East Surrey Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed a total of 6 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question requires improvement.

We found the service did not have an embedded proactive and positive safety culture and lessons were not always learnt or disseminated to staff. The service used systems and patient pathways however there were issues with the timeliness of assessing clinical risk. The design, maintenance and use of facilities, premises and equipment did not always keep people safe. The service did not always have enough qualified, skilled and experienced people to keep people safe. The service did not always ensure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, the service had policies to collect, investigate and report safety events. Staff understood how to protect patients from abuse and worked together to care for people that used their services.
 

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients and their families generally felt confident in the hospital's care and safety measures.

Staff were able to identify incidents and gave us examples of things they would report as incidents such as patient falls, medication errors and pressure ulcers. Staff spoke of being open and honest with patients and their families when events had either put patients at risk of harm or had caused them harm. Most staff felt safe to report incidents. Staff explained how learning and improvement actions from incidents was shared with them, these included team meetings, newsletters, handovers and safety huddles. Staff talked about changes the trust had made regarding the monitoring and recording of patient pressure damage. However, the link between this change of practice, incidents reporting and patient safety was not demonstrated by the majority of staff.
The new patient safety incident response framework (PSIRF) was not embedded in the service with the majority of staff yet to receive training.
Staff told us they always tried to address complaints or concerns as soon as possible. The teams attempted to resolve any issues before concerns escalated to become formal complaints. However, staff did not link complaints with patient safety learning.
Divisional leaders acknowledged patient safety was an area that needed focus and explained due to the divisional governance model and the capacity of staff, shared learning across the division and wider hospital could be a challenge.
 

The hospital was implementing a new incident reporting system, but not all functions were currently available, this included information on mortality and morbidity and the ability to track the actions of agreed patient safety action plans.

The service and wider trust had processes in place to collect data, including performance and outcome data, and incidents and complaints. There were policies, procedures and meetings in place to integrate data and to investigate incidents and complaints. The trust provided meeting minutes, matron’s reports and trust presentations to show outcomes and actions required. However, there was a lack of evidence to demonstrate how the service and wider hospital actively learnt from the information to drive continuous improvement and changes in practices to improve care for patients.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were appropriately supported when they felt unsafe or experienced abuse of neglect. People were signposted on how to raise concerns by the hospital.

There was an understanding of safeguarding and how to take appropriate action. Staff were supported by a trust safeguarding team, who made sure the appropriate action was taken, and worked collaboratively with external partners to keep people safe.
Appropriate training was delivered to staff which had resulted in an increased safeguarding awareness and the improvement of staff safeguarding referrals. Qualified nurses had an average of 95% compliance for the 6 safeguarding modules required. However, medical staff’s compliance remained lower than required at 66% compliance.
 

The service had up-to-date policies, which were in line with national guidance and best practice, to ensure staff understood their responsibilities and the actions they must take to ensure people were protected from abuse and neglect.

Patients and relatives told us they clearly understood the risks, safety measures and proper channels for reporting safety concerns in emergencies.

Staff completed risk assessments for patients using national recognised tools. Care plans were developed using this information to provide care and treatment and minimise risks as identified. Staff reviewed patient’s individual risks, care plans and treatment needed during ward rounds, handovers and shift changes. This meant clinical risk was picked up and managed during these times.
The service had introduced electronic patient records (EPR) replacing paper records. Staff felt the introduction of the EPR system meant there was better coordination of care and sharing of information for the patient. Clinical staff could also access all patient information relating to their present and past care in one place which facilitated more timely decision making, particularly in critical situations.
The critical care outreach team supported the wards with deteriorating patients. They were available 24 hours a day, seven days a week. Staff could contact the team if they were worried or concerned about a deteriorating patient. Staff told us deteriorating patients would sometimes be returned to the Acute Medical Unit (AMU) to be cared for as it was felt staff on the AMU had the appropriate skills to care for patients there rather than on the wards. Post inspection we asked how many times this happened in the past year but the trust did not supply this data to us. Divisional leaders of the service expressed this was not ideal and the service was looking at ways to manage deteriorating patients in a different way.
Wards used different techniques to minimise risk and ensure patients were kept safe. Some wards cohorted their patients so that patients at higher risk who needed closer observation were placed in bays closest to the nurse’s station. Other wards had dedicated nurses in each bay who were responsible for the care and supervision of patients in that area only.
 

There was a lack of policies and procedures on assessing clinical risk on admission for staff to follow. 2 patient risk assessments were mandatory when admitting a patient to the hospital, Malnutrition Universal Screening Tool (MUST) and skin assessment. All other assessments were deemed personalised care and decided on by the admitting nurse using their clinical judgement. Staff at all levels were unable to direct us to guidance regarding patient risk assessments on admission, any training received on which assessments to undertake or monitoring and evaluation that risk assessments were selected appropriately and therefore reducing the risk of patient harm. We reviewed patient records on the acute medical unit (AMU), where admission usually occurred, and found, a patient living with dementia and had low blood pressure did not have a falls assessment, capacity assessment or safeguarding on admission. An elderly patient admitted due to an unwitnessed fall, had no medical history taken, no falls assessment, no skin integrity body map completed, and no capacity assessment taken on admission. A patient admitted for tachycardia and musculoskeletal pain had no falls assessment, and we found evidence where elderly care patients had not been assessed for risk of falls. Although no actual harm was found at the time potential harm to patients was found. There was a lack of standardisation of patient risk assessments, no measure of consistency of their application by staff and a lack of assurance regarding patient safety.
Whilst on the medical care wards we asked if patients ever arrived to the admitting wards without what they deemed the appropriate risk assessments completed. We were told they were, and ward staff would complete any missing risk assessments. However, no feedback was given to the previous area, usually the acute medical ward (AMU), meaning no learning was shared. In addition, there was an increased risk of harm to patients as risks had not been mitigated for in a timely way.
The service used a nationally recognised tool, the national early warning score 2 (NEWS2) system to monitor patients who were deteriorating and to escalate care. However, NEWS2 audit identified poor compliance with guidance with results showing a lack of appropriate monitoring and escalation recorded. The impact of this for patients had not been evaluated by the service or wider trust. It had been recommended that there needed to be improve awareness of the tool, and to re-educate staff on the concepts behind NEWS2 and the importance of escalation. The service did not provide any information on how this was happening.
 

Patient and relative feedback was positive regarding the environment where they were cared for. Wards were clean and free from odours. Patients felt safe and their privacy and dignity was maintained.

Staff know how to report maintenance issues and faulty equipment.

All wards we visited were secure with a swipe or call entry. Due to the design of the acute medical unit (AMU) and the frequency of people entering and exiting the facility the door was mostly kept open. We found throughout the medical care service hand sanitiser stations not clearly signposted and empty hand sanitisers.
Wards were generally well maintained and clutter free. However, some wards, due to lack of storage or amount of equipment needed were more cluttered.
The ward environments were not always appropriate for the patients being cared for. For example, the AMU was busy and noisy environment with open bays. Patients with more complex needs such as dementia, were not cared for in areas which were quieter or more contained, and during the inspection we observed staff having to take a confused patient back to their bed. The AMU had 3 side rooms but were mainly used for patients with infections that needed to be isolated. Elderly care wards had not been designed in a way to make them dementia friendly. Two of the elderly care wards, where patients were medically fit but waiting for onward packages of care, had no outdoor space easily available to them. In addition, access in and out of the ward was difficult for both patients and visitor with mobility issues due to the long and uneven pathway from the main building to the wards. However, some wards such as the cardiology wards were light, spacious and airy and had an outside area for patients to enjoy.

Equipment was clean, stored appropriately and maintained. Emergency equipment was available and regularly checked for compliance. Consumables, including hazardous substances were stored appropriately.
 

There were arrangements to monitor the safety and upkeep of the premises and equipment. For example, environmental risk and ligature assessments were carried out on the wards. However, information reviewed post inspection showed this to be out of date or not fully completed. We found pull cords in toilets and bathrooms that were a ligature risk including in the acute medical unit where patients with more complex needs were cared for.

Post inspection the trust informed us they had taken actions to rectify some of the issues highlighted in this report, for example the installation of new hand sanitiser dispensers, pull cords replaced with detachable anti-ligature models, hearing loop faults resolved and a review of hospital wayfinding and signage.

Patients told us they felt safe and knew how to contact staff if needed. Some patients and their relations felt there were not enough staff, to respond to everyone’s needs and felt this was particular evident at mealtimes. They acknowledged that staff were doing their best. Family members appreciated the dedication of the staff but felt they were overworked.

Staff told us they completed mandatory and statutory training appropriate and relevant to their role. However, data provided by the trust showed nursing staff were meeting the trust target for 8 out of the 15 modules and medical staff only 1 out of the 17 modules required.
Staff told us they received support to deliver safe care. This included supervision and annual appraisals. Data provided by the trust showed that medical staff had almost reached the trust target of 90% for appraisal completion. However, a third of the nursing staff had not had an appraisal during the last 12 months. Without appraisals performance could not be evaluated, areas of improvement identified, and professional development supported appropriately.
Information submitted by the trust post inspection showed there was staff shortages in certain areas of the medical care service. Staff told us this could sometimes impact on the care they could give patients. The service employed bank and agency staff when needed to fill staffing gaps and to keep patients safe. However, not all of these shifts were filled when required. For example, the average percentage of unfilled nursing shifts in the 6 months prior to the inspection where, 37% of bank staff and 78% of agency shift.

Post inspection the trust informed us that although staffing pressures remained especially in high need areas, the trust had used targeted bank incentives and improved the roster lead time, and these had seen signs of improvement in staffing levels. For example, the average unfilled shifts between March and May 2025 on the acute medical unit (AMU) was 17%.

We observed staff carrying out their duties to make sure people received safe, good quality care that met their needs. Some wards were calm with staff available to care for patients, whilst other wards, the staff appeared rushed and call bells not responded to in a timely manner. We also observed some wards where staff were required to look after 2 bays rather than 1 due to staff shortages on the ward.

The service followed trust policies and procedures to ensure safe recruitment practices to make sure all staff, including agency staff and volunteers, were suitably experienced and competent to carry out their role. All completed an induction programme once employed by the trust.
The service used recognised patient acuity and dependency tools and national guidance to determine safe staffing. However, data provided by the trust post inspection showed for the 3 months prior to the inspection, across the medical wards, 33% of shifts where understaffed. When the data was broken down this showed 4 wards had 47%, 47%, 49% and 60% of shifts understaffed respectively, and the acute medical unit had 52% of shifts understaffed. Understaffed hospital wards can lead to poorer quality of care due to the inability to adequately attend to all patients’ needs and increased stress for existing staff.

The service had a vacancy rate of 13%. However, some areas had more of a shortage than others. For example, the acute medical unit (AMU) had a 24% nursing staff vacancy rate.

Post inspection the trust informed us the medical specialities vacancy rate in May 2025 was 11%.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Most patients reported receiving their medicines on time.

Ward staff explained how medicines were requested and supplied to the wards from pharmacy. Staff had mixed views on the discharge processes including medicines to take out (TTOs). They explained that whilst the processes generally worked as activity increased, it was more likely that parts of the discharge process would get omitted. Examples they gave included discharge summaries including TTOs not being written up in a timely manner, following patients moving wards, TTOs would be sent to the previous ward due to out-of-date information. Following assessment by staff, patients could self-administer their medicines. However, patients who were self-administering medicines had to ask staff to open their patients own drugs locker limiting the opportunities for self-administration. Staff described how they would access approved additional information about medicines via the trust intranet.

The e-prescribing and medicines administration (ePMA) system had been rolled out and was now business as usual. Staff described how incident reviews including an assessment how the ePMA could have impacted on the incident. Following this analysis the ePMA pathways were revised if required. The pharmacy team explained how they prioritise pharmaceutical care plans based on patients' pharmaceutical risk. This process was especially useful when patient numbers increased or at times of staff shortages.

Medicines including controlled drugs, medical gases and medicines requiring refrigeration were stored securely. Records for controlled drugs and fridge temperatures were completed. However, fridge temperatures from 2 areas were not following the trusts procedures. Whilst the fridges were functioning, the records indicated they were outside of their recommended temperature range and had not been investigated. National guidance was not being followed to record minimum and maximum fridge temperatures. Therefore, we were not assured that medicines requiring refrigeration were stored within their recommended temperature ranges. The location had a T28 waste exemption certificate from the Environment Agency for the denaturing of controlled drugs that were no longer required or out of date.
Outlets for accessing piped medical were on all wards we visited but had not been reviewed in line with the NHS National Patient Safety Alert – Eliminating the risk of inadvertent connection to medical air via a flowmeter. When we raised this with the Chief Pharmacist actions were taken to resolve the concern and review the governance processes that monitored the trust's compliance with safety alerts.