You are here

Inspection Summary


Overall summary & rating

Outstanding

Updated 18 January 2019

Our rating of services improved. We rated it them as outstanding because:

  • There was a genuinely open culture in which all safety concerns raised by staff and people who use the service was highly valued as integral to learning and improvement.
  • All staff were open and transparent, and fully committed to reporting incidents and near misses. The level and quality of incident reporting showed the levels of harm and near misses, which ensured a robust picture of quality. There was ongoing, consistent progress towards safety goals reflected in a zero-harm culture.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe. Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • There was an exceptional culture of data-driven continuous improvement and transformation at the trust, and this was supported by a comprehensive meeting structure and detailed performance reporting processes. All staff were actively engaged in activities to monitor and improve quality and outcomes.
  • We saw unmistakable evidence of sustained improvement achieved through investment in new facilities and increased capacity that resulted in enhanced effectiveness and responsiveness. This was due to a firmly-embedded and positive culture of openness and transparency, supported by a skilled, stable leadership and clear systems of control and governance.
  • There was a strong, visible person-centered culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who use the service, those close to them and staff, was strong, caring and supportive.
  • Staff at all levels clearly and passionately described how they met patients’ needs and demonstrated a good awareness of protected characteristics including race, sexuality, and disability. We saw a variety of resources made available to staff to help them support these population groups. We saw flexibility, choice and continuity of care reflected in the service delivered. Staff were well supported by the mental health liaison team and the frailty and interface team.
  • People’s emotional and social needs was highly valued by staff and was embedded in their care and treatment.
  • The trust overall score for the National NHS Staff Survey was in the top 20% for the three years preceding the inspection.  In some scores they ranked in the top 4 organisations nationally.
  • Patients could access the service when they needed it, seven days a week. Services ran on time. Patients were kept informed of any disruption to their care or treatment.
  • Trust performance for cancer waiting times was better than the operational standard and the national average in the most recent two quarters.
  • There was an active review of complaints, how they were managed and responded to, and improvements were made as a result across the services.
  • We saw comprehensive leadership strategies in place, such as the SASH+ programme, which helped promote and sustain the desired organisational culture. We found a skilled, stable and highly visible senior management team that possessed a deep understanding of issues, challenges and priorities affecting their service.
  • The strategy and supporting objectives are stretching, challenging and innovative while remaining achievable. A systematic approach is taken to working with other organisations to improve care outcomes, tackle health inequalities and obtain best value for money.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
Inspection areas

Safe

Good

Updated 18 January 2019

Effective

Good

Updated 18 January 2019

Caring

Outstanding

Updated 18 January 2019

Responsive

Outstanding

Updated 18 January 2019

Well-led

Outstanding

Updated 18 January 2019

Checks on specific services

Medical care (including older people’s care)

Outstanding

Updated 18 January 2019

  • We saw unmistakable evidence of sustained improvement achieved through investment in new facilities and increased capacity, that resulted in enhanced effectiveness and responsiveness. This was thanks to a firmly-embedded and positive culture of openness and transparency, supported by a skilled, stable leadership and clear systems of control and governance.
  • Staff felt confident they could raise concerns and report incidents, which were regularly reviewed to aid learning. Lessons learned were effectively shared and we saw changes implemented within the wards as the result of investigations.
  • Despite challenges in nurse recruiting, there were sufficient numbers of clinical 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 followed trust policies and best practice with regards to the department’s environment and equipment. Premises and facilities were presented to a high standard, visibly clean and suitable for their intended purpose. Infection control and equipment management were regularly monitored.
  • The service undertook 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. Patients and relatives, we spoke with gave overwhelmingly positive feedback about the care they received.

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.

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.

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.

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.

Outpatients and diagnostic imaging

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.

Surgery

Outstanding

Updated 18 January 2019

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

  • The management of medicines was good. Cupboards on the wards were well stocked, locked and labelled correctly. Medicine cupboards in theatres were also well stocked and medicines that were coming up to their expiry were marked to show this. We checked ten different packs at random and they were all in date.
  • There was a strong incident reporting culture in the surgical division where staff felt comfortable to report incidents as there was a no blame culture. Staff we spoke with described how details of incidents were communicated in weekly messages from the chief of surgical services. They were then further shared and discussed in team safety huddles for those that hadn’t yet seen the messages.
  • Staff we spoke with had a good awareness of how to manage suspected sepsis following a wide-ranging review that had been carried out by the service.
  • Patient’s pain was managed well and pain relief was given when required. The surgical division had access to a dedicated pain team, seven days a week.
  • Patients had a lower expected risk of readmission for elective admissions when compared to the England average. Patients at the trust also had a lower expected risk of readmission for non-elective admissions when compared to the England average.
  • We observed many interactions between staff, patients and relatives. We saw that patients were treated with compassion. We heard examples of how staff, on different wards had gone the extra mile to do things for their patients.
  • A number of other patients told us how the staff were all compassionate and did what they could for them. We also looked at some of the thank you cards that had been received across the surgical wards. These described how they or their loved ones had been cared for during their time in hospital and offered heartfelt thanks to the staff.
  • Surgery services were planned around the needs of the local population. Patients were treated as individuals and the care provided reflected this.
  • Complaints were fully investigated and responses reflected this. There was clear evidence that learning was taken from complaints and that learning was shared with the complainant.
  • The surgical division was led by a triumvirate comprising the Chief of Surgery, the Associate Director, Clinical Services and the Divisional Chief Nurse.
  • We found that they were an effective, cohesive team that were aware of their strengths and weaknesses.
  • The surgical division had a well-defined governance structure. This was overseen by the Surgical Divisional Board. The aim of the Surgical Division board was to ensure local accountability for performance and risk management through regular review of its governance processes and oversight and review of local risk registers, incidents, complaints and clinical audit processes to ensure oversight and management of risks were well established. The service had had to close two theatres for major refurbishment in the summer of 2018. In response to this they had been able to build two temporary theatres and have them fully operational within four weeks.
  • The service had a comprehensive risk register. This identified risks and categorised them using a Red, Amber, Green (RAG) system, defined by a method of scoring the risk by the likelihood of it happening and the impact.

However,

  • The trust set a target of 80% for completion of mandatory training. Although compliance had been achieved in 24 out of 29 courses, it was considered that a trust target of 80% was low.
  • Ambient temperatures were not being monitored in any of the clinic rooms where medicines were stored.
  • General surgery and ophthalmology patients at East Surrey hospital had a higher expected risk of readmission for elective admissions when compared to the England average.
  • Ear, nose and throat (ENT) patients at East Surrey hospital had a higher than expected risk of readmission for non-elective admissions when compared to the England average
  • The Friends and Family Test response rate for surgery at Surrey and Sussex Healthcare NHS trust was 22% which was worse than the England average of 27% from July 2017 to July 2018

Urgent and emergency services

Good

Updated 18 January 2019

  • There were arrangements to keep both adults and children safe from abuse which were in accordance with relevant legislation. Staff had received training, were able to identify children and adults who might be at risk of potential harm, knew how to seek support and worked with other agencies.
  • The service was providing safe care. There were sufficient staff to meet the needs of patients although the service was heavily reliant on a temporary workforce. The children’s department had two registered children’s nurses on each shift. This was in line with Facing the Future: Standards for Children in Emergency Care Settings 2018.
  • Staff kept themselves, equipment and the premises clean. Staff complied with systems to control and prevent the spread of infection. Staff demonstrated good hand hygiene practice and safe disposal of sharps.
  • Medicines were stored, prescribed and given well and medicines fridge temperatures checked.
  • The room used for assessing patients with mental health needs was compliant with the Psychiatric Liaison Accreditation Network standard.
  • Patients were given enough food and drink to meet their needs. Pain levels were assessed, and patients received adequate pain relief.
  • Staff understood and complied with the relevant consent and decision-making requirements of legislation, including the Mental Capacity Act, 2005.
  • Staff provided compassionate and respectful care. Staff provided emotional support to patients and relatives and involved patients and those close to them in decisions about their care and treatment.
  • The service collected and monitored data about clinical outcomes and this was used to improve practice.
  • The service was delivered by staff that were competent, trained and supported by their managers, to provide safe and effective care. The service provided regular training and development opportunities for staff. There were established developmental career pathways for different roles.
  • Patients were encouraged to report concerns and complaints; these were treated seriously, investigated and lessons learnt. There was good oversight of complaints and incidents and there was learning from them.
  • Adult patients arriving by ambulance were rapidly assessed in the rapid assessment and treatment area by the nurse in charge of the department. This assessment was required to determine the seriousness of the patient’s condition and to make immediate plans for their ongoing care. This is often known as triage. Standards set by the Royal College of Emergency Medicine states that this should take place within 15 minutes.The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. The trust met the standard for four of the 12 months in the period (April, May, June and July 2018) from August 2017 to July 2018 and were better than the England average for all months in the period.
  • All disciplines of staff had a shared focus and purpose to ensuring patients received the best possible care and experience. Staff morale was good, and staff were positive about the overall leadership of the trust.
  • Staff in the emergency department felt well supported by the rest of the hospital and the executive team. There were some good examples of multidisciplinary working. The department was well supported by the mental health liaison team and the frailty and acute medical team.
  • Leaders were visible and accessible in the emergency department; staff respected the local management team and felt well supported by them. Staff felt they were invested in and valued. Leaders and staff felt the executive management team understood the challenges they faced and were focused on implementing system-wide change.

However:

  • There were significant numbers of registered nurse vacancies and heavy reliance on temporary staff. The service did not provide consultant presence 16 hours a day at weekends in line with the Royal College of Emergency Medicine’s recommendations.  Although the service provided 17 hours consultant presence Monday to Friday, which exceeded the RCoEM guidance, it only provided 14 hours per day consultant presence on a Saturday and Sunday which was not in line with the guidance. A consultant was on call outside the hours of midnight and 7am and were able to give advice over the phone or come in if required.
  • Not all prescriptions were stored securely within the department we found some within a patient area. The following day we saw that managers had taken action to ensure these were stored securely.
  • Substances subject to the Control of Substances Hazardous to Health regulations 2002 were not stored securely within one housekeeping trolley which was left unattended in the department. The following day we saw that managers had removed the product from the trolleys whilst they reviewed the processes surrounding substances subject to these regulations.
  • Patient records and risk assessments were not consistently completed either electronically or on paper.
  • A patient who received rapid tranquilisation was not monitored for signs of deterioration in line with hospital policy. After our inspection the department undertook an audit which showed patients who had received rapid tranquilisation who met the criteria of the policy had documented observations.
  • There were no chaperone signs advising patients of their right to a chaperone.
  • We observed informal comfort rounds were undertaken but these were not always documented as completed.
  • Staff were not able to tell us who the mental health lead was for the service.
  • Mandatory training and appraisal compliance was low and did not meet the trust target. Additional information provided to us by the trust showed overall mandatory training compliance was 70% which was below the trust target of 80%. We saw the department had developed a rolling two-year educational programme which would ensure staff received mandatory and statutory training.
  • The median time from arrival to initial assessment was consistently worse than the overall England median in all months over the 12-month period from August 2017 to July 2018. In the latest month, July 2018, the trust’s median time from arrival to initial assessment was 18 minutes compared to the England average of eight minutes.
  • Additional data showed between September 2017 and September 2018 the average median time for initial assessment for ambulances attendees was 20 minutes. This was still not in line with Standards set by the Royal College of Emergency Medicine. However, performance was improving between April 2018 and September performance varied between an average mean of 15 minutes (May 2018) and 20 minutes.
  • We reviewed audit data in relation to screening for sepsis which showed variable compliance. Between January 2018 and July 2018 compliance varied between 62% (June) and 94% (February). The trust did not supply anymore up to date audit data in relation to sepsis. However, we saw the service had acted upon the poor audit results and had developed a comprehensive action plan to improve the screening and management of sepsis.

Maternity

Outstanding

Updated 18 January 2019

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

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff we spoke to had clear understanding of key midwifery skills and were regularly provided with training updates.

  • Safeguarding vulnerable adults, children and young people was given sufficient priority. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • There was an active and appropriate engagement in local safeguarding procedures and effective work with other relevant organisations. The named safeguarding midwife received supervision from the deputy safeguarding designated nurse from Surrey and West Sussex CCG. The trust had implemented an online child protection information sharing programme to enhance the safeguarding processes and sharing of information. The system checked national database to identify any pregnant woman who may be on a pre-birth child protection plan.

  • The service had suitable premises and equipment and looked after them well. The maternity unit was starting an extension and redesign of the neonatal unit and antenatal clinics. Work had started to move clinics but work for the neonatal unit was planned to go ahead in 2019. The extension will increase the size of the neonatal unit, providing two intensive care cots’, six high dependency cots and 17 special care cot’s.

  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. A risk assessment was completed on initial booking assessment with some mandatory fields in place to ensure questions to assess risk were asked by midwives. Women were continued to be risk assessed during each antenatal contact and postnatally. This ensure up to date risks were considered at all times.
  • Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses and felt supported to do so. Monitoring and reviewing activity enabled staff to understand risks and give clear, accurate and current picture of safety. 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.
  • There was a truly holistic approach to assessing, planning and delivering care and treatment to people who use services. The service provided care and treatment based on national guidance. New evidence-based techniques and technologies were used to support the delivery of high quality care. Managers checked to make sure staff followed guidance.
  • Policies and clinical updates were monitored well. Audits were reviewed yearly and updated in line with any clinical updates from the National institute for health and clinical effectiveness (NICE) and Royal College of Obstetricians and Gynaecologists (RCOG) guidelines. All policies we reviewed were current and a review date was seen.
  • Staff were committed to provide and promote a normal birth. The birth options team worked collaboratively with women to personalise their birth choices and a woman’s individualised needs were reflected when planning how care was delivered. The ‘bumps to birth’ initiative was in place to provide women information in regard to the birth options available to them at the trust.
  • Women who had a intrapartum death had a plan in place to ensure pain relief was adequate for labour. Staff discussed women’s level of pain and subsequent management plans during handover. This ensured all staff knew which women required review of their needs in relation to pain. Intrapartum death is the death of a baby in the uterus.
  • Evidence showed the service regularly reviewed the effectiveness of care and treatment through local and national audits to improve outcomes. The service developed safety pin notices from areas of concern highlighted, following review of audits. The safety pins were used to share lessons and guidance with all staff to improve patient care. Safety pins were displayed in all clinical areas, discussed within safety huddles and weekly updates sent to staff.
  • There was a 24-hour multidisciplinary review of specific high-risk cases as well as twice daily safety huddles. Safety huddles were short multidisciplinary briefings designed to give, clinical and non-clinical, staff opportunities to escalate and discuss any operational concerns. Staff felt these briefings were beneficial and inclusive to all staff.
  • People were truly respected and valued as individuals and were empowered as partners in their care and feedback from patients confirmed this. In line with the National Institute of Health and Care Excellence guideline QS15, Statement 1: Patients are treated with dignity, kindness, compassion, courtesy, respect, understanding and honesty.
  • There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity.

  • The women and partners we spoke with during the inspection were very complimentary about the care and attention they had received. For example, women and partners described their care as ‘outstanding’. Other comments included ‘staff were amazing’, ‘my midwife listened and was supportive’ and ‘staff were caring and listened’.
  • The bereavement midwife worked closely with the gynaecology team to ensure women received sensitive care following a pregnancy loss at any gestation. Pathways of care had been designed to support women and partners with contact and support was offered up to two years following the birth of their baby. We observed examples where parents were supported to take their baby home for a few hours, for a walk outside or given the time to hold, bathe and dress their baby.
  • People’s individual needs and preferences were central to the planning and delivery of tailored services. The maternity unit offered a consultant led and midwifery led birthing unit. The services are flexible, provide choice and ensure continuity of care. Home births were encouraged and the service provided a team of specialist home birth community midwives.
  • There were innovative approaches to providing integrated person-centred pathways of care that involve other service providers, particularly for people with multiple and complex needs. The service had a birth options team. The team met with women and their partners to offer choices around the birth of their baby. Senior managers told us the birth options clinic gave women a voice and an active part in their birth.

  • The service took account of patients’ individual needs. The unit provided support and arrangements for women whose first language was not English. The maternity unit were aware of the local demographic and knew there was a high population of Asian and Polish women using the service. Two midwives recognised the need to support these patients and produced national birth records in Urdu and Polish.
  • The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care. Senior managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. The leaders within the maternity unit showed they had integrity. They were knowledgeable, experienced and well respected by all staff we spoke to during our inspection.

  • The midwifery senior leaders and matrons had an inspiring shared purpose to deliver and motivate staff to succeed. Comprehensive and successful leadership strategies were in place to ensure delivery and to develop the desired culture. We found the head of midwifery to be highly respected by all staff we spoke with. Staff felt valued and listened to and told us the head of midwifery was visible daily and would offer support whenever asked.
  • The leadership focused on continuous improvement and staff were accountable for delivering change. Safe innovation was celebrated. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care. The introduction of the innovation huddle encouraged maternity teams to integrate ideas and improvement into their practice. The huddle took place on the delivery suite and was complemented by the use of a visual management board.

However:

  • The trust had a target of 100% for one to one care in labour which is in line with NICE NG4 Safer Midwifery Staffing guidelines. Since June 2018 to the trust were compliant on average between 97%. However, we were informed by senior midwives that all women in established labour did have one to one care.
  • Staff did not check medicines kept in the emergency drug fridge every day. We found out of 90 days, there were 15 days where checks were missed.
  • Daily checks of controlled medication had mostly been carried out on the maternity ward and delivery suite. However, we saw out of 88 checks there were three checks missing and with two on consecutive days.
  • The unit had experienced high rates of induction of labour and an audit was due to take place to assess why the high increase had occurred. National guidelines show induction of labour to be 29%, the average for the maternity unit was 34% at the time of our inspection.

Outpatients

Good

Updated 18 January 2019

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

  • Staff received effective training in safety systems, processes and practices and understood how to protect people from abuse and their responsibilities regarding the Mental Capacity Act 2005.
  • Standards of cleanliness across the department were maintained. There were systems in place to monitor and audit infection control activities.
  • The design, maintenance and use of facilities and equipment kept people safe. Equipment was maintained and monitored to ensure it was fit for use.
  • People’s individual care records, including clinical data was written, stored and managed in a way that kept people safe. The management of medical records had improved since our previous inspection.
  • Medicines in outpatients were managed safely. Medicines and prescription pads were kept locked when not in use.
  • Lessons were learned and improvements made when things went wrong. Issues were discussed in daily safety huddles where improvements were identified and shared.
  • The service provided care and treatment based on national guidance. Speciality clinics operating within the outpatient department followed relevant national guidance and participated in national and local audits.
  • The service made sure staff were competent for their roles. There were induction arrangements for new staff and the department’s compliance with appraisal rates exceeded the trust target.
  • Staff gave patients enough food and drink, where appropriate, to meet their needs whilst in the outpatient department.
  • People were treated with compassion, kindness, dignity and respect, when receiving care. Staff communicated with people in a way that supported them to understand their care and treatment.
  • A working group to review access to the department for patients with physical and learning disabilities was in operation.
  • The facilities and premises were accessible to patients and clearly signposted. Where there were limitations on space within waiting areas staff acted to mitigate risk and the trust was working to improve the environment. Signposting within the department had improved since our previous inspection.
  • The ‘did not attend’ rate for the outpatient department at East Surrey Hospital was better than the national average.
  • People had timely access to initial assessment, test results and diagnosis and treatment. Referral to treatment times were monitored and performance for non-admitted and incomplete pathways had improved and was better than the national average in recent months.
  • Trust performance for cancer waiting times was better than the operational standard and the national average in the most recent two quarters.
  • Data showed that the proportion of cancelled clinics within outpatients had reduced.
  • There was evidence of learning and improvement from complaints. Complaints were responded to in line with the trust’s complaints policy.
  • Leaders were visible and there was a clear vision and set of values, with quality and sustainability as the top priorities. An outpatient strategy had been developed in line with the trust strategy.
  • Staff and leaders alike reported that the culture within the service had improved since a previous inspection when staff reported feeling frustrated and not listened to by managers. Staff told us they felt valued.
  • There were governance structures and processes to manage current and future performance and robust arrangements for identifying, recording and managing risks, issues and mitigating actions.
  • There were clear and robust service performance measures which were reported and reviewed.
  • The trust had systems and processes in place to engage with patients, staff, the public and local organisations to plan and manage services.
  • There were standardised improvement tools and methods, and a trust-wide continuous improvement approach in operation within the outpatient department.

However;

  • Patients undergoing minor surgical procedures within the outpatient department were not giving consent until they were in the procedure room which was not in line with best practice.
  • In some outpatient areas there was limited space for private conversations to be held with patients, including those where bad news was being delivered.
  • Toys in the department were not subject to routine cleaning schedules.
  • Resuscitation equipment within the cardiac clinic was subject to daily and weekly checks but there were some gaps in the recording of these.