The Care Quality Commission
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Royal Surrey NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

All Inspections

During an assessment of the leadership of the trust

Date of assessment: 11 to 20 June 2024. Royal Surrey NHS Foundation Trust provides health care services from Royal Surrey County Hospital in Guildford and adult community healthcare services from Cranleigh Village Hospital, Haslemere Hospital and Milford Hospital. Milford and Haslemere community hospitals provide health care services to adults across Guildford and Waverley. Royal Surrey County Hospital provides emergency and general hospital services to a population of more than 330,000 across south west Surrey. It is also home to the Trust’s specialist tertiary Cancer Centre, which offers diagnostic and treatment services to a population of up to two million across Surrey, West Sussex, Hampshire and to patients from across the UK and abroad. The Trust sees around 336,000 outpatients a year, 90,000 patients are admitted for treatment, around 81,900 patients attend the Emergency Department, and they deliver around 3,000 babies. The Trust employ over 4,500 members of staff and the Trust is supported by a group of 400 volunteers.

We assessed all 8 of the quality statements in the well-led key question used when assessing an NHS Trust using our current framework.

We identified positive findings within all of the eight quality statements, there were no areas of concern. There was an inclusive and positive culture of continuous learning and improvement where innovations were encouraged. Leaders had the skills and knowledge, experience and credibility to lead well. They demonstrated their integrity and honesty which was recognised by their staff. The culture was described as belonging to a family. Development opportunities were available to all. There was a clear system of governance and risk management based around delivering safe and good quality care and treatment. Working towards ‘no harm’ was a key priority for the Trust. There were effective governance and management systems. Information about risks, performance and outcomes was readily available and used effectively to improve care. Leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person centred and sustainable and to reduce inequalities. A key part of the Trust’s strategy and goals was working with their system partners to improve care for the population. There was an understanding of the impact the Trust's activities had on the environment, and they were striving to make a positive contribution in reducing this.

The Trust level assessment followed two assessments of the Trust’s frontline services (assessment service groups - ASGs). The initial assessment of the Trust’s services was a planned assessment.

The locations and ASGs we assessed included the acute paediatric service provided at Royal Surrey Hospital and the community adult inpatient service at Milford Community Hospitaland Haslemere Community Hospital. We undertook these assessments to ensure we had an understanding of the range of services provided by the Trust ahead of our Trust level assessment.

The Trust used the quality improvement methodology of ‘True North’ to drive their strategy. They had 5 key objectives and the Trust’s organisation strategy 2022-2025 set out their plan to deliver these. The strategy had been developed with collaboration with the local community, staff and stakeholders. This was a shared vision and strategy which staff were aware of and understood. Trust initiatives were clearly linked to the Trust strategies and goals. The Trust was engaging with other providers of health and social care services, and stakeholder, to ensure the delivery of their strategy considered local plans. The Trust understood its place in a maturing system, working to benefit them both. Partners were satisfied that the Trust’s strategic objectives were aligned to the objectives and priorities within the local system and felt the Trust would be able to deliver against the strategic objectives. The overarching strategy was supported by several focused strategies and business plans which linked to the Trust’s goals and values. There were processes in place to ensure risks to the delivery of the Trust’s strategies were understood and actions plans developed to address them. There was a focus on promoting equality and diversity and information shared demonstrated action was taken to address workforce inequalities. Staff supported the Trust’s vision, values, and strategic goals. The Trust values were said to shine through everything. Staff said they felt like they belonged to a family, and there was a positive supportive culture.

Governance systems

It was possible to effectively link assurance across strategy, risk and delivery of services. All salient points were captured through a good range of accurate and timely data and information, with clear links through from the strategic priorities to the board assurance framework. Communication channels were open and effective, ensuring issues were promptly addressed. Chiefs of Service and Divisional Heads were crucial in maintaining the balance between business and medical operations, fostering a culture of collaboration, innovation, and continuous improvement. Their strategic oversight, partnership working, and commitment to sustainability and efficiency helped drive the organisation forward, while ensuring high-quality patient care and operational excellence.There was a good range of accurate and timely data and information available to understand performance and quality with steps taken to make improvements as needed. Enhanced data presentation enabled better understanding and management of operational metrics, contributing to informed decision-making and strategic planning. There were clear governance, management and accountability arrangements. Risks were captured, validated, and moderated with a clear reporting and escalation processes. Issues were quickly identified and actions taken. There was an established process for gathering, analysing and escalating performance data in an accessible format to the board consistently and regularly. The information enabled the board to scrutinise operational performance, identify areas of risk, and predict likely future performance through trend analysis. There were also systems to ensure the board’s committees had performance data relevant to their areas of focus and there were dashboards to monitor performance in key areas. The board assurance framework (BAF) provided information on current risks to achieving the Trust’s strategic objectives. The BAF included identified gaps in assurance, the controls in place, the effectiveness of controls, and action plans to further mitigate the risks. The board assurance framework was considered at meetings of the board and risks and issues, including financial sustainability, were evident in deliberations.

Freedom to Speak Up

There were clear processes for staff to raise concerns, with various channels available to them, including freedom to speak up champions, the freedom to speak up guardian, local managers, leaders and union representatives. Staff felt able to speak up without fear of detriment, felt supported to do so and there was a confidence any issues raised were dealt with. When something went wrong people received a timely apology and were invited to engage in the review process.

Compassionate and inclusive leadership

Leaders acted with integrity, effectiveness, credibility and kindness. The Trust had an established leadership team, which while not fully reflective of the population served, had the experience, capacity, capability and integrity to ensure the Trust delivered its objectives while ensuring risks were identified and mitigated. They were knowledgeable about issues and priorities at organisation and service level. Leaders were curious and demonstrated emotional intelligence. Leaders were visible throughout the organisation, and described by staff and patients as accessible, available, and responsive. The staff survey supported the view the Trust had compassionate leaders. Leaders were actively working with the local healthcare system and partners outside the local system encouraging growth. Leaders across the organisation had access to support and opportunities to develop and maintain their credibility and skills. High quality leadership was sustained through safe, effective and inclusive recruitment and succession planning. All staff had opportunities to develop, and this included development for future leaders. Leaders understood how to build a positive culture amongst the staff. There was a commitment to staff health and wellbeing. The Trust considered whether there were trends in relation to grievances, considering variance for different staff groups, professional roles or locations as well as for staff with protected characteristics. There was a task and finish group focused on reducing harassment along with the health and wellbeing team which monitored reports of episodes violence and harassment and ensured staff were offered support.

Workforce EDI

Leaders at all levels were committed to building a fair culture where all staff were treated equally and where people felt safe to raise concerns about injustice. Staff spoke positively about the Trust’s culture and leaders and the way they were actively engaged in reviewing and shaping the organisation's culture in the context of equality, diversity, and inclusion. The staff networks were established and engaged with each supported by an executive lead. There was an awareness of disparities faced by staff in terms of bullying and harassment with actions being taken to address these. Through strategic planning, robust reporting, and continuous engagement, the Trust aimed to foster a culture that valued diversity and promoted excellence across all levels of the organisation. Staff equality and diversity and inclusion training included cultural awareness and inclusive and compassionate training. Key priorities centred around reflecting the diversity of staff and leadership, ensuring equality diversity and inclusion considerations for protected characteristics were integrated at all levels. Staff were supported to work flexibly, and there was a team culture of respect, kindness and understanding. Discriminatory behaviour and unfair treatment were not tolerated.

Partnerships and Communities

The Trust engaged with people and communities to seek their views and feedback and to ensure co production. Members of the local population had direct influence on how the Trust was run as governors, there were also a number of patients groups working directly with staff, to provide feedback and influence change and improvement. Leaders were clear about their duty to collaborate and work in partnership with others, in the local system and wider afield. There was a clear focus on what was best for the local community and an understanding of the importance of sharing information and learning and working together to drive improvement. Leaders at all levels supported a culture of proactively seeking the views of, listening to and acting on feedback from patients, carers and communities. The local provider collaborative was developing, and the Trust was actively engaging, with relationships becoming established. The Trust had worked in partnership with others, supported others, provided mutual aid and worked cohesively to drive improvements for the population served. The Trust was working in collaboration with the local university with shared research facilities and support framework and was a host site for the national institute health and care research.

Learning, improvement and innovation

The Trust’s commitment to learning, innovation and research was clear, particularly the focus on patient outcomes. There was evidence of both the commitment and passion within the provider collaboratives led by the Trust. There were examples of partnership working and innovation in relation to involving communities and co-production. Staff and leaders had a good understanding of how to drive improvement. Staff spoke passionately about being able to drive local improvements which included being able to act on feedback from people using their service. There were forums and mechanisms for the sharing of learning including newsletters, learning sets, debriefs and celebrations of success. The Trust was quick to escalate challenges and concerns, and engaged in reviews to ensure when things did not go to plan learning occurred and was shared. Improvement and innovation included quality improvement, research and good ideas. The Trust was committed to research, with joint university appointments and active studies in surgery, anaesthetics and dietetics, support with research projects was available from the research team. Enhanced data presentation allowed for better understanding and management of operational metrics, contributing to informed decision-making and strategic planning. The Trust had adopted a learn together approach to encourage full engagement with families, so they were fully involved with a review process when things went wrong.

Environmental Sustainability

The Trust had a Green Plan, in line with national guidance, and had undertaken a carbon footprint of the Trust’s activities to outline clear objective and targets for the future. There was appropriate governance in place to ensure performance against targets and a board level lead for Net Zero. Leaders were engaged with the Trust’s Green Plan and had clear goals and a vision for their journey to Net Zero. There was a clear understanding of how the workforce had a role to play in them achieving Net Zero. The Trust was not effectively promoting their positive achievements in reducing their carbon footprint and encouraging all staff to get involved. While the Trust had not been involved in many collaborative projects with the integrated care system (ICS) they were keen to work within the system towards the ICS Green Plan targets. The Trust was engaging with colleagues across the country in national initiatives for reducing emissions in the NHS for example the Green Theatre Checklist. Within estates, there was a clear understanding of where reduction in emissions could be achieved and they had been successful in these initiatives. The Trust recognised there was further work to be done in ensuring the principles of net zero were embedded into all areas of the planning and delivery of patient care.

During an assessment of Community health inpatient services

Royal Surrey Foundation NHS Trust operated both Milford and Haslemere Hospitals. Both hospitals had two wards that provided community inpatient care for older adults. Haslemere Hospital had 16 beds and Milford Hospital had 30 beds.

We assessed a limited number of quality statements from the safe, effective, responsive and well-led key questions and found good practice in these areas. This was the first inspection of these hospitals. We did not rate the Hospitals as we did not assess enough quality statements in each key question to provide a rating.

We conducted this assessment as part of our NHS Well-led inspections. We assessed 6 quality statements over safe, effective, responsive and well-led.

At this inspection we found that there were low vacancy rates at the hospitals and enough staff were on duty to meet patients’ needs. There were good policies and procedures in place around medication management, that staff followed. Staff completed care plans for all patients. Staff told us they had useful links with other organisations which helped ensure patients could be discharged or transferred as needed. There were monthly clinical governance meetings in place to review the care provided and learn from any incidents that occurred.

However, medical gas stores were originally designed for cylinder sizes no longer held by the service, however gas storage was owned and managed by the landlord. The prescriptions for oxygen, we reviewed, did not include a target oxygen saturation rate.

24 January to 22 February 2018

During a routine inspection

We found there had been a number of improvements throughout the trust, which had accelerated in the past year. Performance was good. During our unannounced visit in January, we observed the trust benefiting from extensive preparations made for ‘winter pressures’ and they were responding well to the seasonal demand on services.

Overall, our rating for the trust stayed the same:

  • The trust was rated as good for safe, effective, caring, and responsive. Outpatients improved from requires improvement to good and maternity was rated as outstanding.
  • We did not inspect urgent and emergency care, surgery, services for children and young children or end of life care.

We are monitoring the progress of improvements to these services and will re-inspect them as required.

17-18 and 23 October 2013

During a routine inspection

The Royal Surrey County Hospitals NHS Foundation Trust is based at the Royal Surrey County Hospital. It is a leading general hospital and specialist tertiary centre for cancer, oral and maxillofacial surgery and pathology. The trust also has a very strong reputation for minimally invasive and laparoscopic surgery, which are used widely across the surgical specialties. It runs outpatient clinics at Cranleigh, Haslemere and Woking hospitals.

The trust has over 520 beds, 14 operating theatres, two MRI scanners, four CT scanners, interventional radiology equipment and a gamma camera. 

It serves a population of 320,000 for emergency and general hospital services and employs 3,100 staff, making it the second largest employer in Guildford. Every year, the trust sees 240,000 outpatients, 58,000 inpatients, and 72,000 patients in accident and emergency. It delivers more than 3,200 babies every year.

Overall, the trust was providing services that were safe, effective, responsive, caring and well-led. However, there were some areas for improvement.

The culture throughout the trust was very open, and staff were very enthusiastic, positive and knowledgeable about the trust’s overall vision and strategy.

The Board structure and portfolio structure is relatively new and there is still some embedding required. The CEO is well respected and popular with the staff and he and board members were visible throughout the trust. There was evidence of good leadership at the majority of department levels and a lot of innovation by staff to continually improve the patient’s experience. There are a number of processes for communication flow from and to the Board and departments. However, priorities at the departmental level had not been captured at trust level, and there is some lack of connection to the Board. This led to the executive team being unclear on its understanding ofsome of the issues in departments, and there was a general perception throughout the trust that the executive team and local teams are progressing at different paces and priorities were not always aligned.

The quality strategy focused on national targets and future developments without defining some key quality and safety priorities of the organisation. Thus members of the Board were not able to articulate all of the quality strategy for some basic quality issues specific to the trust.

Operational management was not fully connected from Board to departmental level and not all middle management had a clear understanding of the range of risks across the trust. There is a risk register that looks at risks highlighted by the specialist business units, but it was not evident that the Board reflects a trust-wide perspective.

The trust was working to full capacity in most departments with cancellations of elective surgery on one of the days of the visit, and this was providing a challenge for them. The trust recognised this problem, and it had a number of plans to improve the capacity of the hospital in the long term. The full alignment of capacity issues and the impact of patient experience could not be fully articulated by the trust. Although capacity was being created within theatres and critical care to support cancer services, the impact of this in pressure on ward beds could not be evidenced within the business planning. The trust had paid less attention to how it would manage the current capacity issues, and the impact they were having on the experience of patients, until it implemented the long-term plans. These capacity issues included:

  • Staffing levels for support/administration staff.
  • Staffing on some wards, particularly care of the elderly. 
  • Managing capacity issues in outpatients, particularly in ophthalmology. 
  • Managing issues such as discharge letters and GP correspondence.

The trust had plans for the development of its cancer services to meet the needs of patients. This will inevitably put further challenges on capacity and staffing requirements. The trust will need to address these before it puts its plans to expand cancer services into action.

Patients were generally very positive about the care they received at the hospital. They were very supportive of the trust and keen to be involved in the improvement at the hospital. The vast majority of patients that contacted us and those we spoke with commended the care they received at the trust. However some patients we spoke to at the listening event and who had contacted us directly had not had good experiences and some reported delays in their complaints being dealt with a timely fashion. They had little opportunity to engage with the trust other than through the complaints system. The trust was developing more ways to engage with patients and the community, but it had not fully implemented its ideas. However, there was some innovative work taking place at departmental level.

Cancer services were safe, effective, responsive and well-led. They were at full capacity, and staffing in some areas left little allowance for contingency planning and unplanned absences. On occasions this did impact on the effectiveness of services and their ability to be caring. The staff themselves were caring, but not all patients had their expectations met, and the cancer patients experience survey identified a number of areas where the trust needs to make improvements. 

Staff were positive and engaged, and nursing staff levels were being managed well at departmental level, despite staff shortages in some areas.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.