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Epsom General Hospital Requires improvement

We are carrying out checks at Epsom General Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 May 2018

Our rating of services stayed the same. We rated them as requires improvement because:

  • Mandatory training and appraisal completion figures were low. Staff did not always have their performance reviewed or have the opportunity to discuss development needs.
  • Staffing levels on wards were lower than the recommended safe staffing guidelines at times. Some staff told us they were tired and felt overstretched due to staff shortages and this was starting to affect their morale.
  • Governance and risk management processes were not as strong or effective across all areas we inspected. Incidents were not always reported, which limited the opportunities to review and learn from them. Staff did not always receive feedback on low level incidents.
  • In the emergency department, some key safety targets were not being met and patient outcome measures were not always subject to scrutiny and action. Safety checking procedures were not always carried out routinely.
  • There remained problems with old equipment and the replacement programme was running at a slow pace.
  • In surgery, the service provided to operating theatres for provision and processing of surgical instruments was less than satisfactory. Little had been done to resolve this matter.
  • In maternity, the trust continued to focus more on trust wide outcomes rather than outcomes by unit, which obscured differences between the two units. The overall vision for the unit was not well defined. There was a lack of clarity on whether the maternity service was one service at two locations or two separate units.

However;

  • Clinical staff ensured that patient treatment and care was delivered with kindness and compassion. Patients felt well cared for and were treated with dignity and respect by staff.
  • Staff used professional guidance and best practices, including risk assessment tools and consent procedures to support the provision of safe and responsive care.
  • There was a positive culture of team work, multidisciplinary working, and a strong sense of commitment to doing what was right for patients.
  • Seven day on site cover was provided by consultants, the pharmacy and physiotherapy teams and was well established.
  • The trust planned and provided services in a way that met the needs of local people.

Inspection areas

Safe

Requires improvement

Updated 14 May 2018

Effective

Requires improvement

Updated 14 May 2018

Caring

Good

Updated 14 May 2018

Responsive

Good

Updated 14 May 2018

Well-led

Requires improvement

Updated 14 May 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 27 May 2016

Overall, we found that outpatients and diagnostic imaging were good. The service was rated as good for safety, caring, responsive and well-led. The effective domain was inspected but not rated.

Patients, visitors and staff were kept safe as systems were in place to monitor risk. Staff were encouraged to report incidents and we saw evidence of learning being shared with the staff to improve services. There was a robust process in place to report ionising radiation medical exposure (IR(ME)R) incidents and the correct procedures were followed. The pathology department had a comprehensive quality management system in place with compliance targets set at higher than the national average to improve safety and quality. There was evidence of quality improvement in place following the restructure of pathology services. The focus on low radiation doses in radiology was excellent.

The environments we inspected were visibly clean and staff followed infection control procedures. Records were almost always available for clinics and if not, a temporary file was made using available electronic records of the patient. Staff were aware of their responsibilities within adult and children safeguarding practices and good support was available within the hospital.

Nurse staffing levels were appropriate and there were few vacancies. The diagnostic imaging vacancies were higher, particularly ultra sonographers. There was an ongoing recruitment and retention plan in place.

There was evidence of service planning to meet patient need such as the contract for MRI services. National waiting times were met for outpatient appointments and access to diagnostic imaging although the wait for MRI services had increased. A higher percentage of patients were seen within two weeks for all cancers than the national average, but the cancer waiting times for people waiting less than 31 days from diagnosis to first definitive treatment and the proportion of people waiting less than 62 days from urgent GP referral to first definitive treatment were both below the national average.

Staff had good access to evidence based protocols and pathways. There was limited audit of patient waiting times for clinics, but patients received good communication and support during their time in the outpatients and diagnostics departments. Staff followed consent procedures and had a good understanding of the Mental Capacity Act 2005.

We observed and were told that the staff were caring and involved patients, their carers and family members in decisions about their care. There was good support for patients with a learning disability or living with dementia. The outpatients department at Epsom hospital had good information display boards available for staff and patients to access.

Staff were aware of the complaints policy and told us how most complaints and concerns were resolved locally. The service had no open complaints at the time of the inspection.

The outpatients and diagnostic imaging departments had a local strategy plan in place to improve services and the estates facilities. From December 2015, the current outpatient services that are in Clinical Services Directorate, will move to a new Outpatients and Medical Records Division. Staff expressed some concern over these changes.

Governance processes were embedded across outpatients and diagnostics. The directorate was commended on its risk register in a recent review of risk registers in the trust. Senior managers told us the newly appointed Quality Manager had made significant improvements in making sure priorities, challenges and risks were well understood. Good progress was evident for improving services for patients.

We found good evidence of strong, local leadership and a positive culture of support, teamwork and innovation.

Maternity

Requires improvement

Updated 14 May 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

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

  • We still had some concerns about infection control in the theatre outside the sterile area of the operating table, such as the use of tape and putty like adhesives on walls and equipment and the failure to remove numerous adhesive residues.
  • The service did not meet expected standards in some patient outcomes, particularly the rate of caesarean section. Actions were in hand to identify the reasons underlying these, but had not yet improved performance.
  • The trust continued to focus more on trust wide outcomes rather than outcomes by unit which obscured differences between the two units. The services at each site had different commissioners with slightly different priorities.
  • We found out of date paper versions of policies on the unit and staff were not aware these were out of date
  • The overall vision for the unit was not well defined. There was a lack of clarity on whether the maternity service was one service at two locations or two separate units. Some staff worked cross site and others were locally based. All staff were recruited to the trust maternity department yet clinicians at one site were considered independent enough to advise on Serious Incidents at the other site.

However;

  • Staff had taken note of many concerns raised at the previous inspection and made improvements. For example, we saw there were now a range of audits taking place in relation to risk areas, there had been improvements in recording and learning from incidents, there was consultant cover evenly spread throughout the week and obstetricians were more engaged in management and management was more visible to staff.
  • Risks to women were well-identified in antenatal care, there was an effective vaccination scheme for pregnant women and safeguarding was well-managed.
  • Women had a choice of where to give birth and the proportion of home and birth centre births were rising and almost all women had one to one care in labour.
  • The governance arrangements and their purpose were clearly structured. Collection of data had improved to provide better oversight of the service.
  • New management and staff changes had led to a less hierarchical culture and brought in some new ideas.

Maternity and gynaecology

Requires improvement

Updated 27 May 2016

We judged the maternity and gynaecology services as requiring improvement.

Systems and processes were in place for reporting and investigating incidents in maternity but dissemination of learning from incidents and complaints was inconsistent. In gynaecology incident reporting was very low. The service was slow to implement change. For example responding to failure to achieve its own or national performance targets in maternity services and despite limitations to restrict admissions of women in labour to lower risk women, some staff voiced safety concerns.

The trust mainly monitored maternity services based on merged data from both maternity units. This was unhelpful in terms of monitoring maternity performance at Epsom, which was smaller, less busy and served a different population and employed Epsom-based staff. Although we requested performance data specific to Epsom the trust was not able to provide this in many cases.

Most of the clinical guidelines had been reviewed recently in line with national guidance but not all staff were aware of key changes. There was limited evidence that national or local audits had an impact on practice.

Women and their partners were generally positive about the care they received. They understood and felt involved in their care. Women received the emotional support they needed.There was a mainly positive response to the Friends and Family Test, with a reasonably high response rate among woman who stayed in the maternity wards of 33%. The response on outpatient services were much lower.

Midwives were aware of the characteristics of the local population and responsive to their needs. However, it was less clear whether the pattern of medically led antenatal clinics met the specific clinical needs of the local Epsom population. There was limited engagement with either staff or with the local community about the design of the service.

Management of the maternity service was weak and obstetricians were not sufficiently engaged in the maternity service. Midwives felt Epsom hospital was low on the trust priorities. Managers did not identify, analyse and manage the risks of harm to women that were specific to Epsom and highlighted on the local maternity dashboard Staff provided little challenge to one another. The culture was hierarchical. Several staff said they had spoken up about concerns, but no action resulted. They felt the service was complacent.

Aside from the weaknesses in incident reporting, we had no concerns about gynaecology.

Medical care (including older people’s care)

Requires improvement

Updated 14 May 2018

Our rating of this service went down. We rated it as requires improvement because:

  • Mandatory and safeguarding training and appraisal completion figures were low.
  • Staffing levels on wards were lower than the recommended safe staffing guidelines at times.
  • Records completion such as Do Not Attempt Cardiopulmonary Respiration (DNACPR) forms and malnutrition universal screening tool were not consistent.
  • Staff did not always record mental capacity assessments and best interests meetings and decisions in patient care records, when appropriate.
  • Control of Substances Hazardous to Health (COSHH) products were not always stored safely.
  • Complaints took longer to be responded to than the timescales set out in the trust’s complaints policy.

However;

  • There were good systems in place to identify risks, implement policies and procedures, and report incidents. The storage and management of medicines was good. Leadership was well respected and accessible to staff. The service’s vision, values and strategy were clear and well known and understood by staff. Complaints were investigated and learning from complaints was demonstrated.
  • CRISIS (Care, Recognition, Initial, Stabilisation In Simulation), was part of mandatory training for all nursing staff and key junior medical staff and allowed multi-professional staff to simulate their management of medical emergencies in a safe environment.

  • There was good multidisciplinary team working. Seven day cover was provided by consultants, the pharmacy and physiotherapy teams and was well established.
  • Staff inductions were provided and staff felt supported and were provided with development opportunities.
  • Patients felt well cared for and were treated with dignity and respect by staff.

Urgent and emergency services (A&E)

Requires improvement

Updated 14 May 2018

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

  • Although we found some improvements had been made since our previous inspection, particularly with regard to the responsiveness of the service, there remained areas which required further improvements.
  • Governance and risk management processes were not as strong or effective as would be expected. Incidents were not always reported, which limited the opportunities to review and learn from them.
  • Some key safety targets were not being met and patient outcome measures were not always subject to scrutiny and action. Safety checking procedures were not always carried out routinely.
  • The completion of mandatory safety training by staff was less than expected and was unlikely to be achieved within the current year.
  • Staff did not always have their performance reviewed or have the opportunity to discuss development needs.
  • All staff did not understand when and how a Deprivation of Liberties Safeguard authorisation should be used for patients who lack capacity to agree to admission.

  • The use of rapid tranquilisation medication was not monitored.

  • Staff did not always record mental capacity assessments and best interests meetings and decisions in patient care records.

However:

  • Clinical staff ensured that patient treatment and care was delivered with kindness and compassion. Staff used professional guidance and best practices, including risk assessment tools and consent procedures to support the provision of safe and responsive care.
  • Patients were protected from avoidable harm; their mental health and other individual needs were considered and acted upon by staff.
  • There was a positive culture of team work, multidisciplinary working, and a strong sense of commitment to doing what was right for patients.
  • Although nursing and medical staffing remained a challenging area, the day to day arrangements were focused on staffing the department to safe levels.
  • Some of the performance information related to service responsiveness was showing a positive trend of stability compared to the national average.
  • There were improvements to the environment of the paediatric emergency department since the last inspection including moving to a larger area, having its own reception, a dedicated triage room and children not being brought through the adult area.

Surgery

Good

Updated 14 May 2018

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

  • Since our last inspection, the surgical division had been restructured and now provided a more streamlined system. There were clear accountable roles and responsibilities and more oversight and scrutiny for individual specialities.
  • The pre-operative pathway for patients had vastly improved. There was a new surgical care suite, which provided a more dignified and spacious area for patients, carers, and relatives.
  • The pre-assessment services had improved. Patients were now seen at the one centre where all tests could be completed without the need of visiting different areas within the hospital.
  • The surgical risk register had been updated and renewed and we found surgical services had a good grasp on the risks within their division.
  • The service managed serious and moderate safety incidents well. Lessons learned as a result of investigation were shared with staff. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Patient records had good input from a range of clinical staff that cared for the patient.
  • Safety checks and risk assessments were carried out on patients. There was routine monitoring of patient related outcomes, together with local and national audits and associated action plans.
  • The trust planned and provided services in a way that met the needs of local people. Consultants worked closely with senior leaders to improve the responsiveness of the service.
  • Staff were kind and compassionate to patients and made an effort to ensure their individual needs were attended to.
  • Staff of different roles worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

However:

  • Staff did not always receive feedback on low level incidents.
  • There remained problems with old equipment and the replacement programme was running at a slow pace.
  • The service provided to operating theatres for provision and processing of surgical instruments was less than satisfactory. Little had been done to resolve this matter.
  • The recording of venous thromboembolism (VTE) rates had not yet improved to the required level.
  • Staff across all roles told us they were tired and felt overstretched due to staff shortages and this was starting to affect their morale.
  • There was a lack of suitable resting facilities for on call anaesthetists and the female theatre changing room lacked sufficient ventilation.
  • Nurses within the discharge team, told us the local management style was hierarchical and they did not feel part of a team. They did not feel their voice was heard.

Intensive/critical care

Requires improvement

Updated 27 May 2016

We rated the critical care unit as ‘requires improvement’ overall. We found that although staff were reporting incidents, there was no system in place to ensure that all staff were learning from these incidents. We identified gaps in record keeping and safe storage of medicines. The unit was bright and airy but there were no individual rooms so patient with infections could not be isolated. The unit used a high number of agency nursing staff to meet staffing requirements. Staff reviewing patients on the unit did not always comply with infection control practices such as being bare below the elbow and hand washing. Patients had to be escorted off the unit to access toilet facilities.

There was a lack of agreed guidelines specific to the critical care unit and no system to ensure consistency of care, even though three different consultants cared for patients in one day. The unit had a larger number of delayed discharges compared to similar units. This led to mixed sex breaches, although the unit was currently not recording these breaches.

The strategy for the unit had not been agreed due to difficulties in reaching an agreement among the critical care workforce across the two sites and staff were not aware of the vision for the unit. Not all risk had been identified on the risk register and some risk had been on the register for some time and senior staff were still unclear on the timescale to address these risks.

The unit had good outcomes for patient when compared to similar units and staffing was in line with national guidelines. The unit had lower out of hours discharges compared to similar unit and staff in other areas did not report difficulties in accessing critical care. The unit managed booked beds for elective patients efficiently to ensure patients do not have their operation cancelled due to a lack of critical care beds. Staff, including agency, received a good induction and competency based assessment prior to caring for patients independently. Doctors in training received good teaching and support from consultants and patients and their relatives spoke highly of the staff and the care they received on the unit.

Services for children & young people

Requires improvement

Updated 27 May 2016

Throughout the inspection, managers and staff told us they had concerns about staffing levels. We were told the trust had implemented the ‘Safer Staffing’ model for ensuring there were sufficient staff on duty to meet children’s needs and the service met nationally recommended staffing ratios, but we found examples of staffing ratios falling below these levels. There was also a large number of vacant medical staff and high use of locums to cover for medical staff who were off sick or on maternity leave. There was a system in place for reviewing staffing levels if the dependency levels of children increased, but it was not always possible to allocate additional staff particularly if dependency levels increased.

Ward staff relied on information about safeguarding concerns being brought to their attention by emergency department (ED) staff if the child was admitted via ED, by checking manual records or by contacting social services. The information was not held on computer. There was a risk that the manual records were incomplete or could be lost and therefore there was a risk that staff may not always be able to identify and protect children at risk of abuse. It is important to note that these arrangements were the adopted standard practice of the local authority who were responsible for maintaining the child protection database and was consistent across a number of acute services in Surrey.

Staff uncertainty about the future structure of the trust had contributed to difficulties recruiting and retaining staff resulting in staffing pressures on the ward. Developing a strategy for the service had also been problematic without clarity about the organisation’s future. Managers had responded to the uncertainty by developing a five-year business and service strategy.

An executive director provided board level leadership for children’s services. Paediatric services were part of the Women and Children’s Directorate with clinical leadership from a consultant obstetrician and a consultant paediatrician. There was no governance lead for children’s services.

End of life care

Good

Updated 27 May 2016

The Specialist Palliative Care (SPCT) team provided end of life care and support six days a week, with on call rota covering out-of-hours. There was visible clinical leadership resulting in a well-developed, motivated team.

The Director of Nursing had taken the executive lead role for end of life care, along with a Non-Executive Director (NED) to ensure issues and concerns were raised and highlighted at board level. Trust board received EOLC report outlining progress against key priorities within the EOLC strategy, including audit findings, themes from complaints and incidents, evidence of learning and compliance with end of life training requirements.

The SPCT provided a rapid response to referrals, assessed most patients within one working day, their services included symptom control, end of life care (EOLC), and support for patients and families, advised them on spiritual and religious needs and fast-track discharge for patients wanting to die at home.

Most of the nursing staff were complimentary about the support they received from the SPCT. Junior doctors particularly appreciated their support and advice, and said they could access the SPCT at any time during the day. They recognised that the SPCT worked hard to ensure that end of life care was well embedded in the trust.

Nursing staff knew how to make referrals to the SPCT and referred people appropriately. The SPCT assessed patients promptly to meet their care needs. The chaplaincy and bereavement service supported patients’ and families’ emotional and spiritual needs when people were at the end of life.

Referrals for patients who required support during end of life care were made electronically to the specialist palliative care team from clinicians throughout the trust. The specialist palliative care team had daily morning briefings to update on changes in patients’ condition, assess new referrals and allocate work for the day.

The National Care of the Dying Audit 2013/2014 (NCDAH) demonstrated that the trust had not achieved three out of seven organisational key performance indicators. At the time of the inspection, the trust had not fully rolled out the replacement of the LCP, and this delay meant that staff were not fully supported to deliver best practice care to patients who were dying. The leadership failed to apply enough urgency to have an individual plan of care in place.

Elective Orthopaedic Centre

Outstanding

Updated 27 May 2016

We rated this service outstanding as there was an open and transparent safety culture in practice and patient outcomes were amongst the best in the country. When things went wrong, there was thorough analysis and investigation owned by staff and changes weremade in a timely way. The approach to staffing and skill mix across all staff groups meant that highly skilled staff always cared for patients.

Patient outcomes and patient satisfaction consistently exceeded national averages. Innovative practice in recording outcomes was the basis for national guidelines. The lead surgeon used patient outcomes to validate and proactively change each consultant’s performance. The service was proactively met the needs of the population it served, coordinating with referring hospitals, external and community providers to ensure the surgical pathway was appropriate.

Staff understood the ethos of the service values, and unequivocal in praising the support received from leadership team and there were measurably high levels of staff satisfaction. Patients who used the service were actively involved in the way the service operated.