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Inspection Summary


Overall summary & rating

Good

Updated 8 June 2014

East Surrey Hospital is the only hospital that forms Surrey and Sussex Healthcare NHS Trust. This hospital was an acute hospital and provided accident and emergency (A&E), medical care, surgery, critical care, maternity, children and young people’s service, end of life care and outpatients services, which are the eight core services always inspected by the Care Quality Commission( CQC) as part of its new approach to hospital inspection.

East Surrey Hospital had 650 beds and provided a wide range of inpatients medical, surgical and specialist services as well as 24-hour A&E, maternity and outpatients services.

We carried out this comprehensive inspection to Surrey and Sussex Healthcare NHS Trust as an example of a low-risk trust as determined by CQC’s intelligent monitoring system. The inspection took place between 20 and 22 May 2014 and an unannounced inspection visit took place between 6pm and 10.30pm on 6 June 2014.

Overall, this hospital is good but the outpatients service required improvement.

Our key findings were as follows:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • The hospital was clean and well maintained. The trust’s infection rates for Clostridium difficile and MRSA were within an acceptable range, taking account of the size of the trust and the national level of infections.
  • Patients whose condition might deteriorate were identified and escalated appropriately and the mortality rates for the hospital were within the expected range.
  • The vast majority of patients reported a positive experience to us during our visits. The NHS Friends and Family Test showed the trust performed above the England average between November to February 2014. The A&E friends and family test was above the England average.
  • We found patients were supported to eat and drink, but we found a small number of patients on one ward who had dry mouths and did not have the appropriate documentation completed to indicate they had received mouth care.
  • Nurse staffing levels on the wards were generally satisfactory and staff, although busy, could meet the needs of their patients. There was some reliance on bank/agency or locum staff but this was very well managed and did not have any adverse effects on the delivery of care. The trust was actively recruiting more doctors but faced the same challenges that many trusts in England faced.
  • The maternity service was very busy but was providing good care to women with excellent facilities.
  • The trust consistently met the four-hour waiting time target in the A&E department. The flow of patients within the department was good and we did not witness any patient who had waited in excess of four hours before a decision was made to admit them.
  • We found patients who were placed in beds on wards that were not their specialism were given safe care. There were good processes in place to track these patients and ensure they received the appropriate care and treatment.
  • Critical care services provided safe and effective care. The caring and emotional support, as well as the leadership on the unit, was exceptionally good.
  • Children received safe and effective care but the environment limited the ability to provide care to adolescents that was individualised to their specific needs. Staffing levels for children were safe and there was good leadership in place.
  • Patients received good quality end of life care. Staff were supported by a specialist palliative care team. Patient care was well managed and we found some excellent examples of care being delivered.
  • Outpatient services required improvement. Patients were treated with compassion, but many appointments were cancelled at short notice; and because clinics were so busy, patients often had to wait a long time to be seen. Medical records were often incomplete because notes could not be obtained in time for clinic appointments.
  • Mortality rates were within expected ranges and there were no indicators flagged as being a risk or an elevated risk.
  • Medical records, medical secretaries and ward clerks felt they had not been listened to as much as they could have been and expressed concern about some of the changes that were taking place.
  • Without exception, clinical staff were proud to work for the trust and spoke very positively about the effective leadership within the trust. Staff recognised the significant progress the trust had made, particularly in the past two years. The commitment to the trust was exceptionally good.
  • The work the trust had done on major incident preparedness was good.
  • The trust was focusing on the performance of complaint handling and extra resources had been put into place within some of the divisions. We saw performance was improving and both clinical staff and the executive team were committed to this.

We saw several areas of outstanding practice including:

  • There was very poor mobile signal at the Crawley Hospital site. Relatives were given a bleep that meant they could be contacted if they left the clinical areas. This meant that people were not restricted to stay in one place for long periods and could be effectively contacted by staff.
  • The pre-assessment clinic at Crawley Hospital had been extended into the evening in a response to feedback and local demand.
  • We visited one surgical ward where a patient who had a dementia diagnosis was being cared for. The circumstances around the admission meant that the patient’s spouse was also admitted to hospital at the same time. This caused anxiety for both patients, especially for the patient with dementia. This ward identified a two bedded side room and ensured that both patients were kept together to alleviate the anxiety and distress of the rest of their admission.
  • We saw staff wearing “ask me anything” badges. These badges encouraged patients and their loved ones to engage with staff to improve communication.
  • Staff (including the chaplain, catering and ward staff) had arranged for a patient near the end of life to have a “wedding” with a small party afterwards. The catering staff provided a wedding cake for the celebration. Although there wasn’t time for this to be an official marriage ceremony it was an example of staff working together to meet the individual needs of their patients.
  • The facilities provided for women in the midwife-led birthing unit were outstanding.
  • The care on the neonatal intensive care unit was outstanding. The staff team were committed to ensuring best practice and optimal care for the babies admitted to the unit.
  • We visited Woodland ward within the surgical directorate, where we judged the leadership to be outstanding. We saw a very effective multidisciplinary approach to care delivery and consistent commitment to ensuring patients’ individual needs were met.
  • The trust has recognised that their location, close to a major international airport, increased the likelihood of girls presenting in the A&E department with complications of female genital mutilation. The safeguarding implications of this had been incorporated into the training programme.

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

Importantly, the trust must:

  • Carry out a review of the outpatients service to ensure there is adequate capacity to meet the demands of the service.
  • Implement a system to monitor and improve the quality of the outpatients service that includes the number of cancelled appointments, waiting times for appointments and the number of patients that do not have their medical records available for their appointment.

In addition the trust should:

  • Review the training provided to clinical staff on the Mental Capacity Act to ensure all staff understand the relevance of this in relation to their work.
  • Ensure that a review of mouth care is undertaken so that staff are clear where this should be recorded in the patient’s care record.
  • Review the action taken to engage with medical secretaries, ward clerks and medical records staff to ensure these groups feel more included in decisions relating to their role.
  • Review the working environment for the medical records staff.
  • Continue to focus on improving the trust’s performance on complaints handling.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 8 June 2014

Effective

Good

Updated 8 June 2014

Caring

Good

Updated 8 June 2014

Responsive

Good

Updated 8 June 2014

Well-led

Good

Updated 8 June 2014

Checks on specific services

Maternity and gynaecology

Good

Updated 8 June 2014

The service was offering good, safe compassionate care for women and their partners. The refurbished facilities of the new midwife-led birthing unit provided excellent facilities for normal, uncomplicated births in a relaxed, calm, non-clinical environment. The consultant-led facilities were soon to be refurbished to the same standard and offer excellent multidisciplinary care and treatment. An active service user group had been involved in planning for and making the changes to the service.

Midwife to birth staffing levels were not in accordance with recommended guidance with one midwife to every 34 births. Funding had been allocated for additional midwives and recruitment was underway which meant  the ratio of births to midwives would improve. The staff were well trained, experienced and committed and the leadership was very good, particularly at head of service and matron level. There was a clear vision and strategy and the culture was open with an emphasis on learning from feedback in order to improve the service. Standards were based on evidence-based practice and national guidance.

Medical care (including older people’s care)

Good

Updated 8 June 2014

We saw that patients were treated with respect and that their privacy and dignity were protected. We observed care that was in line with current guidance and best practice. The medical division had robust systems for monitoring safety, quality and performance including systems for reporting accidents and incidents. Generally there were sufficient staff to provide care although not all wards were consistently meeting the staffing levels they had deemed were necessary. We found that patient’s individual care needs were met including pain relief and nutrition and hydration, although the provision of mouth care was not clearly recorded. We found one patient who had a pressure ulcer that had not been reported. Patients were adequately monitored and there were systems to manage those who condition was deteriorating. There was a focus on developing care for people living with dementia.

We found staff had received training on the Mental Capacity Act and the Deprivation of Liberty safeguards (DoLs) but not all staff were able to demonstrate a clear understanding about how it related to their role. We did not find this was having an actual impact on patient care.

The division was not responding to complaints within the agreed timescales. The trust recognised the need to improve performance on complaints and extra resources for the medical division were put in place in April 2014. Performance was improving and was being closely monitored through the governance arrangements at both divisional and trust board level.

Demand for medical beds often outstripped supply. In these circumstances there were arrangements to increase capacity through the use of additional beds. There were systems to ensure that care and treatment remained safe, that it was regularly reviewed and that there were staff accountable for these areas. Staff told us they felt supported by their leaders. There were arrangements to gather patient feedback and we saw that this feedback resulted in staff taking appropriate actions.

Urgent and emergency services (A&E)

Good

Updated 8 June 2014

The emergency department was providing safe care. There were sufficient staff to meet the needs of patients The department was clean and arrangements were in place to manage and monitor the prevention and control of infection. Evidence-based systems were used for treating very sick patients and risks were monitored and addressed. Staff were aware of clinical guidance for patients with specific needs or diseases. Patients were confident in the staff’s ability to deliver high quality care. We saw excellent team working across disciplines with therapy staff available every day in chemical decision unit (CDU) promoting effective discharge.

Patients felt they were listened to and we observed patients being cared for with compassion and kindness. The trust had performed consistently better than the A&E national target since October 2013, with 95% of patients waiting less than four hours to be admitted, transferred or discharged. There were systems in place to ensure A&E responded to patients’ needs appropriately and in a timely manner. Support for patients with a learning disability or mental health problem was readily available; although services for children with mental health problems were difficult to access. Complaints and concerns were dealt with appropriately but the time taken to respond was not always in accordance with the trusts own policy. The emergency department was well led and staff were proud of the work they did. Governance processes involved all disciplines of staff as well as a patient representative.

Surgery

Good

Updated 8 June 2014

Patients who used the service experienced safe, effective and appropriate care and treatment and support that met their individual needs and protected their rights. The care delivered was planned and delivered in a way that promoted safety and ensured that people’s individual care needs were met. We saw patients had their individual risks identified, monitored and managed and that the quality of service provided was regularly monitored. We found the clinical environments we visited and other communal areas in the hospital meticulously cleaned. Hospital-acquired infections were monitored and rates of infection were of a statistically acceptable range for the size of the trust.

Outcomes for patients were good and the department followed national guidelines. Complaints were investigated and handled in line with standard policy. We saw the trust use patient’s complaints and comments used as a service improvement tool and the trust actively encourage feedback from its patients and their relatives or loved ones.

Intensive/critical care

Good

Updated 8 June 2014

Patients we spoke with gave us examples of the good care they had received in the unit. The leadership of the unit created a culture of reporting and learning from incidents. There was good multidisciplinary working to ensure patient needs were met. Guidance form recognised professional bodies were followed and audited to ensure their effectiveness.

Patients were treated with compassion, care and dignity. The service demonstrated responsiveness to the needs of patients and the local population. Changes were being made to the management of high dependency unit (HDU) to improve patient flow through the service.

Services for children & young people

Good

Updated 8 June 2014

Services for children and young people were good. Most children and parents told us the staff were kind and attentive; the staff were described as ‘lovely’ and ‘funny’. Ward areas and equipment were generally, clean and appropriate infection control measures were in place. There were enough trained staff on duty to ensure that safe care could be delivered. There were thorough nursing and medical handovers that took place between shifts to ensure continuity of care and knowledge of patient needs.

Younger children received very good inpatient care and the ward was resourced to ensure their wider needs were met. Good facilities and staff support encouraged a parent to stay in hospital with their baby or child. The quality of care of adolescents was limited by the accommodation; we observed instances where the privacy and dignity of teenagers was not respected. The care on the neonatal intensive care unit was outstanding. The staff team were committed to ensuring best practice and optimal care for the babies admitted to the unit.

Senior staff communicated well and staff were positive about the service. There was clear evidence that the wider multidisciplinary team worked well together for the benefit of the younger patients. Children’s experiences were seen as the main priority. Staff felt supported by their managers and were encouraged to be involved in discussing their ideas for improvements.

End of life care

Good

Updated 8 June 2014

We found that the trust had systems in place to ensure end of life care was safe and met the needs of patients and that staff were committed to providing person centred care to patients who were receiving end of life care. Patients spoke positively about the way they were being supported with their care requirements. Relatives also spoke very positively in regard to the support they and their relatives received.

The specialist palliative care team were responsible for ensuring that end of life care was delivered to staff within the ward areas as part of their mandatory training. The specialist palliative care team had developed an end of life care pathway tool which was in use in all the ward areas we visited. Staff in all of the ward areas we inspected were aware of the tools used for patients receiving end of life care and all staff were aware of how to contact the specialist palliative care team.

Outpatients

Not sufficient evidence to rate

Updated 31 March 2016

Since our last inspection there had been a significant change in the outpatient management structure to provide more robust governance. An outpatient board had been established and reported to the executive committee. This board was supported by an outpatient delivery group.

Nursing leadership had been strengthened in the department since our last visit with a new structure and an emphasis on stronger leadership with the introduction of more senior roles and a matron.

The trust had made significant changes and improvements to the management of medical records. 

We saw improvements in the level of reporting incidents and there were mechanisms in place to provide feedback following an incident. However, some staff were still unsure how to report incidents and had not accessed the training in the electronic system.

Although there was increased attendance in training in the Mental Capacity Act, some staff were unable to tell us how they would effectively apply the act in practice to situations that may arise in the department.