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Royal Surrey County Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 22 June 2020

We conducted an inspection of: Emergency and urgent care, medical care and end of life care. During our inspection, we spoke with 74 staff and 24 patients and relatives.

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

  • The trust controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. The design, maintenance and use of facilities, premises and equipment kept people safe.
  • The trust had enough staff with training in key skills to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and, in most areas, kept good care records. The service collected safety information, managed safety incidents, learned lessons from them and used this to improve the service.
  • The trust generally managed medicines effectively. There was ready access to expert prescribers, oversight by the pharmacy team and innovative support for non-specialist prescribers. The level of medicine errors was low.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them and their families on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Throughout the trust staff treated patients with compassion and kindness, mostly respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided high quality emotional support to patients, families and carers.
  • There were innovative approaches to providing integrated person-centred pathways of care that involved other service providers, particularly for people with multiple and complex needs.
  • Across the trust there were some innovative approaches to providing integrated person-centred pathways of care that involved other service providers, particularly for people with multiple and complex needs. People’s individual needs and preferences were central to the delivery of tailored services. The services were flexible, provide informed choice and ensured continuity of care. The design of facilities and premises in areas of the trust were innovative and met the needs of a range of people who used the services.
  • There was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that meets these needs, which was accessible and promotes equality. People could access the service when they needed it and did not have to wait too long for treatment.
  • It was easy for people to give feedback and raise concerns about care received at the trust. The trust treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • Throughout the trust leaders were highly visible and approachable for patients and staff. The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Staff understood the trust vision and values, and how to apply them in their departments and work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.
  • The trust engaged well with patients and the community to plan and manage services. All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

However:

  • In some areas across the trust, mandatory safeguarding and Mental Capacity Act training compliance for both nursing and medical staff was low compared to the trust target.
  • In some areas we saw records of patients’ care and treatment were not always clear or stored securely.
  • We found regular checks of emergency medicines and equipment in the emergency department were not always carried out by staff in line with trust policy.
  • The trust had not always met some national audits standards in line with the England average but had action plans to deliver improvements.
  • Across the trust most people were encouraged to dress in their own clothes and had support to maintain their dignity, there were two occasions when we noticed that individual staff members had not paid enough attention to ensuring patients were appropriately covered.
  • Data captured and provided by the emergency department showed they did not meet the Department of Health’s standard for emergency departments which states that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department.
  • The trust was unable to provide emergency department data in the format as required by the national emergency care dataset. However, they had agreed plans to improve data capture and reporting systems to comply with requirements.
Inspection areas

Safe

Good

Updated 22 June 2020

Effective

Good

Updated 22 June 2020

Caring

Good

Updated 22 June 2020

Responsive

Outstanding

Updated 22 June 2020

Well-led

Good

Updated 22 June 2020

Checks on specific services

Medical care (including older people’s care)

Outstanding

Updated 22 June 2020

Our rating of this service improved. We rated it as outstanding because:

  • The service had enough staff with training in key skills to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk and managed medicines effectively. Staff assessed risks to patients, acted on them and kept good care records. The service collected safety information, managed safety incidents, learned lessons from them used this to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them and their families on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, mostly respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • There were innovative approaches to providing integrated person-centred pathways of care that involved other service providers, particularly for people with multiple and complex needs. People’s individual needs and preferences are central to the delivery of tailored services. The services were flexible, provide informed choice and ensured continuity of care. Facilities and premises were innovative and met the needs of a range of people who use the service.
  • There was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that meets these needs, which was accessible and promotes equality. People could access the service when they needed it and did not have to wait too long for treatment.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • Leaders were highly visible and approachable in the service for patients and staff. The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services. All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

However:

  • Although the majority of patient interactions were positive, we did witness some patients not being treated with dignity.
  • The service should continue to improve mandatory training figures to meet trust targets.

Services for children & young people

Good

Updated 18 December 2013

Over all we found Childrens services to be safe, caring, effective,  responsive and well-led.  The children’s unit was modern and well equipped and reflects the ideas and contributions of children and young adults who use the service. The unit was 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 paediatric service had 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.

Critical care

Good

Updated 18 December 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 expectations 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 the  ICU 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 a multi-professional team working across the unit and with other hospital providers in the area. This meant the service was well-led.

End of life care

Outstanding

Updated 22 June 2020

Our rating of this service improved. We rated it as outstanding because:

  • The service had sufficient staff with training in key skills to care for patients and keep them safe. They exceeded the recommended medical and specialist nursing staff levels recommended by the Royal College of Physicians.
  • Staff understood how to protect patients from abuse, and managed safety well. All staff spoken to had a very good understanding of safeguarding and how it might present in end of life care.
  • The service managed medicines effectively. There was ready access to expert prescribers, good oversight by the pharmacy team and innovative support for non-specialist prescribers. The level of medicine errors was low.
  • Staff provided extremely good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Comprehensive assessments of personal care and treatment needs and preferences were used to inform care planning and delivery.
  • Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and supported them to make decisions about their care. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, mostly respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided high quality emotional support to patients, families and carers.
  • There were innovative approaches to providing integrated person-centred protocols of care that involved other service providers, particularly for people with multiple and complex needs. End of Life care was a priority of the Integrated Care Provider system with health and social care agencies, and representatives from the voluntary sector, working well together.
  • People’s individual needs and preferences were central to the delivery of tailored services. The services were flexible, provide informed choice and ensured continuity of care.
  • There was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that meets these needs, which was accessible and promoted equality. People could access the service when they needed it and did not have to wait too long for treatment. The Supportive and Palliative Care team were very responsive and very much promoted the idea of a good death.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with staff.
  • Leaders were highly visible and approachable in the service for patients and staff. The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care.
  • Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.
  • The service engaged well with patients and the community to plan and manage services. All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

However:

  • Whilst most people were encouraged to dress in their own clothes and had support to maintain their dignity, there were two occasions when we noticed that individual staff members had not paid sufficient attention to ensuring patients were appropriately covered.

Surgery

Good

Updated 18 December 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. 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. 

Urgent and emergency services

Good

Updated 22 June 2020

Our rating of this service stayed the same. We rated it as good because:

  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. The design, maintenance and use of facilities, premises and equipment kept people safe.
  • Staff completed risk assessments for each patient swiftly. They removed or minimised risks and updated the assessments. Staff identified and quickly acted upon patients at risk of deterioration.
  • The service had enough medical, nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • The service used systems and processes to safely prescribe, administer, record and store medicines.
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983.
  • Staff gave patients enough food and drink to meet their needs and improve their health. Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way.
  • They supported those unable to communicate using suitable assessment tools and gave pain relief to ease pain.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. They did not always meet the standards in line with the England average but had action plans to deliver improvements.
  • The service made sure staff were competent for their roles and doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They used agreed personalised measures that limit patients' liberty. However, compliance rates for training was just below trust target.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patient's personal, cultural and religious needs.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
  • The service planned and provided care in a way that met the needs of local people and the communities served. The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously.
  • Leaders had the integrity, skills and abilities to run the service. The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders operated effective governance processes, throughout the service and with partner organisations. Leaders and teams used systems to manage performance effectively.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • All staff were committed to continually learning and improving services. Leaders encouraged innovation and participation in research.

However:

  • Mandatory training compliance was low compared to the trust target of 90%.
  • Data showed for both nursing and medical staff, not all had received safeguarding training and compliance rates were low against the trust target.
  • Records of patients’ care and treatment were not always clear or stored securely.
  • We found regular checks of emergency medicines and equipment were not always carried out by staff in line with trust policy.
  • The service had not always met the Royal College of Emergency Medicine audits standards in line with the England average but had action plans to deliver improvements.
  • Compliance rates for Mental Capacity Act training was just below trust target.
  • Data captured and provided by the service showed they did not meet the Department of Health’s standard for emergency departments which states that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department.
  • The trust was unable to provide data in the format as required by the national emergency care dataset. However, they had agreed plans to improve data capture and reporting systems to comply with requirements.

Gynaecology

Good

Updated 25 May 2018

  • Openness and transparency about safety was encouraged. Staff understood their responsibilities relating to the reporting of incidents. Incidents and concerns were addressed at team meetings and safety huddles. We saw evidence that incidents had been used to drive improvement within the service.
  • The gynaecology outpatient clinic, theatres, ward and equipment were visibly clean and staff adhered to infection control policies and protocols. This was consistent with the monthly hand hygiene, bare below the elbow audits where the service consistently achieved scores of 100%.
  • Staff understood the importance of collaborative working in order to improve patient outcomes. Throughout the service, staff from different professional backgrounds were observed consulting each other to ensure the patients were given care by the relevant practitioner in a timely manner.
  • Patients were very complimentary about the care they received. They said they were well informed about the treatments they were having and staff had time to answer any questions they had.
  • The trust proactively monitored staffing levels and patient acuity. The ward matron was able to maintain safe staffing levels at all times by deploying staff with the required skills from one area to another. There was always a nurse on each bay to attend to patients throughout the day.
  • Treatment and care was provided in accordance with the National Institute for Health and Care Excellence (NICE) guidance and quality standards. Divisional leads regularly monitored the publication of new guidelines ensuring local guidelines were up to date and reflected current practice.

However,

  • Staffed lacked training in key areas of care. We found that nursing staff on Compton ward did not have accredited gynaecology training for every shift. Staff had to contact the gynaecology specialist nurses or the on call doctor if a patient required urgent gynaecology care.
  • Patients’ names were visible to all visitors in the gynaecology outpatient clinic, which raised concerns about the lack of patient privacy.
  • Staff on the ward were using patient group directions which had expired in September 2017.

Maternity

Outstanding

Updated 25 May 2018

Our rating of this service improved. We rated it as outstanding because:

  • Staff recognised and responded quickly to changes in the risks to people who use the maternity services, including community care. Risks to people who used the services were assessed, monitored and managed on a day to day basis. These included signs of deteriorating health, medical emergencies and behaviour that challenges.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Openness and transparency about safety was encouraged. Staff felt able to raise concerns and report incidents, which were regularly reviewed to aid learning. We saw learning from incidents was widely shared and saw changes within the department as a result of incidents.
  • There were sufficient numbers of staff with the right qualifications, training and experience to meet the needs of patients. Staffing was reviewed regularly to ensure the correct skill mix and numbers of staff on the wards and throughout the department.
  • Staff adhered to trust policies and best practice with regards to the department’s environment and equipment. Premises and facilities were visibly clean and suitable. Infection control and equipment management were regularly monitored.
  • The service undertook a series of audits to ensure they regularly reviewed the effectiveness of care and treatment of patients. These showed that the care delivered was meeting national standards.
  • Patients received co-ordinated care from a range of different staff, teams and services. Staff worked collaboratively to meet patients’ individual needs, including their mental health and emotional wellbeing.
  • Staff responded compassionately when people needed help and supported them to make informed choices about the care they received. Women were supported to breastfeed.
  • Women had access to a range of pain relief methods including birthing pools. Epidurals were available 24 hours, seven days a week.
  • We saw several innovative approaches to providing integrated person centred pathways of care that involved other service providers. We found an energetic and ambitious workforce that took accountability and ownership for changes within the department.

  • Care and treatment was co-ordinated with other services and staff were responsive to patients’ requests, with reasonable adjustments being made where possible to remove barriers, for example patients with physical disabilities having the option of a water birth.
  • The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care.
  • Leaders at all levels demonstrated high levels of experience, capability and had the capacity to deliver sustainable care with compassion. Leaders understood the challenges to achieve quality and sustainability, and demonstrated they could identify the actions needed to address them.

  • Staff and managers demonstrated commitment to best practice performance and risk management. Risk and performance was reviewed and managed through a series of local and trust wide meetings.

Outpatients

Good

Updated 25 May 2018

Our rating of this service improved. We rated it as good because:

  • Staff were encouraged to report incidents. Managers investigated incidents and shared lessons with the whole team and the wider trust. Continued learning and information sharing happened at daily huddles in the outpatient department.
  • There were clear performance trackers for the service providing information of the overall performance of the department, staffing levels and staff performance such as training. The trackers identified that the department was in line with trust’s targets for mandatory training, safeguarding, able to identify staffing levels and manage risks.
  • Staff working in outpatients were above trust targets for mandatory training and had achieved 100% completed for safeguarding training level two and three.
  • Patients received care that was of a high standard based on national guidelines and there was an audit programme to review the effectiveness of this care.
  • One stop clinics provided swift treatment and diagnosis for patients in several specialities. This meant that patients were seen by a team of health care professionals on the same day reducing the need for multiple hospital visits.
  • Patients received coordinated care because staff worked well and supportively together. Staff were passionate about the service and spoke enthusiastically about developing services, improving services and innovation.
  • Feedback from patients was overwhelmingly positive about care and the department was open to improving and changing the environment based on patient comments.
  • Staff responded compassionately when people needed help, and access to information for people with disabilities, impairments and sensory losses was available.
  • Procedures were in place to manage waiting times for patients being referred from their GPs and for treatment and there were improvement plans to meet overall referral to treatment times for all patients.
  • Staff worked hard to minimise delays and meet patient demand.
  • There was strong, clear leadership and staff said they felt well managed and well-led. Staff said the matron and senior nurses were visible and supportive within the department, they felt valued, listened to and respected and did not have concerns about addressing issues or concerns with their line managers.
  • We saw lots of innovation and enthusiasm when talking to staff within outpatients. The matron in outpatients was a finalist in; The Nursing Times award for innovation after developing a ‘safer staffing tool’ in use across the trust.

However:

  • The phlebotomy drop-in clinic had long waits and a small waiting area.
  • Some medicated eye drops in the ophthalmology department were found to be stored insecurely. Treatment rooms had not been locked when not in use and medicines were not locked away.
  • Confidentiality was not maintained in some areas where doors were left open during consultations and the use of curtained areas for height and weight measurements did not protect patient confidentiality.
  • The trust was in breach of cancer waiting time standards for patients receiving their first cancer treatment within 62 days of an urgent GP referral.

  • Car parking capacity was an issue for patients and the trust.