Royal Surrey NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation
• Environmental sustainability – sustainable development

This service scored 91 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

In assessing this Quality Statement, we considered feedback from leaders, staff, people using the services and local system partners, as well as reviewing Trust processes and survey results.

The Trust’s strategy True North was launched in 2022 and consisted of 5 strategic goals. The overarching strategy was supported by several focused strategies and business plans which linked to the Trust’s goals and values. These included but were not limited to a clinical strategy, a people strategy and a digital strategy.

The strategy had been developed with collaboration with the local community, staff and stakeholders. To ensure the strategy was community focused, it was developed through engagement with internal and external stakeholders including staff, governors, patient and carer groups, NHS partners and local authorities. Local people were encouraged to engage through community events and public meetings.

A key part of the Trust’s strategy and current goals was working with their system partners to improve care for the population. The Trust was working to bring care closer to home with access to diagnostics tests at their community sites and through virtual clinics. They were also reviewing and changing pathways and investing in facilities, so patients had access to care in a timely way. This included investing financially in the development of new buildings to better enable the safe, effective and efficient care of patients requiring surgery. Patients had been involved in the design for the new building along with some engagement with the local system around capacity and need, they also visited other similar units before decisions were made about the final model.

Partners spoke positively about how 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. It was felt 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 Trust was said to have good oversight of their objectives supporting the delivery of their strategy and the risks to them achieving their goals with clear links between the strategy, the board assurance framework and the risk register. Members of the executive team were able to clearly articulate how the Trust’s current objectives supported the Trust’s goals.

Members of the leadership team took active roles in the system working to ensure both the Trust and the population benefited from plans and strategies. The Trust chair was the convenor of the Committee in Common (CIC), a subcommittee of all of the provider collaborative boards. This was said to be the vehicle for driving all system programmes. They were also actively engaged with working with others to ensure they could deliver the best service for the population including ensuring care was delivered in the best place in the system. Systemic anticancer therapy, maternity, paediatrics, and mental health in the acute setting were described as areas requiring common solutions to transform services.

The Trust used a culture dashboard to aid them in identifying any areas of risk or concerns in relation to the Trust's culture.

The Trust mission was ‘Together we deliver compassionate, safe care everyday’ and ‘the Trust vision was to provide nationally celebrated, community focused health and care’. There were four Trust values caring together, continuously improving, learning together and excelling together. The values were well-established across the Trust.

The culture of the organisation included a focus on learning and improvement. 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 had been taken to address workforce inequalities. Members from the senior leadership team and the board were active participants in staff networks and groups, and each had an executive sponsor. All leaders had equality diversity and inclusion (EDI) objectives included in their Performance Development Reviews (PDRs). We heard how these had helped raise the profile of EDI, supported with training and had resulted in an increase in discussions between all Trust leaders. One team spoke positively about the change in diversity of their team which was partly attributed to this initiative.

There was a shared vision and strategy which staff were aware of and understood. Staff could link initiatives they were involved with to the Trust strategies and goals. Staff supported the vision, values, and strategic goals. The Trust values were said to shine through everything. The Endoscopy unit had engaged with the system work to reduce patients waiting time, they had reviewed their working pattern and rather than extend in to seven day working had changed to three sessions a day, 5 days a week and staff had flexed their working day to meet this change. This had had a positive impact on patient waiting times and had enabled the Trust to support partners in reducing their waiting times.

Staff and leaders demonstrated a positive compassionate listening culture promoting Trust and understanding. Staff said they felt like they belonged to a family, and there was a positive supportive culture. We observed staff greeting others by name with interactions between all staff groups at all levels. Leaders were open, honest, and transparent accepting responsibility when things went wrong. They were clear about their responsibilities to monitor and review progress against the delivery of the strategy and local plans. There was an understanding of equality, diversity and human rights, and staff and leaders prioritised safe, high quality compassionate care.

The Trust placed consideration of health inequalities at the heart of its ways or working. Governance processes ensured consideration of differences in access and outcomes which were used to improve outcomes for all. Data provided allowed for differences to be identified. The Trust was working with a local specialist college to review accessibility for people with a learning disability and or autism. Members of the Trust’s patient panel sat on the boards and committees and contributed to any new transformation work happening in the Trust.

Staff described a supportive and safe culture, where there was openness and transparency, and people challenged things without it being personal. Staff felt able to raise safety concerns and challenge unsafe practice; learning and candour were emphasized in relation to patient safety. Staff felt confident to report incidents, with a high incident reporting rate. The importance and effectiveness of this had been demonstrated during the implementation of the new electronic patient record system, where the analysis of incidents had enabled effective management of issues, working with the designers to address the ‘glitches’.

The Trust had processes to identify and address behaviours that were inconsistent with the values of the NHS. The Trust’s grievance and disciplinary policies were within their review dates at the time of our assessment. Processes to ensure staff remained fit and proper for their roles was effective and ensured staff remained qualified and suitable for the role they had.

In the staff survey undertaken in 2023 the Trust scored above the average for all elements: ‘We are compassionate and inclusive’ (7.52), ‘We are recognised and rewarded’ (6.15), ‘We each have a voice that counts’ (6.91), ‘We are always learning’ (5.82), ‘We work flexibly’ (6.26), ‘We are a team’ (6.98), ‘Staff engagement’ (7.15) and ‘Morale’ (5.95). 2023 results for ‘We are safe and healthy’ have not been reported due to an issue with the data. ‘We are safe and healthy’ scored 5.92 in 2022 and was also above average.

In assessing this Quality Statement, we considered feedback from leaders, staff, people using the services and local system partners, as well as reviewing Trust processes and survey results.

We observed the Trust’s board meeting, attended a quality meeting and reviewed minutes. In all meetings we observed leaders acting with integrity, effectiveness, credibility and kindness. The Trust actively supported diverse communication needs and ensured meetings were accessible.

People who used services, and those who supported them, described Trust leaders as approachable and responsive to feedback, with a willingness to engage.

Data from the NHS Workforce Race Equality Survey (WRES) showed staff had a higher belief their organisation provided equal opportunities for career progression or promotion compared nationally, Results from the last two years of the survey showed the Trust consistently performed better than the national average.

Leaders could describe succession planning within the Trust and several members of the executive team had progressed within the organisation. Leaders had access to support and opportunities to develop and maintain their credibility and skills. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities. Some spoke positively about their desire to progress further, and the supportive approach being taken to enable them on this journey. 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. Staff recruited from overseas had been supported to develop into senior roles and there was a mentoring programme to develop more international recruited staff into senior roles such as band 7 and above. One nurse leader shared how they had been able to develop at a pace which suited them and allowed them to be flexible, only progressing when they were ready to do so and had the time to dedicate to their development. The Trust had been fully supportive at all stages of their journey. There was a dedicated leadership hub on the Trust intranet, where all leaders could access resources and development packages were available.

The Trust was open to feedback and commissioned and responded to external board reviews covering board effectiveness and cultural maturity.

The Trust had processes in place to identify and address behaviours that were inconsistent with the values of the NHS.

The Trust considered whether there were trends in relation to grievances. They considered 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.There was an awareness internationally recruited staff often faced bullying and harassment from patients. Initiatives include educational posters and frontline support to address inappropriate behaviour immediately.

Reports covering wellbeing, violence, aggression, and sexual safety, align with the HR strategy and were used to provide assurance to the board.We heard about how sexual safety was taken seriously and when concerns were raised about the behaviour of a member of professional staff, it was escalated through human resources (HR), while this was addressed support packages were put in place for the staff.

Processes to ensure staff remained fit and proper for their roles were effective and ensured staff remained qualified and suitable for the role they had.

Leaders were visible throughout the organisation, and described by staff as accessible, available, and quick to respond. Leaders told us they undertook regular visits to frontline services. These visits improved leadership visibility and ensured leaders were able to triangulate the information received through the Trust’s governance systems, particularly in relation to staff experience. Member of the executive team and the board visited services, with non-executive directors (NED) buddied with areas. They said this helped them with gaining insights into day-to-day challenges, which enhanced their effectiveness as a NED. There had been active involvement in maternity and neonatal safety, including unannounced visits and attendance at monthly safety meetings.This was described by staff as supportive at time of increased scrutiny on maternity and neonatal services nationally, with Trust leaders and the board being supportive, available and listening with interest. The results of the staff survey supported the view the Trust had compassionate leaders.

Partners told us they felt that the Trust board had the experience, capability and personal values to lead the Trust. The leadership team was described as open, honest and transparent, and visible in both the organisation and the system, with staff taking the leads on some system wide initiatives. They were actively working with the local healthcare system encouraging growth and with partners outside the local system when it would bring local benefit. Leaders were curious and demonstrated emotional intelligence. The medical director was the lead for the paediatric pathway and spoke of the inequities across Surrey. Work had started in relation to general anaesthetic MRI (GAMRI) to create a pathway to enable patients to move across organisations. They had hosted a day with all the Paediatricians with support from the integrated care board with a focus on standardisation and shared pathways.

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. There was a greater range of diversity below the executive team. Leaders were knowledgeable about issues and priorities at organisation and service level. They led by example while modelling inclusive behaviours. Staff spoke positively about being involved in change, that their opinion and view mattered, and time was invested to ensure they were involved which made them feel valued. Work was on going post pandemic to revitalise the board of governors and ensure they were representative of the population served, Staff governors were representative of the diverse work force and the Trust was looking to introduce a youth governor.

The Trust’s board comprised of 8 executive directors including the chief executive and 8 non-executive directors including the Trust’s chair and one associate non-executive director. The non-executive directors came from a variety of backgrounds including health, business, transformation and digital and were described as meeting the needs of the Trust. The executive team held a range of individual portfolios covering areas including but not limited to quality, risk management, finance, procurement and organisational development, health and well being and EDI.

There was a board development plan in place developed though the triangulate of information including skills review, appraisals feedback from chair or CEO and an annual effectiveness review. Digital had been a focus over the last year,

The effectiveness of Trust Board and its Committees was evaluated on an annual basis in line with the Code of Governance for NHS Provider Trusts. Following the most recent review the Trust was found to be well led, and the Board and Committees were found to be effective. The board was found to be well-functioning, a safe environment, with constructive challenge, clear respect amongst its members with good governance. The Board and its Committees were seen to be performing well and demonstrated commitment to continuous improvement.

Fit and proper persons checks were in place for all directors in line with the requirements of the regulation. All files we reviewed showed the Trust had completed appropriate checks of directors’ suitability for their roles. All directors had received an annual appraisal within the previous year.

Leaders understood how to build a positive culture amongst the staff. There was a commitment to staff health and wellbeing, and the Trust’s health and wellbeing strategy aligned with the overarching HR strategy. There was a health and wellbeing lead. The health and wellbeing committee sat under the people committee and included trauma risk management (TRiM) managers and representatives from the counselling service, the Trust partnership with Mind Matters, and complementary therapies. There was a large team of mental health first aider which was reported to have been well received by staff who spoke positively about being able to speak with someone about their mental wellbeing. The Trust hosted long COVID and menopause cafes offering peer support. To help tackle isolation programs like five-a-side football and badminton had been developed and through system working with psychological services the Trust was able to offer bespoke sessions on managing anxiety and bereavement. The Trust‘s staff survey scores had seen a 5% improvement in relation to health and wellbeing.

In assessing this Quality Statement, we considered feedback from leaders, staff, people using the services and local system partners, as well as reviewing Trust processes and survey results.

The evidence that we reviewed demonstrated an open culture in which staff felt able to raise concerns, report incidents and suggest improvements. There was no fear of detriment, staff were confident that their feedback, suggestions and concerns would be welcomed and lead to improvements in the Trust. Leaders’ role-modelled good speaking up behaviours, they listened to staff feedback and concerns, they demonstrated candour and empathy when things went wrong, and they celebrated speaking up.

Staff felt able to speak up within the Trust. The 2023 NHS Staff Survey showed that 65.8% of staff agreed with the statement ‘I feel safe to speak up about anything that concerns me in this organisation’. This was higher than the national average of 62.31% although slightly lower than the Trust’s 2022 score of 65.8%. The Trust’s survey response rate was 46% which was higher than the national median.

Staff felt leaders would act to address concerns. The NHS Staff Survey showed 54.07% of staff agreed with the statement ‘If I spoke up about something that concerned me, I am confident my organisation would address my concern’. This was higher than the Trust’s 2022 score of 53. 5%% and higher than the national average of 47.6%.

There was one freedom to speak up guardian, who worked the equivalent of one day a week, they were supported by a network of 44 champions. While this appeared to be a limited resource, staff felt able to speak up without fear of detriment, felt supported to do so and had options available to them as to whom they spoke with. Staff were very happy to speak with their line managers and leaders in their area. Staff representatives described the leadership team as approachable and responsive and that they were welcome to raise any issues. As a demonstration of their emotional maturity, leaders at executive and board level had proactively engaged with staff following a national event which was appreciated by staff, as they made sure they were available and accessible if staff wished to talk or share local concerns. Leaders responded quickly when concerns relating to bullying were raised and allegations were taken seriously.

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, and union representatives. There was a culture where people felt confident to speak up, share their concerns and make suggestions. Concerns were investigated sensitively and confidentially with lessons shared and acted on. Local solutions and resolutions were encouraged 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. They were kept informed of any actions planned to prevent a re-occurrence. There had been a focus on dealing with violence and aggression with an improving picture seen in the staff survey results. The freedom to speak up guardian had open access to executive level support from the chief nursing officer, with whom they met weekly, with additional support from one of the non-executive directors with whom they met quarterly, although they were always contactable by email.

The Freedom to Speak Up Guardian felt they had enough time to undertake their role and described a positive relationship with the executive and NED lead. The champions helped to increase the diversity of access and minimise barriers, some of the internationally recruited staff were champions, and in recognition students may not feel able to speak up students had become champions along with practice development staff. While champions did not formally manage contacts they did pass on contacts or acted as a bridge if staff wanted to remain anonymous. The Freedom to Speak up Guardian reported quarterly to the national guardian office and formally to the Trust board on an annual basis. They also met more frequently with the Joint Negotiation and Consultative Committee which enabled them to cross reference what they were hearing to help ensure resource was being invested in the right initiatives in the right places.

Partners felt the Trust did have a culture where staff could feel free to raise concerns. They said they knew this because leaders acted with openness, honesty and transparency. Leaders were described as naturally curious. The Trust freedom to speak up guardian was engaged in the system wide freedom to speak up group.

The Freedom to Speak up Guardian spoke with new staff as part of the induction process and had undertaken targeted engagement where concerns were identified, such as meeting with junior doctors to discuss speaking up, which enabled them to raise concerns about their experiences in the emergency department with drunk people and their inappropriate behaviour. These concerns had helped to inform the development of the Trust sexual safety policy.

The Trust board received an annual formal report into Freedom to Speak Up. The latest report showed the numbers of staff raising concerns via the Trust’s Freedom to Speak Up process had increased since the previous year. The data showed 30 concerns had been raised by staff in 2022/23. This had increased to 38 in 2023/24.

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. There was a sense of collective effort across the Trust with effective and widespread collaboration. The staff networks were inclusive and accessible, and each staff network was supported by an executive lead. Staff spoke positively about the adjustments made to support them to carry out their role well. Leaders were aware of disparities faced by staff, particularly in terms of bullying and harassment with action taken to address this. To ensure equality, diversity and inclusion was a focus for the Trust the executive team and the board had specific and measurable equality diversity and inclusion objectives.

There was a focus on creating a supportive, inclusive, and equitable work environment. 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. Leaders were taking steps to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. This included an ongoing review of policies, procedures and quality impact assessments (QIA) to tackle structural and institutional discrimination and bias to achieve a fair culture for all.

Equitable access for patients was a priority and the Trust was actively working with staff to raise awareness about the protected characteristics of patients, while ensuring internal initiatives directly informed and improved patient care. There was 95% compliance with staff equality and diversity and inclusion training which included cultural awareness and inclusive and compassionate training. The equality diversity and inclusion committee, along with staff networks, were crucial in shaping the Trust’s approach. The committee reported through the people committee to the board. The key priorities were centred around reflecting the diversity of staff and leadership, ensuring equality diversity and inclusion considerations for protected characteristics were integrated at all levels. Resources to support diversity and inclusion initiatives were readily available to everyone. There was a strong direction of travel in the equality diversity and inclusion strategy which included the values it aimed to promote, this was being updated. The strategic ambitions included “To achieve equality of opportunity for everyone who works at Royal Surrey; To ensure our management structure reflects our workforce; To combat health inequalities in our community; To make Royal Surrey a safe and welcoming place for everyone. The activities for 2024 were reflect our workforce in our leadership; implement a shadow board; improve and empower our staff networks and establish Royal Surrey as an Anchor Institution.” While the equality, diversity and inclusion agenda were led by an individual, it was reported to be everyone's business, with effective and widespread collaboration. The lead was supported by the director of human resources, the executive sponsor and they met with the CEO quarterly. The role was growing and maturing in the organisation.

Staff told us leaders acted to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. They gave us examples of how the leaders in the Trust worked to make it a more inclusive workplace. 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. Staff with protected equality characteristics experiences of applying for promotion, opportunities to act-up and/or development opportunities was positive. A member of staff shared with us their positive experience of using the reasonable adjustment plan process, which resulted in the Trust providing a suitable workspace to meet their needs. Due to fatigue, there was also a flexible working agreement in place.

The Workforce Race Equality Standard (WRES) requires NHS organisations to self-assess against nine indicators of staff experience and opportunities in the workplace. Four of the WRES indicators relate specifically to workforce data, four are based on data from the National NHS Staff Survey questions and one considers representation on the Trust Board

The Trust scored better than the national average for staff experiencing harassment, bullying or abuse from staff in the last 12 months, staff experiencing discrimination at work from manager / team leader or other colleagues in the last 12 months. The Trust also scored better for staff believing that the organisation provides equal opportunities for career progression or promotion than the national average. This NHS Workforce Race Equality Standard (WRES) indicator measured through the 2023 NHS Staff Survey, indicated better experiences for these staff members when compared nationally. White staff at the Trust scored better for all 4 of the metrics, indicating worse experiences for staff from all other ethnic groups when compared to white staff. This was in line with national trends. The Trust’s results still showed slightly better experiences for staff members when compared nationally except for staff from all other ethnic groups receiving harassment, bullying or abuse from patients, relatives or the public.

The Workforce Disability Equality Standards (WDES) from the 2023 NHS Staff Survey results showed that staff with a long-term condition or illness were notably different to results for staff without a long-term condition or illness at the Trust, indicating poorer experiences for staff with long-term conditions or illnesses. Results compared favourably with the national average for 5 of the 7 questions whether Royal Surrey Hospital NHS Foundation Trust staff had a long-term condition or not. This indicated better experiences for staff with long term conditions or illnesses at the Trust when compared nationally.

Only two measures scored worse than the average. Less than a third (30.7%) of staff with a long-term health condition experienced harassment, bullying or abuse from patients/service users, their relatives or the public in the last 12 months, reduced from 33.8% in 2022, this compares with 29.8% nationally (33.0% in 2022). Also, the number of staff with a long-term condition who reported harassment, bullying or abuse they experienced at work was 45.9% - lower than the national average of 50.64%.

The Trust showed mixed results, compared with other Trusts, for colleagues experiencing discrimination on the grounds of sexual orientation and disability. For staff members who indicated that they experienced discrimination on the grounds of their sexual orientation, the score had decreased from 3.03% in 2019 to 2.61% in 2023. For those who experienced discrimination on the grounds of disability, the score worsened from 6.22% in 2019 to 10.19% in 2023. The Trust performed well in comparison to all other Trusts for questions relating to culture and treatment from other members of staff. Eighty three percent of staff agreed with the statement ‘I enjoy working with the colleagues in my team’. This, as well as every other question related to the “We are a team: Team working” questions scored better than the national average (81.2%).

The Trust monitored equality, diversity and inclusion in line with the NHS Workforce Race Equality Standard. Ethnic diversity in staff groups of 30.14% was higher than the national average (21.3%) but did reflect the diversity of local people accessing services. White staff represented 87.4% of staff at management grades at band 8a-9. There were higher levels of diversity in clinical management grades at all bands.

Partners felt the Trust actively promoted equality, diversity and inclusion both internally and within the local system. Partners were aware of the Trust’s staff equality, diversity and inclusion networks. Partners were positive about the commitment demonstrated by leaders to supporting equality, diversity and inclusion.

Partners reported the Trust provided good development and support for international recruited staff, which was supported by success stories of progression within the organisation. There were examples of how staff had been supported to develop from staff nurses to divisional leaders, with others continuing on a supported development pathway to support succession planning.

The Trust had processes to monitor fairness in recruitment and career progression to ensure equally good outcomes for staff in equality groups. The Trust had an action plan to address the indicators with improvement identified in the WRES and WDES reports. Progress against the action plan was monitored by the Quality and People Committee.

The Trust monitored gender pay gaps and the board received an annual report. The Trust had a stable work force of 76% female staff and 24% male. The Trust’s mean Gender Pay Gap had decreased slightly over the last 12 months, from 24.1 % to 23.5%. The overall trend in recent years has been a decrease in the gender pay gap, which stood at 28.6% in 2020 and 31.2% in 2018.

The Trust executive team led by the chief executive consisted of 7 directors the finance director; chief operating officer; director of transformation and digital; director of strategy and director of human resources; Chief nurse and medical director. The organisation was made up of 6 divisions led by a triumvirate, consisting of a Chief of Service, associate director of operations and an associate director of nursing or equivalent.

There was shared ownership of risk and staff and leaders understood their roles and responsibilities. The quality governance risk portfolio was split between the chief nurse and the medical director. The triumvirate had direct access to executive leaders, fostering a responsive and supportive environment. Communication channels were open and effective, ensuring issues were promptly addressed.

The triumvirate were described as being crucial in maintaining the balance between business and medical operations, fostering a culture of collaboration, innovation, and continuous improvement. Their strategic oversight, partnership efforts, and commitment to sustainability and efficiency helped drive the organisation forward, ensuring high-quality patient care and operational excellence.Monthly triumvirate meetings with colleagues allowed for focused discussions on patient pathways, strategic issues, and direct communication with top leadership, ensuring constant collaboration and preparation for addressing critical topics. There was a direct line to the executive leadership team, enabling them to voice concerns, seek assistance, and provide updates during minuted meetings. Sessions covered quarterly performance reviews, constitutional target assessments, and evaluations of Trust key performance indicators. Chiefs of Service participated in meetings linked to strategic rhythm, including clinical executive forums. These forums offered opportunities to reflect on organisational culture and proposed business cases.

There was a good range of accurate and timely data and information available to understand performance and quality and improvements were made as needed. Leaders described how enhanced data presentation enabled better understanding and management of operational metrics, contributing to informed decision-making and strategic planning. The Endoscopy unit leader shared with us how they had used information about waiting lists, theatre utilisation and working patterns to inform discussion about how best to increase the unit capacity. This resulted in an increase from two to three sessions a day, 5 days a week with staff flexing their working day to meet this change. This had been an enabler in them significantly reducing their waiting lists and being in a position to offer aid to others.

Governance was used to learn, improve, and innovate driving improvements in care quality and service delivery across all areas of the Trust. Quality improvement projects were encouraged and celebrated, with a celebration wall sharing information about all the initiatives for all to see. One of these had involved working with and listening to services users to bring appointments closer to home, through the use of a mobile unit, reducing the time required to attend appointments.

The Trust was part of the emergency preparedness network and had strategies and guidance to respond to a major incident. They participated in and engaged in the evaluation of preparedness exercises. To ensure critical services were maintained in the face of a crisis, business continuity plans were in place providing clear guidance to staff delivering a service when dealing with a crisis or incident which affected part or all of day-to-day operations. Plans detailed which functions needed to be enhanced, reduced or suspended, depending on the nature of the function and the emergency taking place.

Partners spoke positively about being able to effectively link assurance across strategy, risk and delivery of services. All salient points were said to be 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. The Trust was quick to recognise, acknowledge and escalate risk identified. This was evident when they introduced the new electronic patient records and shared their experiences, through a published guidance document, to assist others.

There were clear governance, management and accountability arrangements. The Trust sought and responded to feedback. In response to evaluation of effectiveness of board meetings, the meeting and reporting structure had recently been reviewed and changed. While it was too early to evaluate the effectiveness and impact of this, initial feedback was positive. A clinical audit and effectiveness committee had also been reinstated to help with monitoring and assurance with compliance with for example National Institute for Health and Care Excellence guidance, oversight of clinical quality improvement projects and audits.

Risks were captured, validated and moderated with a clear reporting and escalation processes. There was a clear awareness of issues, risk and challenges with things quickly identified and action taken when they arose. Safety and performance information was displayed on the wards. There were some examples of the Trust considering health inequalities in their plans for example screening for Hepatitis C in areas where there were high levels of homelessness. However, it was not clear how the Trust maintained oversight of the impact of their actions or how they captured information about health inequalities in the area.

The Trust had recently introduced a new electronic patient record system working in partnership with another local acute Trust. The Trust had captured the risks and challenges they accounted and had used this information to produce guidance for others to help them on their journey, the aim was to help reduce the issues announced by others through the sharing of their learning. Arrangements were in place to ensure records were kept confidentially and securely. There was a digital road map to ensure continued development with clear objectives for the next 3 years.

The Trust had a process for gathering, analysing and escalating performance data in an accessible format to the board consistently and regularly. They oversaw a set of key performance indicators, comprising quality and safety measures determined in response to the Trust’s known risks and priorities, as well as priorities determined by external regulators, commissioners, and partner organisations from across the health and care economy. The board received a monthly performance report scorecard aligned to the five Care Quality Commission domains: safe, effective, caring, responsive, and well-led. The information enabled the board to scrutinise operational performance, identify areas of risk, and predict likely future performance through trend analysis. Information included a commentary on key challenges, the risk and the key actions along with the supporting date with an indication of variation, assurance and assurance level. Meeting minutes supported there being open discussion and challenge.

The Trust had systems to ensure the board’s committees had performance data relevant to their areas of focus. The Trust had dashboards to monitor performance in key areas. The Trust’s committee chairs provided a chair’s report to the board detailing the risks requiring escalation, the areas discussed by the committees and the decisions made.

The Trust’s performance against key constitutional performance standards improved in almost all respects in 2023-24. The Trust met year-end targets to eliminate waits for elective care of 78 weeks or more, except for reasons of patient choice or clinical complexity, and improving the speed of recovery was a key objective for 2024-25. For 65 week waits, the backlog peaked at 490 on 13th May 2024. Since then, the backlog had been slowly reducing with 427 patients waiting over 65 weeks for treatment as of 10th June 2024. This continued to be a focus for the Trust working towards a target of eliminating 65 week waits by the end of September. This provider had fewer incomplete referral to treatment pathways lasting longer than 65 weeks than the regional average. In recognition the quality of data could be better when receiving lengths of waits, work was also taking place to strengthen quality of data with a planned changed in the reporting platform used. The Trust achieved and sustained the 62-day wait standard at the 85% target for cancer treatment for all tumour groups.

Timeliness of care for people attending on an urgent or emergency basis improved across the course of the year, culminating in the Trust exceeding the March 2024 national target of treating 76% of these attendances within four hours of arrival. Better than the England average and slightly better than regional average. The Trust performs slightly better than other Trust’s in the region for ambulance turnaround times with a low of 33 minutes compared to 34 minutes.

The Trust had Summary Hospital-level Mortality Indicator (SHMI) banding lower than the national average at a value of 0.78 placing it in the top ten Trusts.

A comprehensive workforce plan implemented in 2023/24 resulted in a reduction in the midwifery vacancy rate from 20% to 6%. This has included international recruitment and a preceptorship programme for newly qualified staff. There was a continual plan of talent management and succession planning to ensure retention of staff. The Trust had an improving staff turnover rate which from January 2023 to December 2023 had improved, from 20.8% (Jan 2023) down to 18% (Dec 2023) and as of June 2024 this was at 11.9%. in line with sector average. The Trust had made significant improvements including increasing their recruitment activity, converting agency/bank workers to substantive roles and enhancing their recruitment and on-boarding processes. The impact of this was a significant reduction in vacancy rates with the Trust spending 30% less on agency staff compared to 12 months ago.

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. All BAF risks had been reviewed by executive leads and monitoring committees and had been updated accordingly. Board papers were linked to the BAF making it clear which committee had oversight of which risk. Information included a review of the risk and the impact of any data and information on the risk. From minutes it was evident this information was considered at meetings. There was also evidence new and emerging risks were discussed with consideration given to the level of risk and inclusion on local and Trust level risk registers. There was also clear consideration of the impact on known risk and the validation of risks and or the removal of risks from the risk registers.

The Trust had effective governance and oversight of the staff use of the Mental Health Act. The Trust was registered with the Care Quality Commission to detain patients under the Mental Health Act. There were appropriate measures to ensure that peoples’ rights were respected and that the powers were used correctly to keep people safe. The Trust had a mental health lead and a mental health working group with representation form the local mental health trust. The mental health lead was actively engaged across all areas of the Trust supporting staff to care for patients with mental health needs and ensuring patients’ rights were being considered and respected. They reported a good working relationship with local providers and the Integrated care system.

The Trust had mental health and acute multi-disciplinary team (MDT) three times a week. They reviewed all mental health patients in the acute Trust. This ensured prompt assessment, action planning, care planning and discharge planning for patients admitted with a deterioration of their mental wellbeing. This has improved the patient’s care and treatment whilst these patients remained in the acute Trust.

The Trust had processes to prevent and control infections. The Trust’s board received an annual and mid-year infection prevention and control (IPC) report. The Trust had effective governance of Infection prevention and control measures that meant the Trust complied with the requirements of the National infection prevention and control manual (NIPCM) for England. The Trust had processes to prevent and control infections. There was a team of infection control nurses who covered all were the Trust provided a service. They were supported by 111 IPC champions. The infection control committee met 3 monthly. There was representation on other meetings including the audit committee, matrons committee and health and safety committee. The team met weekly. There was said to be a good reporting culture. A multi factorial quality improvement project on MSSA had resulted in a 43% reduction through a review and delivery training and including the use of dressing packs. Any learning is shared through the IPC magazine. There was a good compliance with hand hygiene and bare below the elbow with compliance above 90%. Members of the IPC team where influential in the system helping with the design of system protocols and sharing their own learning.

There were processes to manage the financial resources and sustainability of the Trust. The Trust had a strong track record of financial sustainability and as a Foundation Trust, had built up significant cash reserves. A culture of financial responsibility was embedded within the organisation. Steps were being taken to increase assurance of job planning and delivery in support of transformation and improved productivity.

At the time of the inspection, the audit of the 2023-24 accounts was not yet complete. The Trust’s internal audit provider had given the Trust moderate assurance about the operation of its internal controls for both 2022-23 and 2023-24. The Trust had a good track record of delivering agreed management actions.

The membership of the Audit Committee comprised the chairs of the Board’s assurance committees, giving the opportunity for an integrated approach to risk management and assurance. The Board assurance framework was considered at meetings of the Board and risks and issues, including financial sustainability, were evident in deliberations.

The Trust engaged with people and communities to seek their views and feedback and to ensure co production. A Young Peoples Life Cafe, a psychosocial approach to supporting terminally ill young people live well with cancer, whilst preparing for end of life had been developed through working with young people and inspired and informed by their thoughts, ideas, and feedback. Patients, their families and carers were able to nominate teams and individuals who they felt had made a positive impact on their care for a patient’s choice award. They were also invited and encouraged to provide feedback through the friends and families tests and participating in patient surveys. Member 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. The oncology unit was now open on a Saturday following a patients experience project.

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. This had included taking health improvement opportunities to the local community. An outreach project taking mobile units to different public events to reach men not engaging with testing for prostate cancer was instigated in response to insight and intelligence from within the community. Leaders at all levels supported a culture of proactively seeking the views of, listening to and acting on feedback from patients, carers and communities. There were examples where feedback from patients had informed design of buildings and pathways including the short stay surgical unit. The Trust had a diverse range of formal and informal ways of working with people and communities to ensure different groups took part, co-ordinating engagement and sharing insights with partners where relevant.

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. Through working with the mental health provider collaborative, improved multi-disciplinary team working was helping to support patients, and a mental health working group had developed a business case to grow the support available in the acute setting.

Staff and leaders engaged with people, communities and partners sharing learning and innovation. They were engaged in joint projects with a focus on continuous improvement. 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. The Trust was instrumental in establishing the Surrey Improves network where providers across the system share quality improvement projects, best practice, and good practise and implement projects across PLACE, a geographical area usually based on local authority boundaries

In March the Trust and their partner received a gold award in the partnership awards. The partner agency had worked with the Trust for over three decades; beginning in 1994 with the catering contract and expanding services since to include cleaning, portering, pest and waste control, car park services and external security. The award recognised a very successful collaboration.

The Trust had a process to respond to complaints from people using services. We reviewed 5 complaints and found all gave detailed responses and clinicians were involved in the reviews although the responses lacked empathy and did not always outline the key themes of the complaint. The Trust reopened 2 complaints compared to 7 the previous year.

For the year 2022 to 2023 the Trust received 311 formal complaints covering 928 complaint subjects an increase on the previous year of 76. The top three subjects received for both years were communication, treatment, attitude and behaviour. Of the 311 formal complaints received, 80 were upheld which equates to 25.7%. a reduction of 0.9% on the previous year. The majority of formal complaints received and investigated, 42%, we are not upheld. Eight complaints were under investigation by the Parliamentary and Health Service Ombudsman (PHSO) and 4 cases had been assessed and not investigated. There was reported to be a very low referral rate to the PHSO and even lower acceptance to investigate by the PHSO. The Trust clinically reviewed all complaints to ascertain any risk or level of harm and acted upon any emerging risk. Where appropriate, complaints were discussed at the Executive Patient Safety Meeting by the Executive Patient Safety Leads for consideration as to whether such cases required investigation via an alternative route, such as the Serious Incident process. Four were declared as either a Serious Incident or required a Learning Panel.

The Trust worked in partnership to safeguard people. Safeguarding activity and complexity, in line with the national picture, had increased across all three of the Trust’s safeguarding teams in 2023/24. The maternity safeguarding reporting activity increased by 10% in 2023/24, the Children’s Safeguarding Team saw a 28% increase in activity and the Adults Team a 35% increase. in 2023/24 the teams supported greater numbers of complex safeguarding cases involving multi-agency partnership working for high-risk domestic abuse, criminal and sexual exploitation, mental health, and self-neglect. There had also been an increase in partnership working across professional, organisational and geographical boundaries within mental health, learning disability and autism teams, and several police forces, with three cases requiring Court of Protection involvement. The Trust’s internal audit of Maternity and Paediatric Safeguarding, demonstrated a high level of safeguarding compliance for both services. The Safeguarding Adult Team launched a Domestic Abuse, Sexual Abuse and Assault pathway in August 2023. In November 2023 the Trust hosted and led a multi-agency partnership safeguarding conference attracting 127 attendees.

People were encouraged to provide feedback with an active patients’ forum and a patient panel. People participated in learning when things went wrong, with open and honest conversations taking place. Following a medicine incident, to ensure learning was shared, a child and their mum had participated in a medicine error film.

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. Staff were passionate about the ‘Bid for Better’ process where staff were invited to bid for funding to provide a service, These had included providing clothing for those who came to hospital in their pyjamas helping to respect their dignity, dragonfly box, for families of patients approaching the end of their life , phototherapy for babies at home, to reduce jaundice and post-operative ice lollies.

With £30k of funding from Royal Surrey Charity a new initiative had been launched to purchase portable phototherapy devices and deliver treatment to newborn babies with jaundice at home. Jaundice is a common condition in newborn babies caused by elevated levels of bilirubin, a yellow pigment found naturally in the blood. The standard treatment is phototherapy (exposure to light waves) traditionally delivered in hospital and several sessions can be required. The portable devices can now be taken to the family home by a trained healthcare professional. This helps reduce the number of visits to hospital, aiding family bonding and reducing stress.

There were forums and mechanisms for the sharing of learning including newsletters, learning sets, debriefs and celebrations of success. The quality improvement (QI) team provided support and education encouraging people to become QI practitioners. A Zero Harms Quality Improvement Project included Reduction of Meticillin Sensitive Staphylococcus aureus (MSSA) had aimed for a sustained reduction in avoidable cases by March 2024. This included collaboration across divisions, emphasizing three key areas: observational audits of invasive devices, safety huddles within clinical teams and aseptic non-touch technique training compliance. The outcome of the project showed a reasonable reduction in hospital-acquired cases of MSSA and had led to increased confidence among nurses to challenge clinical practices.

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. The Trust worked in partnership with a local Trust through the implementation of the electronic patients record, and the partnership working continued as the system matured. In recognition of the challenges, they experienced the Trust had developed and published a guide to complement available guidance, filling the gaps they found to support others with a smoother transition.

Improvement and innovation included quality improvement, research and good ideas. Measuring outcomes and impact was an essential part of any initiative. There was process in place to ensure learning took place when things went wrong, this was supported by leaders who adapted a reflection and problems solving approach. Training on thematic reviews had been provided to be used as part of the Trust’s drive for harm free care and had been used to undertake a review of Venous thromboembolism (VTE) assessment and management, resulting in a cascade of learning and reconfirmation of best practice. This remained a quality priority for the Trust with an aim to reduce VTE related harm for patients in the Trust, to improve existing processes and develop new ways of working which minimises risk and promotes safety (including patients as partners in their own care).

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. As a result, one patient had participated in a learning exercise where they had felt considered and listened to. The SWARM approach had been adopted and used successfully ensuring safety incident huddle took place as close as possible in time and place to the incident, enabling a blame-free investigation and leading to prompt action.

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. There was a drive to increase interest non-medical research. The Trust was introducing professional nurse advocates to provide support and clinical supervision.

The Trust had four surgical robots helping them to address their elective backlog and meet increasing demand for surgical procedures. This means that the Trust was one of the best resourced robotic centres in the UK. The robot offers 10 times magnified 3D vision to enable surgeons to carry out operations which were more precise, with less blood loss, minimally invasive and less painful, resulting in a quicker recovery time for patients. Initially it was anticipated there would be an extra 100 patients a year, but the plan was this would increase further with additional theatre space and manpower when the new Cancer and Surgical Innovation Centre was complete.

An initial clinical study being led by two of the Trust’s gynaecological cancer lead clinicians had shown promising results and been published in the International Journal of Gynaecological Cancer. The MIRRORS study, funded by women’s cancer charity GRACE, assessed whether it is possible and safe to perform robotic surgery, rather than open surgery, for advanced stage ovarian cancer in patients who have already undergone initial chemotherapy. The study found in 87% of patients who opted to be part of the study there was reduced blood loss during surgery and the length of average time spent recovering in hospital reduced from six days (for open surgery) to 1.5 days (for the robotic option). A large scale randomised controlled trial is now being planned to confirm the initial findings. If successful, this could lead to a significant change for women diagnosed with this condition.

In the 2023 NHS Staff Survey, the Trust scored 5.82 or the people promise element ‘We are always learning’ which was better than the national average, and an increase from 5.57 in 2022.

The Trust had an internal audit plan, an annual audit cycle and had, registered 177 local audits, with 67 reports submitted. There were currently 84 audits still ongoing data collection and 26 had been given extensions due to various reason for operation pressures which focused prioritisation of clinical care. One audit, The Management of Upper GI Bleeds (UGIB) was specifically designed to review and audit the management of all GI bleed patients admitted to Trust against the benchmark set by NICE. The resulted demonstrated clear compliance with NICE recommendations for timing, resuscitation, and treatment.

During 2023 – 2024, the Trust participated in 50 national audits and 2 national confidential enquiries covering relevant health services the Trust provided. The Trust reviewed all national clinical audit reports with the relevant senior leadership team/s. Learning from national audit programmes was shared, through the Clinical Audit and Effectiveness committee and the internal newsletter (Governance Matters). For example, a review of findings for National Asthma and COPD Audit Programme - Chronic Obstructive Pulmonary Disease (COPD) identified a need for robust access to spirometry results for acute exacerbation of COPD. The Clinical measurements team were working with the electronic records team so they could upload results, so they were readily available to all clinical staff.

The Trust had used accreditation to ensure they were meeting definable standards in key clinical cares including (for example UNICEF baby friendly accreditation and Joint Advisory Group on GI Endoscopy (JAG)

The Trust had systems to learn from deaths, inquests, patient safety incidents and alerts from national bodies. The systems were effective and highlighted learning that was disseminated and used to improve the quality and safety of care and treatments.

The Trust’s processes for learning from deaths focussed on a holistic review of patients who died whilst in the care of the Trust. Reports from death reviews showed that learning was identified and used to bring about improvements for other patients.

During the reporting period 2023- 24, 929 patients died. This comprised the following number of deaths. Of the 929 deaths 144 underwent subject judgment reviews (SJR), 3 underwent Serious Incident investigations and 2 underwent both SJRs and Serious Incident investigations. Of the 929 deaths, 0 (representing 0%) were judged to be more likely than not to have been due to problems in the care provided to the patient.

The Trust has ratified and published its PSIRF policy and plan following presentation to the board in January 2024 and the system stakeholder event in March 2024. The Trust had undertook an extensive safety profile exercise which included the review of Incident data for period 2019-2023, Complaints and PALS data for period 2022/23, Legal data ‘Snapshot of Recent Cases and Learning’, Harm Free Care data and reports including falls and pressure damage, Divisional Safety Profile Presentation Workshops, and Patient Safety Culture Workshop. The Trust had met the national deadline with their policy and plan effective from 1st April 2024.

Leaders were engaged with the Trust’s Green Plan and had clear goals and a vision for their journey to Net Zero. There was clear support for motivated clinicians to undertake projects and research in sustainability, with time and resources allocated to this. Staff felt valued in their work and there was a clear understanding of how the workforce had a role to play in them achieving Net Zero. Education was available to staff on sustainable healthcare. However, there was a gap in communication with the Trust not effectively promoting their positive achievements in reducing their carbon footprint and encouraging all staff to get involved.

The Trust had not been involved in many collaborative projects with the integrated care system (ICS) but was 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 some areas, such as estates, there was a clear understanding of where reduction in emissions could be achieved and they had been successful in these initiatives. An example of this was the recent installation of solar panels and the approach to planning of the new cancer centre which followed net zero standards. However, 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. An example of this would be to identify how to reduce emissions associated with clinical pathways to ensure high quality care is delivered with as low of a carbon footprint as possible.

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.