.
  • There was good multidisciplinary teamwork and collaborative care.

Caring

  • Patients and their relatives commented positively about the care they received and the attitude of the staff. Staff provided care in a compassionate and kind way that preserved patients’ dignity. Patients felt supported and involved in their care and treatment.
  • Whilst Family and Friend Test feedback was positive, the response rate was notably low.
  • Patients were kept informed of their treatment, given detailed information about their diagnosis, and given time to ask further questions.

Responsive

  • At Epsom ED for the 12 months between November 2014 and October 2015, 94% of patients were seen, admitted, transferred or discharged within four hours.
  • In all but neurology and dermatology, the medical directorate achieved the 18 week referral to treatment standard. The average length of stay at Epsom was slightly longer for non-elective care than the England average.
  • The medical directorate was slow to respond to complaints, achieving an 8% response rate within designated timescales.
  • Not all women received one to one care in labour.
  • National waiting times were met for outpatient appointments and access to diagnostic imaging although the wait for MRI services had increased.
  • A higher percentage of patients were seen within two weeks for all cancers than the national average, but the cancer waiting times for people waiting less than 31 days from diagnosis to first definitive treatment and the proportion of people waiting less than 62 days from urgent GP referral to first definitive treatment were both below the national average.

Well-led

  • Vision and strategy within departments were not well developed or known by all staff.
  • There were good local governance structures and reporting mechanisms in place, however we found a lack of responsiveness to some known challenges and concerns.
  • In critical care, the strategy for the unit had not been agreed due to difficulties in reaching an agreement among the critical care workforce across the two sites and staff were not aware of the vision for the unit. Not all risk had been identified on the risk register and some risk had been on the register for some time and senior staff were still unclear on the timescale to address these risks.
  • The trust monitored maternity services based on merged data from both maternity units. This was misleading because the units were very different, with different staff and serving different populations.
  • The hospital had a number of innovative projects underway, including some related to patients living with dementia. We saw several areas of outstanding practice including:
  • The leadership of the outpatients and diagnostic imaging teams was outstanding with staff inspired to provide an excellent service, with the patient at the centre.
  • The diagnostic imaging department worked hard to reduce the patient radiation doses and had presented this work at national and international conferences. However, there were also areas of poor practice where the trust needs to make improvements.

We saw several areas of outstanding practice, including:

  • The leadership of the outpatients and diagnostic imaging teams was outstanding with staff inspired to provide an excellent service, with the patient at the centre.
  • The diagnostic imaging department worked hard to reduce the patient radiation doses and had presented this work at national and international conferences.
  • The safety and leadership of the SWLEOC, where outcomes for patients were consistently excellent and based on national guidelines.

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

Importantly, the trust must:

  • Ensure there are adequate numbers of nurses and midwives to deliver safe and quality care.
  • Implement agreed guidelines specific to the critical care units.
  • Ensure the management, governance and culture in the critical care units, supports the delivery of high quality care.
  • Obtain feedback from patients/relatives in the critical care units, so as to improve the quality of the service.
  • Identify, analyse and manage all risks of harm to women in maternity services
  • Ensure identified risks in maternity services are always reflected on the risk register and timely action is taken to manage these risks.

  • Improve the quality and accuracy of performance data and increase its use in identifying poor performance and areas for improvement.

In addition the trust should:

  • Ensure cardiac monitors used in the majors area in ED and major incident equipment are fit and ready for use in the event of a major incident.
  • Ensure the target for 85% compliance for mandatory training is met.
  • Ensure staff always comply with infection control practices.
  • Ensure child protection notifications from the trust are up to date.
  • Ensure staff appraisals are completed as required.
  • Ensure all relevant staff are clear about how the Deprivation of Liberty Safeguards should be used.
  • Ensure there are agreed guidelines specific to the critical care unit and that there are systems to ensure consistency of care.
  • Improve the response times to complaints in the medical directorate.
  • Ensure all women receive one to one care in labour.
  • Improve the 31 day cancer waiting times for people waiting from diagnosis to first definitive treatment and the 62 day waiting time for people waiting from urgent GP referral to first definitive treatment.
  • In critical care, ensure there is an agreed strategy for the unit that includes the critical care workforce across the two sites and that all risks are identified and on the risk register.
  • In maternity, ensure monitoring data is separated by location.
  • Improve and strengthen governance within the ED.
  • Develop the leadership skills of labour ward coordinators to prepare them for this role and hold them accountable for their performance.
  • Monitor action plans to ensure timely response to risk actions.
  • Ensure the consultant hours in the emergency department meet the RCEM recommendation of 16 hours a day, seven days a week of clinical consultant working.
  • Ensure that the paediatric emergency department complies with Royal College of Paediatric and Child Health staffing guidelines.
  • Ensure all staff working with children are adequately trained to an agreed and measureable standard.
  • Ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
  • Increase the number of sonographers in radiology.
  • Improve compliance with all stages of the World Health Organization (WHO) Surgical Safety Checklist across all surgery services.
  • Ensure local anaesthesia drugs are stored separately from general anaesthesia drugs in all operating theatres.
  • Take further steps to update and improve operating theatre infrastructure and equipment.
  • Improve scheduling of surgical procedures to improve theatre utilisation and efficiency.
  • Ensure all reported risks in surgery services are addressed in a timely way.
  • There is access to seven day week working for radiology services.
  • Staffing is improved in radiology for sonographers.
  • Improve the response rate of patient feedback.
  • Ask patients and relatives for feedback on critical care.

  • There are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
  • There are appropriate processes and monitoring arrangements in place to improve the 32 and 61 day cancer targets in line with national targets.
  • There is improved access for beds to clinical areas in diagnostic imaging.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 27 May 2016

Effective

Requires improvement

Updated 27 May 2016

Caring

Good

Updated 27 May 2016

Responsive

Requires improvement

Updated 27 May 2016

Well-led

Requires improvement

Updated 27 May 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 27 May 2016

We judged the maternity and gynaecology services as requiring improvement.

Systems and processes were in place for reporting and investigating incidents in maternity but dissemination of learning from incidents and complaints was inconsistent. In gynaecology incident reporting was very low. The service was slow to implement change. For example responding to failure to achieve its own or national performance targets in maternity services and despite limitations to restrict admissions of women in labour to lower risk women, some staff voiced safety concerns.

The trust mainly monitored maternity services based on merged data from both maternity units. This was unhelpful in terms of monitoring maternity performance at Epsom, which was smaller, less busy and served a different population and employed Epsom-based staff. Although we requested performance data specific to Epsom the trust was not able to provide this in many cases.

Most of the clinical guidelines had been reviewed recently in line with national guidance but not all staff were aware of key changes. There was limited evidence that national or local audits had an impact on practice.

Women and their partners were generally positive about the care they received. They understood and felt involved in their care. Women received the emotional support they needed.There was a mainly positive response to the Friends and Family Test, with a reasonably high response rate among woman who stayed in the maternity wards of 33%. The response on outpatient services were much lower.

Midwives were aware of the characteristics of the local population and responsive to their needs. However, it was less clear whether the pattern of medically led antenatal clinics met the specific clinical needs of the local Epsom population. There was limited engagement with either staff or with the local community about the design of the service.

Management of the maternity service was weak and obstetricians were not sufficiently engaged in the maternity service. Midwives felt Epsom hospital was low on the trust priorities. Managers did not identify, analyse and manage the risks of harm to women that were specific to Epsom and highlighted on the local maternity dashboard Staff provided little challenge to one another. The culture was hierarchical. Several staff said they had spoken up about concerns, but no action resulted. They felt the service was complacent.

Aside from the weaknesses in incident reporting, we had no concerns about gynaecology.

Medical care (including older people’s care)

Good

Updated 27 May 2016

We rated medicine as good for effective, caring, responsive and well led; and good overall, but as requiring improvement for safe. Wefound mandatory training and staff appraisal completion rates were low; some wards repeatedly fell below the trust's infection control thresholds' and patients were able to access areas of wards that might compromise their safety.

The hospital had recently undergone a recruitment drive which had enabled it to fill some of its nursing and medical vacancies. This had helped address the 23% nursing and 11% medical vacancy rate it had carried over the past financial year.

We reviewed seven patients’ records and almost all were well completed, legible and evidenced multidisciplinary input.Staff were aware of how to reportincidents and demonstrated the learning that hadbeen taken from a recent Never Event at another site within the trust. (Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.)

On this inspection we found the hospital to be visibly clean. However data supplied by the trust indicated that wards repeatedly fell short of the infection prevention control compliance threshold. Sluice rooms on wards were not lockable, and provided easy access to hazardous substances.

The service had systems to review performance and disseminate the results to staff. The hospital participated in national audits with mixed results compared to the England average. The hospital had a mandatory training programme in place however for most staff groups the completion rate was low, as was the completion rate for staff appraisals. Staff spoke of pressures of work, particularly low staffing numbers that prevented them attending training days.

There was a lack of clarity amongst staff with regard to how the Deprivation of Liberty safeguards should be used.

Staff provided care in a compassionate and kind way that preserved patients’ dignity. Patients felt supported and involved in their care and treatment. Staff also felt supported by their line managers to provide high quality care. We observed a culture that focused on meeting the needs of individual patients and their families, although staff expressed concerns at the staffing levels which they felt were detrimental to patient care.Service leaders had systems to assess how well they were doing and were aware of any challenges they faced.

In all but neurology and dermatology, the medical directorate achieved the 18 week referral to treatment standard. The average length of stay at Epsom was slightly longer for non-elective care than the England average.

Whilst Family and Friend Test feedback was positive, the response rate was notably low. The medical directorate was slow to respond to complaints, achieved just an 8% response rate withindesignated timescales.

Governance arrangements in the medical directorate were satisfactory in some areas but could be improved in others. Staff commented on very good multidisciplinary teamwork; collaborative care and line management support. A number however commented on the dysfunctional cross site working. The hospital had a number of innovative projects underway, including some related to patients living with dementia.

Urgent and emergency services (A&E)

Requires improvement

Updated 27 May 2016

The ED at Epsom General Hospital was not meeting the Royal College of Emergency Medicine (RCEM) recommendation that an emergency department should provide medical emergency cover 16 hours a day, 7 days a week. The ED was reliant on using bank and agency nursing staff and locum doctors to fill vacant staffing posts. In the children’s ED, the staffing levels did not comply with the Royal College of Paediatrics Child Health (RCPCH) guidelines and there were periods of time when there was no paediatric nurse on duty thismeant there was a risk to patient safety.

The adult and paediatric ED were often overcrowded. Patient flow through the department required improvement and was often blocked by internal capacity issues within the trust. Walk in patients waited long periods to be triaged within the department. Clinical priority was assessed at reception by a receptionist who assigned a red sticker to patients’ notes if they deemed them a priority. Patients often waited for long periods in the department after the decision to admit (DTA). Surgical patients often had the longest wait with limited access to surgical reviews by specialist doctors. During our Inspection, we observed the use of the ambulatory care unit (ACU) to care for patients awaiting a bed on the ward. We saw significantly increased waiting times for patients being admitted compared with patients who would be discharged.

Cardiac monitors used in the majors areas required updating and this had been an ongoing risk for over a year, without an adequate solution. This may cause clinicians to be unaware of unwell and deteriorating patients within the department. Major incident equipment we observed was out of date and not ready for use in the event of a major incident.

The current nursing vacancy rate of 27% meant that bank and agency staff were used on a regular basis. Between April 2014 and March 2015, the average percentage of shifts covered by bank and agency staff was 28% in the adult ED and 29% in the paediatric department.

We observed on two occasions that when the department was busy, there was no effective shift coordination as the nurse-in-charge had no clear visualisation of the overall department, for example, the number of patients and types of patients in the paediatric department and the minors area. We saw nurses from the paediatric department had to come out of the department to inform the nurse-in-charge of the pressures they were under and give an updated status of the department.

During our visit, we observed four walk in patients waiting between 40-45 minutes to see the triage nurse. Data provided by the trust for the month of October 2015 demonstrated that patients could wait up to 59 minutes to be seen by the triage nurse. The four-hour waiting standard requires all EDs to see 95% of attending patients within four hours of their arrival. At Epsom ED for the 12 months between November 2014 and October 2015 94% of patients were seen within this target.

Vision and strategy within the department were not well developed or known by all staff working within the department. There were mixed views about the departments future and staff were unaware of trust values.

There were positive comments from patients and their relatives about the care received and the attitude of the staff. Patients were kept informed of their treatment, given detailed information about their diagnosis, and given time to ask further questions.

Surgery

Requires improvement

Updated 27 May 2016

Epsom General Hospital provides a range of day case, elective and emergency surgical services to a mostly local population of patients from south west London and north east Surrey, including Epsom, Merton and Sutton. 13,100 surgical procedures were carried out in 2014. Epsom General Hospital is used mostly for day case and elective surgery, with 83% day case procedures, 16% elective procedures and 1% non-elective procedures in 2014.

There are eight operating theatres at Epsom General Hospital covering general surgery, orthopaedics, cardiovascular and urology. They operate Monday to Friday 8:30am-5:30pm, with additional availability for elective lists at weekends. The post-operative recovery facility has five bays. There are 22 inpatient surgical beds in the designated surgical wards and 15 day case only beds.

Surgical activity at Epsom General Hospital is managed by one directorate within the trust. This inspection focused on the services provided by the Surgery, Critical Care and Anaesthetics directorate. The Regional Services directorate within the trust was responsible for managing the South West London Elective Orthopaedic Centre and renal services, which are covered in separate sections of this report.

During our inspection, we visited Swift and Northey wards, the surgical admissions area, day surgery unit, main operating theatres and the recovery area. We spoke with 18 patients and their family members. We observed care and treatment and looked at care records. We also spoke with more than 40 staff members, including allied healthcare professionals, nurses, doctors in training, consultants, ward managers and senior staff. In addition, we reviewed national data and performance information about the trust.

Intensive/critical care

Requires improvement

Updated 27 May 2016

We rated the critical care unit as ‘requires improvement’ overall. We found that although staff were reporting incidents, there was no system in place to ensure that all staff were learning from these incidents. We identified gaps in record keeping and safe storage of medicines. The unit was bright and airy but there were no individual rooms so patient with infections could not be isolated. The unit used a high number of agency nursing staff to meet staffing requirements. Staff reviewing patients on the unit did not always comply with infection control practices such as being bare below the elbow and hand washing. Patients had to be escorted off the unit to access toilet facilities.

There was a lack of agreed guidelines specific to the critical care unit and no system to ensure consistency of care, even though three different consultants cared for patients in one day. The unit had a larger number of delayed discharges compared to similar units. This led to mixed sex breaches, although the unit was currently not recording these breaches.

The strategy for the unit had not been agreed due to difficulties in reaching an agreement among the critical care workforce across the two sites and staff were not aware of the vision for the unit. Not all risk had been identified on the risk register and some risk had been on the register for some time and senior staff were still unclear on the timescale to address these risks.

The unit had good outcomes for patient when compared to similar units and staffing was in line with national guidelines. The unit had lower out of hours discharges compared to similar unit and staff in other areas did not report difficulties in accessing critical care. The unit managed booked beds for elective patients efficiently to ensure patients do not have their operation cancelled due to a lack of critical care beds. Staff, including agency, received a good induction and competency based assessment prior to caring for patients independently. Doctors in training received good teaching and support from consultants and patients and their relatives spoke highly of the staff and the care they received on the unit.

Services for children & young people

Requires improvement

Updated 27 May 2016

Throughout the inspection, managers and staff told us they had concerns about staffing levels. We were told the trust had implemented the ‘Safer Staffing’ model for ensuring there were sufficient staff on duty to meet children’s needs and the service met nationally recommended staffing ratios, but we found examples of staffing ratios falling below these levels. There was also a large number of vacant medical staff and high use of locums to cover for medical staff who were off sick or on maternity leave. There was a system in place for reviewing staffing levels if the dependency levels of children increased, but it was not always possible to allocate additional staff particularly if dependency levels increased.

Ward staff relied on information about safeguarding concerns being brought to their attention by emergency department (ED) staff if the child was admitted via ED, by checking manual records or by contacting social services. The information was not held on computer. There was a risk that the manual records were incomplete or could be lost and therefore there was a risk that staff may not always be able to identify and protect children at risk of abuse. It is important to note that these arrangements were the adopted standard practice of the local authority who were responsible for maintaining the child protection database and was consistent across a number of acute services in Surrey.

Staff uncertainty about the future structure of the trust had contributed to difficulties recruiting and retaining staff resulting in staffing pressures on the ward. Developing a strategy for the service had also been problematic without clarity about the organisation’s future. Managers had responded to the uncertainty by developing a five-year business and service strategy.

An executive director provided board level leadership for children’s services. Paediatric services were part of the Women and Children’s Directorate with clinical leadership from a consultant obstetrician and a consultant paediatrician. There was no governance lead for children’s services.

End of life care

Good

Updated 27 May 2016

The Specialist Palliative Care (SPCT) team provided end of life care and support six days a week, with on call rota covering out-of-hours. There was visible clinical leadership resulting in a well-developed, motivated team.

The Director of Nursing had taken the executive lead role for end of life care, along with a Non-Executive Director (NED) to ensure issues and concerns were raised and highlighted at board level. Trust board received EOLC report outlining progress against key priorities within the EOLC strategy, including audit findings, themes from complaints and incidents, evidence of learning and compliance with end of life training requirements.

The SPCT provided a rapid response to referrals, assessed most patients within one working day, their services included symptom control, end of life care (EOLC), and support for patients and families, advised them on spiritual and religious needs and fast-track discharge for patients wanting to die at home.

Most of the nursing staff were complimentary about the support they received from the SPCT. Junior doctors particularly appreciated their support and advice, and said they could access the SPCT at any time during the day. They recognised that the SPCT worked hard to ensure that end of life care was well embedded in the trust.

Nursing staff knew how to make referrals to the SPCT and referred people appropriately. The SPCT assessed patients promptly to meet their care needs. The chaplaincy and bereavement service supported patients’ and families’ emotional and spiritual needs when people were at the end of life.

Referrals for patients who required support during end of life care were made electronically to the specialist palliative care team from clinicians throughout the trust. The specialist palliative care team had daily morning briefings to update on changes in patients’ condition, assess new referrals and allocate work for the day.

The National Care of the Dying Audit 2013/2014 (NCDAH) demonstrated that the trust had not achieved three out of seven organisational key performance indicators. At the time of the inspection, the trust had not fully rolled out the replacement of the LCP, and this delay meant that staff were not fully supported to deliver best practice care to patients who were dying. The leadership failed to apply enough urgency to have an individual plan of care in place.

Outpatients

Good

Updated 27 May 2016

Overall, we found that outpatients and diagnostic imaging were good. The service was rated as good for safety, caring, responsive and well-led. The effective domain was inspected but not rated.

Patients, visitors and staff were kept safe as systems were in place to monitor risk. Staff were encouraged to report incidents and we saw evidence of learning being shared with the staff to improve services. There was a robust process in place to report ionising radiation medical exposure (IR(ME)R) incidents and the correct procedures were followed. The pathology department had a comprehensive quality management system in place with compliance targets set at higher than the national average to improve safety and quality. There was evidence of quality improvement in place following the restructure of pathology services. The focus on low radiation doses in radiology was excellent.

The environments we inspected were visibly clean and staff followed infection control procedures. Records were almost always available for clinics and if not, a temporary file was made using available electronic records of the patient. Staff were aware of their responsibilities within adult and children safeguarding practices and good support was available within the hospital.

Nurse staffing levels were appropriate and there were few vacancies. The diagnostic imaging vacancies were higher, particularly ultra sonographers. There was an ongoing recruitment and retention plan in place.

There was evidence of service planning to meet patient need such as the contract for MRI services. National waiting times were met for outpatient appointments and access to diagnostic imaging although the wait for MRI services had increased. A higher percentage of patients were seen within two weeks for all cancers than the national average, but the cancer waiting times for people waiting less than 31 days from diagnosis to first definitive treatment and the proportion of people waiting less than 62 days from urgent GP referral to first definitive treatment were both below the national average.

Staff had good access to evidence based protocols and pathways. There was limited audit of patient waiting times for clinics, but patients received good communication and support during their time in the outpatients and diagnostics departments. Staff followed consent procedures and had a good understanding of the Mental Capacity Act 2005.

We observed and were told that the staff were caring and involved patients, their carers and family members in decisions about their care. There was good support for patients with a learning disability or living with dementia. The outpatients department at Epsom hospital had good information display boards available for staff and patients to access.

Staff were aware of the complaints policy and told us how most complaints and concerns were resolved locally. The service had no open complaints at the time of the inspection.

The outpatients and diagnostic imaging departments had a local strategy plan in place to improve services and the estates facilities. From December 2015, the current outpatient services that are in Clinical Services Directorate, will move to a new Outpatients and Medical Records Division. Staff expressed some concern over these changes.

Governance processes were embedded across outpatients and diagnostics. The directorate was commended on its risk register in a recent review of risk registers in the trust. Senior managers told us the newly appointed Quality Manager had made significant improvements in making sure priorities, challenges and risks were well understood. Good progress was evident for improving services for patients.

We found good evidence of strong, local leadership and a positive culture of support, teamwork and innovation.

Elective Orthopaedic Centre

Outstanding

Updated 27 May 2016

We rated this service outstanding as there was an open and transparent safety culture in practice and patient outcomes were amongst the best in the country. When things went wrong, there was thorough analysis and investigation owned by staff and changes weremade in a timely way. The approach to staffing and skill mix across all staff groups meant that highly skilled staff always cared for patients.

Patient outcomes and patient satisfaction consistently exceeded national averages. Innovative practice in recording outcomes was the basis for national guidelines. The lead surgeon used patient outcomes to validate and proactively change each consultant’s performance. The service was proactively met the needs of the population it served, coordinating with referring hospitals, external and community providers to ensure the surgical pathway was appropriate.

Staff understood the ethos of the service values, and unequivocal in praising the support received from leadership team and there were measurably high levels of staff satisfaction. Patients who used the service were actively involved in the way the service operated.