East Surrey Hospital

Updated 15 November 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location. From page 3 the ratings and information relate to maternity services based at East Surrey Hospital.

We inspected the maternity service at East Surrey Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Maternity services at East Surrey Hospital provided antenatal, intrapartum (care during labour and birth), and postnatal care for approximately 4600 women and birthing people per year. The service comprised of a day assessment and triage unit, antenatal ward, co-located midwifery led birth unit (MLU), consultant-led delivery suite and a postnatal ward. The MLU had 4 rooms each with en-suite bathrooms and a birth pool. The delivery suite had 1 pool available. The service had a higher proportion of women in the 6th most deprived, and 10th least deprived decile at booking compared to the national average.

The ratings from the maternity services inspection did not change the rating of the location overall therefore our rating of this hospital stayed the same.

East Surrey Hospital is rated Outstanding.

How we carried out the inspection

We provided the service with 48 hours’ notice of our inspection.

We visited maternity day assessment, triage, delivery suite, the antenatal and postnatal wards.

We spoke with 25 midwives and doctors, 2 support workers, and 8 women and birthing people. We received more than 100 responses to our ‘give feedback on care’ posters which were in place during the inspection.

We reviewed 10 patient care records, 16 observation and escalation charts and 15 medicines records. During the inspection we spoke with staff including the director of midwifery, head of midwifery, obstetricians, doctors and midwives. We attended handover meetings and safety huddles.

Feedback received indicated women and birthing people had mixed views about their experience. Feedback included about concerns about delays, poor communication, and support needing to improve. For example, being spoken to unkindly, short staffing, and not being listened to. Positive feedback commented on the reassurance and care given by staff, especially on delivery suite.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 18 January 2019

• We saw unmistakable evidence of sustained improvement achieved through investment in new facilities and increased capacity, that resulted in enhanced effectiveness and responsiveness. This was thanks to a firmly-embedded and positive culture of openness and transparency, supported by a skilled, stable leadership and clear systems of control and governance.
• Staff felt confident they could raise concerns and report incidents, which were regularly reviewed to aid learning. Lessons learned were effectively shared and we saw changes implemented within the wards as the result of investigations.
• Despite challenges in nurse recruiting, there were sufficient numbers of clinical staff with the right qualifications, training and experience to meet the needs of patients. Staffing was reviewed regularly to ensure the correct skill mix and numbers of staff on the wards and throughout the department.
• Staff followed trust policies and best practice with regards to the department’s environment and equipment. Premises and facilities were presented to a high standard, visibly clean and suitable for their intended purpose. Infection control and equipment management were regularly monitored.
• The service undertook audits to ensure they regularly reviewed the effectiveness of care and treatment of patients. These showed that the care delivered was meeting national standards.
• Patients received co-ordinated care from a range of different staff, teams, and services. Staff worked collaboratively to meet patients’ individual needs, including their mental health and emotional wellbeing. Patients and relatives, we spoke with gave overwhelmingly positive feedback about the care they received.

Updated 8 June 2014

Services for children and young people were good. Most children and parents told us the staff were kind and attentive; the staff were described as ‘lovely’ and ‘funny’. Ward areas and equipment were generally, clean and appropriate infection control measures were in place. There were enough trained staff on duty to ensure that safe care could be delivered. There were thorough nursing and medical handovers that took place between shifts to ensure continuity of care and knowledge of patient needs.

Younger children received very good inpatient care and the ward was resourced to ensure their wider needs were met. Good facilities and staff support encouraged a parent to stay in hospital with their baby or child. The quality of care of adolescents was limited by the accommodation; we observed instances where the privacy and dignity of teenagers was not respected. The care on the neonatal intensive care unit was outstanding. The staff team were committed to ensuring best practice and optimal care for the babies admitted to the unit.

Senior staff communicated well and staff were positive about the service. There was clear evidence that the wider multidisciplinary team worked well together for the benefit of the younger patients. Children’s experiences were seen as the main priority. Staff felt supported by their managers and were encouraged to be involved in discussing their ideas for improvements.

Updated 8 June 2014

Patients we spoke with gave us examples of the good care they had received in the unit. The leadership of the unit created a culture of reporting and learning from incidents. There was good multidisciplinary working to ensure patient needs were met. Guidance form recognised professional bodies were followed and audited to ensure their effectiveness.

Patients were treated with compassion, care and dignity. The service demonstrated responsiveness to the needs of patients and the local population. Changes were being made to the management of high dependency unit (HDU) to improve patient flow through the service.

Updated 8 June 2014

We found that the trust had systems in place to ensure end of life care was safe and met the needs of patients and that staff were committed to providing person centred care to patients who were receiving end of life care. Patients spoke positively about the way they were being supported with their care requirements. Relatives also spoke very positively in regard to the support they and their relatives received.

The specialist palliative care team were responsible for ensuring that end of life care was delivered to staff within the ward areas as part of their mandatory training. The specialist palliative care team had developed an end of life care pathway tool which was in use in all the ward areas we visited. Staff in all of the ward areas we inspected were aware of the tools used for patients receiving end of life care and all staff were aware of how to contact the specialist palliative care team.

Updated 15 November 2023

Updated 18 January 2019

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

• Staff received effective training in safety systems, processes and practices and understood how to protect people from abuse and their responsibilities regarding the Mental Capacity Act 2005.
• Standards of cleanliness across the department were maintained. There were systems in place to monitor and audit infection control activities.
• The design, maintenance and use of facilities and equipment kept people safe. Equipment was maintained and monitored to ensure it was fit for use.
• People’s individual care records, including clinical data was written, stored and managed in a way that kept people safe. The management of medical records had improved since our previous inspection.
• Medicines in outpatients were managed safely. Medicines and prescription pads were kept locked when not in use.
• Lessons were learned and improvements made when things went wrong. Issues were discussed in daily safety huddles where improvements were identified and shared.
• The service provided care and treatment based on national guidance. Speciality clinics operating within the outpatient department followed relevant national guidance and participated in national and local audits.
• The service made sure staff were competent for their roles. There were induction arrangements for new staff and the department’s compliance with appraisal rates exceeded the trust target.
• Staff gave patients enough food and drink, where appropriate, to meet their needs whilst in the outpatient department.
• People were treated with compassion, kindness, dignity and respect, when receiving care. Staff communicated with people in a way that supported them to understand their care and treatment.
• A working group to review access to the department for patients with physical and learning disabilities was in operation.
• The facilities and premises were accessible to patients and clearly signposted. Where there were limitations on space within waiting areas staff acted to mitigate risk and the trust was working to improve the environment. Signposting within the department had improved since our previous inspection.
• The ‘did not attend’ rate for the outpatient department at East Surrey Hospital was better than the national average.
• People had timely access to initial assessment, test results and diagnosis and treatment. Referral to treatment times were monitored and performance for non-admitted and incomplete pathways had improved and was better than the national average in recent months.
• Trust performance for cancer waiting times was better than the operational standard and the national average in the most recent two quarters.
• Data showed that the proportion of cancelled clinics within outpatients had reduced.
• There was evidence of learning and improvement from complaints. Complaints were responded to in line with the trust’s complaints policy.
• Leaders were visible and there was a clear vision and set of values, with quality and sustainability as the top priorities. An outpatient strategy had been developed in line with the trust strategy.
• Staff and leaders alike reported that the culture within the service had improved since a previous inspection when staff reported feeling frustrated and not listened to by managers. Staff told us they felt valued.
• There were governance structures and processes to manage current and future performance and robust arrangements for identifying, recording and managing risks, issues and mitigating actions.
• There were clear and robust service performance measures which were reported and reviewed.
• The trust had systems and processes in place to engage with patients, staff, the public and local organisations to plan and manage services.
• There were standardised improvement tools and methods, and a trust-wide continuous improvement approach in operation within the outpatient department.

However;

• Patients undergoing minor surgical procedures within the outpatient department were not giving consent until they were in the procedure room which was not in line with best practice.
• In some outpatient areas there was limited space for private conversations to be held with patients, including those where bad news was being delivered.
• Toys in the department were not subject to routine cleaning schedules.
• Resuscitation equipment within the cardiac clinic was subject to daily and weekly checks but there were some gaps in the recording of these.

Updated 18 January 2019

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

• The management of medicines was good. Cupboards on the wards were well stocked, locked and labelled correctly. Medicine cupboards in theatres were also well stocked and medicines that were coming up to their expiry were marked to show this. We checked ten different packs at random and they were all in date.
• There was a strong incident reporting culture in the surgical division where staff felt comfortable to report incidents as there was a no blame culture. Staff we spoke with described how details of incidents were communicated in weekly messages from the chief of surgical services. They were then further shared and discussed in team safety huddles for those that hadn’t yet seen the messages.
• Staff we spoke with had a good awareness of how to manage suspected sepsis following a wide-ranging review that had been carried out by the service.
• Patient’s pain was managed well and pain relief was given when required. The surgical division had access to a dedicated pain team, seven days a week.
• Patients had a lower expected risk of readmission for elective admissions when compared to the England average. Patients at the trust also had a lower expected risk of readmission for non-elective admissions when compared to the England average.
• We observed many interactions between staff, patients and relatives. We saw that patients were treated with compassion. We heard examples of how staff, on different wards had gone the extra mile to do things for their patients.
• A number of other patients told us how the staff were all compassionate and did what they could for them. We also looked at some of the thank you cards that had been received across the surgical wards. These described how they or their loved ones had been cared for during their time in hospital and offered heartfelt thanks to the staff.
• Surgery services were planned around the needs of the local population. Patients were treated as individuals and the care provided reflected this.
• Complaints were fully investigated and responses reflected this. There was clear evidence that learning was taken from complaints and that learning was shared with the complainant.
• The surgical division was led by a triumvirate comprising the Chief of Surgery, the Associate Director, Clinical Services and the Divisional Chief Nurse.
• We found that they were an effective, cohesive team that were aware of their strengths and weaknesses.
• The surgical division had a well-defined governance structure. This was overseen by the Surgical Divisional Board. The aim of the Surgical Division board was to ensure local accountability for performance and risk management through regular review of its governance processes and oversight and review of local risk registers, incidents, complaints and clinical audit processes to ensure oversight and management of risks were well established. The service had had to close two theatres for major refurbishment in the summer of 2018. In response to this they had been able to build two temporary theatres and have them fully operational within four weeks.
• The service had a comprehensive risk register. This identified risks and categorised them using a Red, Amber, Green (RAG) system, defined by a method of scoring the risk by the likelihood of it happening and the impact.

However,

• The trust set a target of 80% for completion of mandatory training. Although compliance had been achieved in 24 out of 29 courses, it was considered that a trust target of 80% was low.
• Ambient temperatures were not being monitored in any of the clinic rooms where medicines were stored.
• General surgery and ophthalmology patients at East Surrey hospital had a higher expected risk of readmission for elective admissions when compared to the England average.
• Ear, nose and throat (ENT) patients at East Surrey hospital had a higher than expected risk of readmission for non-elective admissions when compared to the England average
• The Friends and Family Test response rate for surgery at Surrey and Sussex Healthcare NHS trust was 22% which was worse than the England average of 27% from July 2017 to July 2018

Updated 18 January 2019

• There were arrangements to keep both adults and children safe from abuse which were in accordance with relevant legislation. Staff had received training, were able to identify children and adults who might be at risk of potential harm, knew how to seek support and worked with other agencies.
• The service was providing safe care. There were sufficient staff to meet the needs of patients although the service was heavily reliant on a temporary workforce. The children’s department had two registered children’s nurses on each shift. This was in line with Facing the Future: Standards for Children in Emergency Care Settings 2018.
• Staff kept themselves, equipment and the premises clean. Staff complied with systems to control and prevent the spread of infection. Staff demonstrated good hand hygiene practice and safe disposal of sharps.
• Medicines were stored, prescribed and given well and medicines fridge temperatures checked.
• The room used for assessing patients with mental health needs was compliant with the Psychiatric Liaison Accreditation Network standard.
• Patients were given enough food and drink to meet their needs. Pain levels were assessed, and patients received adequate pain relief.
• Staff understood and complied with the relevant consent and decision-making requirements of legislation, including the Mental Capacity Act, 2005.
• Staff provided compassionate and respectful care. Staff provided emotional support to patients and relatives and involved patients and those close to them in decisions about their care and treatment.
• The service collected and monitored data about clinical outcomes and this was used to improve practice.
• The service was delivered by staff that were competent, trained and supported by their managers, to provide safe and effective care. The service provided regular training and development opportunities for staff. There were established developmental career pathways for different roles.
• Patients were encouraged to report concerns and complaints; these were treated seriously, investigated and lessons learnt. There was good oversight of complaints and incidents and there was learning from them.
• Adult patients arriving by ambulance were rapidly assessed in the rapid assessment and treatment area by the nurse in charge of the department. This assessment was required to determine the seriousness of the patient’s condition and to make immediate plans for their ongoing care. This is often known as triage. Standards set by the Royal College of Emergency Medicine states that this should take place within 15 minutes.The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. The trust met the standard for four of the 12 months in the period (April, May, June and July 2018) from August 2017 to July 2018 and were better than the England average for all months in the period.
• All disciplines of staff had a shared focus and purpose to ensuring patients received the best possible care and experience. Staff morale was good, and staff were positive about the overall leadership of the trust.
• Staff in the emergency department felt well supported by the rest of the hospital and the executive team. There were some good examples of multidisciplinary working. The department was well supported by the mental health liaison team and the frailty and acute medical team.
• Leaders were visible and accessible in the emergency department; staff respected the local management team and felt well supported by them. Staff felt they were invested in and valued. Leaders and staff felt the executive management team understood the challenges they faced and were focused on implementing system-wide change.

However:

• There were significant numbers of registered nurse vacancies and heavy reliance on temporary staff. The service did not provide consultant presence 16 hours a day at weekends in line with the Royal College of Emergency Medicine’s recommendations.  Although the service provided 17 hours consultant presence Monday to Friday, which exceeded the RCoEM guidance, it only provided 14 hours per day consultant presence on a Saturday and Sunday which was not in line with the guidance. A consultant was on call outside the hours of midnight and 7am and were able to give advice over the phone or come in if required.
• Not all prescriptions were stored securely within the department we found some within a patient area. The following day we saw that managers had taken action to ensure these were stored securely.
• Substances subject to the Control of Substances Hazardous to Health regulations 2002 were not stored securely within one housekeeping trolley which was left unattended in the department. The following day we saw that managers had removed the product from the trolleys whilst they reviewed the processes surrounding substances subject to these regulations.
• Patient records and risk assessments were not consistently completed either electronically or on paper.
• A patient who received rapid tranquilisation was not monitored for signs of deterioration in line with hospital policy. After our inspection the department undertook an audit which showed patients who had received rapid tranquilisation who met the criteria of the policy had documented observations.
• There were no chaperone signs advising patients of their right to a chaperone.
• We observed informal comfort rounds were undertaken but these were not always documented as completed.
• Staff were not able to tell us who the mental health lead was for the service.
• Mandatory training and appraisal compliance was low and did not meet the trust target. Additional information provided to us by the trust showed overall mandatory training compliance was 70% which was below the trust target of 80%. We saw the department had developed a rolling two-year educational programme which would ensure staff received mandatory and statutory training.
• The median time from arrival to initial assessment was consistently worse than the overall England median in all months over the 12-month period from August 2017 to July 2018. In the latest month, July 2018, the trust’s median time from arrival to initial assessment was 18 minutes compared to the England average of eight minutes.
• Additional data showed between September 2017 and September 2018 the average median time for initial assessment for ambulances attendees was 20 minutes. This was still not in line with Standards set by the Royal College of Emergency Medicine. However, performance was improving between April 2018 and September performance varied between an average mean of 15 minutes (May 2018) and 20 minutes.
• We reviewed audit data in relation to screening for sepsis which showed variable compliance. Between January 2018 and July 2018 compliance varied between 62% (June) and 94% (February). The trust did not supply anymore up to date audit data in relation to sepsis. However, we saw the service had acted upon the poor audit results and had developed a comprehensive action plan to improve the screening and management of sepsis.