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Inspection carried out on 21 January 2016

During an inspection to make sure that the improvements required had been made

We carried out a comprehensive inspection of the East Surrey Hospital in May 2014. At that time we rated the outpatients department as requiring improvement because we found many clinic appointments were cancelled at short notice. Clinics were busy and were often running late and where medical records for clinics were often not complete, therefore clinics often saw patients with a temporary notes.

We judged the service was not fully compliant with Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 210, then in force. Consequently we issued a requirement notice, a form of enforcement action which demands providers make necessary improvements to meet the required standards.

The purpose of this inspection was to check improvements had been made, ensuring the terms of the requirement notice had been met. Therefore we did not rate this service.

Our key findings were as follows:

  • The trust had met the conditions of the requirement notice.

  • The trust had introduced systems to regularly assess and monitor the quality of outpatient services.  

  • The trust had suitable arrangements for assessing and managing risks relating to the health, welfare and patients and others.

  • This had been achieved through the establishment of a new management and governance structure and a strengthening of nursing leadership.

  • Arrangements for the management of medical records had improved and more than 99% of full medical records were available at clinic appointments.

  • Punctuality of clinics was much improved and 87% of patients were seen within 30 minutes of their appointment.

  • Although there was an increase in the number of short notice clinics to meet increases in demands, there was now more stringent controls in place and better management of these.

  • There were improved management controls to minimize the number of cancelled clinics.

  • Thirteen additional consultants had been appointed, to assist in the provision of additional capacity to meet increasing demands.

However, there were areas of practice where the trust still needs to make improvements. The trust should:

  • Ensure all staff are trained and able to use the electronic incident reporting system.

  • Develop systems to ensure the consistent checking  of emergency equipment in the outpatients department.

  • Ensure there are arrangements to ensure confidential patient notes are not left unattended in the outpatients department.

  • Ensure all staff have received training regarding the Mental Capacity Act, and are clear about the practical application of this legislation in their work.

  • Consider how the monitoring of actual versus scheduled appointment times could be used to inform further development and improvement.

  • Review signage in the department to improve patient flow through the department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 20-22 May 2014

During a routine inspection

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 carried out on 26, 27 February 2013

During a routine inspection

As part of our inspection we looked at care in Accident and Emergency (A&E), Neonatal Intensive Care (NICU), the children's ward and three wards dedicated to care of the elderly who required medical and/or surgical treatment. We observed staff speaking with patients in a polite and respectful manner.

Most of the people that we spoke with told us that they were happy with the care they received and could not criticise the staff or environment in which they were cared for, in any way. People told us that they had felt involved in the decisions relating to their care and treatment. One person said "staff are all very pleasant". Another said "I was dreading coming into hospital (...) but just look, it's excellent in here".

Patients were able to express their views and were involved in making decisions about their care and treatment. People felt nursing and medical staff were "smashing", "excellent" and "hard working" and explained treatments to them. Care and treatment was planned and delivered in a way that ensured patient's safety and welfare during short stays, however we considered that those people who experienced prolonged stays in hospital did not always have a comprehensive plan of care.

There were effective systems in place to seek appropriate consent from people before care or treatment was carried out.

There were effective systems in place to safeguard people from the risk of harm.

Inspection carried out on 29 June 2012

During an inspection to make sure that the improvements required had been made

During this follow up visit we spoke to patients or their representatives on Godstone and Copthorne wards. In addition, we visited and observed the Accident and Emergency department, the hospitals ‘walk in’ centre and the Pre operative/Pre assessment area (known as POPPA)

Patients indicated that they were treated as individuals and the majority were happy and very satisfied with the personalised care and treatment they received. One patient said, I have more confidence in the nursing staff here than in any other hospital I have been in....staff take a genuine interest in you” Numerous other patients spoken with made positive comments about their care including, "they've treated me very well", "staff are absolutely wonderful" and “I couldn’t have got better care if I had gone private.”

We also received very positive comments from patients about the standards of cleanliness in the hospital and the hygiene control measures in place to protect them from unnecessary harm. For example, a patient told us, "I've got no complaints about the cleanliness and I see staff washing their hands and using the hand sanitizers all the time. Another patient told us they were more than satisfied with hygiene levels on the ward. They said that staff took infection control measures seriously, wore aprons and gloves and washed their hands regularly. One patient was concerned however that some staff who visited the ward, such as porters, didn’t always use the hand sanitizers. The patient felt that was a risk as they visited numerous other wards during the course of their work. Another patient was concerned that some shared equipment was not always cleaned between patient use. An example given was the blood pressure cuff.

Inspection carried out on 23 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 16 December 2011

During an inspection in response to concerns

Prior to this visit, we had inspected the hospital twice in 2011. Our previous inspections assessed the quality of the care provided following concerns raised about poor care and issues relating to dignity and nutrition as part of a national programme of inspections.

We are aware of the challenges East Surrey Hospital is facing with regard to inadequate capacity in their Accident and Emergency (A&E) department and the impact it is having on patients. We know the hospital have secured funding and are now investing in improved facilities, care and safety. During our visit, we saw some evidence of the progress the hospital is making to improve capacity. We have discussed some of the evidence of progress under Outcome 4 ( Care & Welfare of People Who Use Services) of this report.

This report focuses mainly on the use of escalation areas in the hospital. We also assessed the management of infections. We will be inspecting other services in the hospital in the future to carry out checks on their compliance with standards.

We visited the hospital on 16 December 2011 to follow up on the concerns raised with us by an anonymous whistleblower about the safety and functionality of the Pre operative/ Pre assessment area (known as POPPA) and to validate the hospitals written response to those concerns. In addition, we had received concerns around the hospitals infection control measures, discharge planning and the management of serious untoward incidents.

We spoke to numerous patients who were occupying beds in various escalation areas sited around the hospital. Escalation beds are used when the hospital is under pressure and demand outstrips normal bed capacity. Some escalation beds were seen to have been added to the bed numbers ordinarily used in some of the hospitals main wards. These additional beds had been fitted into available empty spaces on wards. Other beds had been set up in areas whose primary function was not a ward, but a space usually afforded to other purposes, such as the discharge lounge or the POPPA area. This area is normally used to assess and prepare patients before they go into the operating theatre. When there are not enough available beds for inpatients, POPPA becomes a small ward area of 5 beds.

We spoke to nursing staff who were working in some of the escalation areas and to more senior nursing staff with responsibility for service outcomes in these areas. We also spoke to staff involved with the Patient Advice and Liaison Service (PALS). PALS supports patients and their carers who may wish to raise a complaint or concern about any aspect of their care and treatment while in hospital. In addition, we spoke with the hospitals infection control lead and the head of nursing who explained the hospitals risk assessments for escalation areas. We briefly fed back some our findings to the hospitals Chief Executive Officer and the Chief Nurse at the end of our inspection.

Patients told us they were largely understanding of the hospitals current bed pressures. One patient said they knew that the hospital trust was in the process of building more wards and said that the hospital had improved a great deal since they were last admitted two and a half years ago. One patient said as they had been so ill on admission that they were very glad to be receiving treatment, regardless of where their bed was actually located in the hospital.

Patients told us that they had been given specific information regarding their condition and staff had generally explained the care and treatment they were to receive during their stay. Some people were still awaiting results of diagnostic tests and decisions to be made about discharge arrangements, which was clearly making them anxious. They said that most staff however had been patient and understanding and had treated them with respect. Three patients said their individual care plans had been discussed with them, but other patients spoken with appeared unaware of any written care documentation and couldn’t remember if it had been shared with them or not. Patients told us that their nutritional needs, where appropriate, were being met and that they were offered timely pain relief.

Concerns were raised specifically by patients in the POPPA escalation area about the lack of facilities available to them. Comments included. “It is so hot and sticky in here. I can’t seem to get any air, and its making me feel worse”. Another patient who had been in the POPPA area for 3 days said, “There is no where to wash. Only one little sink and no mirror either”. Another patient commented about a lack of space between the beds, which left little opportunity for privacy, even with the bed curtains drawn. They said that private conversations, even when spoken in a low voice could clearly be overheard by other people. Another patient was confused as to whether they were allowed to have visitors in POPPA and said that there was very little information available and they didn’t want to bother the nurses. A patient was seen to be struggling to eat their lunch in comfort as there was no over bed tables available. The patient told us that they had a wound on their stomach which made it even more difficult to eat without suitable facilities.

Nursing staff working in the escalation areas who spoke to us said that they had received specific guidance about working in the escalation areas, were confident of their ability to manage the clinical area safely, and largely felt able to secure the care and welfare of patients during their stay. They said that they had sufficient operational support and direction from senior staff if they were unsure about anything, or needed to raise a patient safety concern. Some trained staff from adjacent wards commented that covering for colleagues who were taking their rest breaks in escalation areas was tiresome and annoying. It often meant leaving their own work area/ ward which could prove disruptive and often upset their work plans. However, they largely understood that this was a reasonable management request given the hospitals current circumstances and patient need.

Inspection carried out on 24 March 2011

During a themed inspection looking at Dignity and Nutrition

Patients that were able to speak to us said they were very positive about their care and treatment. One patient said the staff were kind and caring and provided excellent care. Patients felt they were kept informed and either they or their family were involved in making decisions about their treatment. They felt they were given enough information to help with this process. The only area where people did not feel well informed or involved was in relation to their discharge planning, which concerned them. Staff were observed treating patients with respect. Patients confirmed that staff were responsive to their needs and they received care in a kind and respectful way. All patients said that when they called for assistance using the call bell, staff usually came quickly. One patient said, “Sometimes in the morning you might have to wait a bit longer as the staff are really busy then, but generally they are very good. One patient said that staff were discreet, obliging and understanding. All patients were accommodated in single sex bays or single rooms with en-suite facilities.

The majority of patients spoke very positively about their experiences of mealtimes. They said that housekeeping staff were very caring and discussed meal choices with them. They said they always suggested alternatives if there was something on the menu they disliked or were unable to eat. Patients felt they were well supported by staff if they needed help with eating or drinking. A patient on a specialist diet said that although the food was generally very good, it did “lack variety and imagination sometimes”. This lack of variety was particularly evident in the comments patients made to us about the tea time menu. A significant number said they were being offered too many sandwiches at tea time, which they felt limited their choice and became very repetitive.

Inspection carried out on 16 February 2011

During an inspection in response to concerns

Patients said that staff talked to them and explained the care or treatment they were about to provide and asked for their consent. Sometimes their consent to specific types of treatment would be asked for in writing by the doctors caring for them. They told us that they did not feel under pressure to give consent and felt that they had been given sufficient information to make decisions and could change their mind if they needed to.

Patients told us they were very pleased with the service and with the staff but that sometimes treatment was slow or delayed. Some patients told us that there were delays in getting diagnostic tests done. They said that diagnostic tests were scheduled and then rescheduled for a different day, sometimes more than once. Patients told us they were not always provided with an explanation for these delays. They praised nursing staff and doctors as being very knowledgeable and usually responsive. Patients told us they had opportunities to ask questions and were given explanations that reassured them. They felt staff were very approachable and kind. They told us they valued the opinions of the nurses and doctors and felt confident that they understood their care and welfare needs. None of the patients knew what a care plan was however and so did not think they had seen or agreed to one. Patients told us they had opportunities to ask questions and were given explanations that reassured them. They felt staff were very approachable and kind. Some of the patients said they were not provided with information about how long they might be in hospital. They also said they had no knowledge of their discharge arrangements.

Patients were positive about cleanliness and hand hygiene across both of the wards we visited. They felt the wards were kept clean and that the staff worked hard on this, especially in busy areas. A patient who had received treatment on Godstone ward on two separate occasions said they were accustomed to seeing the hospital matron come round to do her monitoring checks for cleanliness and safety of equipment, and were impressed with her thorough approach

People told us that they were happy with the way their medicines were being given to them in hospital. They told us that nurses and pharmacists had explained their medicines to them and they felt that they understood the changes that had been made during their stay. People being treated on the wards told us that they always had their pain relief when they needed it. We saw a pharmacist carefully explaining a new medicine to someone before they went home. We saw a nurse giving someone medicines, explaining to the person what they were doing and following a safe procedure. Someone told us that they were able to keep their inhalers with them so that they could use them when needed which was important to them. Some people had told us before we visited the hospital that there was a delay in them getting their medicines when they were ready to go home.

Inspection carried out on 28, 29 January and 18 February 2010

During an inspection to make sure that the improvements required had been made

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.