Epsom General Hospital

Updated 14 February 2024

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 Epsom General Hospital.

We inspected the maternity service at Epsom General 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.

Epsom General Hospital provides maternity services to the population of southwest London and northeast Surrey.

Epsom General Hospital is 1 of 2 sites for maternity services for the trust. Maternity services at Epsom General Hospital include a consultant led labour ward, alongside midwifery led unit and the Simon Stewart maternity ward providing ante and post-natal care. There is a maternity day assessment unit, triage space on the labour ward and antenatal clinics. Between April 2022 and March 2023 there were 1,791 deliveries at Epsom General Hospital. Maternity services are operated as one service over 2 sites (Epsom General Hospital and St Helier Hospital and Queen Mary's Hospital for Children) with the same leadership team and governance processes.

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

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

Our rating of this hospital stayed the same. We rated it as Good because:

Our rating of Requires Improvement for maternity services did not change ratings for the overall hospital.

We rated safe as Requires Improvement and well-led as Requires Improvement in maternity services.

We also inspected 1 other maternity service run by Epsom and St Helier University Hospitals NHS Trust. Our report is here:

St Helier Hospital and Queen Mary's Hospital for Children - https://www.cqc.org.uk/location/RVR05

How we carried out the inspection

We provided the service with 45.5 working hours notice of our inspection.

We visited the day assessment unit, triage, labour ward, maternity theatres and Simon Stewart maternity ward which included post and antenatal inpatient care.

We spoke with 16 staff including the director of midwifery, head of midwifery, obstetricians, doctors and midwives. We also spoke with spoke with 2 woman or birthing people We received 108 responses to our give feedback on care posters which were in place during the inspection.

We reviewed 7 patient care records, 7 observation and escalation charts and 7 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

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 19 September 2019

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

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
• The service provided care and treatment based on national guidance and evidence of its effectiveness.
• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
• Staff cared for patients with compassion and provided emotional support to patients to minimise their distress.
• The trust planned and provided services in a way that met the needs of local people. The trust had a transition agenda and was rolling out new ways of working including a model of integrated care.
• Managers at all levels in the trust had the right skills and abilities to run a service.
• The trust used a systematic approach to continually improve the quality of its services.
• The trust had effective systems for identifying risks and planning to eliminate or reduce them.
• The trust was committed to improving services. There was a range of quality improvement and patient safety initiatives in progress. However, most of these were relatively new and were not embedded into practice.

However:

• Nurse staffing was a challenge and shifts were not always covered by the planned number of staff. Some staff regularly worked more than their contracted hours to cover staffing shortages.
• We found issues with the monitoring of fridge and room temperatures on some wards.
• Although, the service offered mandatory training in key skills to all staff, some mandatory training courses did not meet the trust’s 95% standard.
• The effectiveness of care and treatment was monitored by managers. However, outcomes of patient care audits were variable.
• Medical care was not meeting the trust’s 85% standards for staff appraisals
• There were issues with regards to discharge lounge closures and discharge summaries being completed within 24 hours.

Updated 29 January 2019

• Safeguarding processes had improved since our last inspection. Staff had instant access to information, which was held electronically. This meant staff were immediately aware if a child was known to social services, was a looked after child, or subject to a child protection plan.

• Staff identified and responded appropriately to changing risks to people who use services, including deteriorating health and wellbeing and medical emergencies. Staff were able to seek support from senior staff in these situations.

• People received safe care and treatment. Vacancy rates for nursing staff had improved significantly since our last inspection.

• Staff understood their responsibilities to raise and record safety incidents, concerns and near misses. Learning from incidents was routinely shared with staff across the service in several ways, such as regular ward meetings.

• The service used a range of evidence-based guidance, legislation, policies and procedures to deliver care, treatment and support to patients.

• From June 2017 to May 2018, the trust performed better than the England average for the percentage of patients aged 1-17 years old who had multiple readmissions for asthma.

• Staff treated patients and their families with kindness, dignity, respect and compassion. We saw that staff took the time to interact with people who use the service and those close to them in a respectful and considerate way.

• The trust provided timely and accessible services for children and young people which reflected the needs of the population served. Trust leaders had worked collaboratively with trust staff, external bodies and children and young people, and their relatives to do so.

• The trust listened and responded to people’s concerns and complaints about services for children and young people, and used these to improve the quality of care. The service received a very low number of complaints.

• Leaders had the required skills, knowledge, experience and integrity to carry out their roles effectively.

• There were clear and effective systems of governance and management across services for children and young people at Epsom General Hospital, in close liaison with St Helier Hospital, the other trust's site.

However:

• Medical staff did not meet the completion rate target of 85% for nine out of the 11 mandatory training modules for medical staff. This meant that not all medical staff had received training essential to providing safe patient care.

• Staff did not consistently monitor the temperature of the fridge in the clinical room in the neonatal unit which was used to store breast milk. This meant there was a risk that breast milk could be exposed to abnormal temperatures, which could cause the milk to deteriorate.

• The trust paediatric policies we looked at were not all up to date. For example, one of the policies we looked at, had expired in September 2017.

• Locum medical staff did not have access to the full information technology systems and could only use a generic log on to access the trust systems. This meant locum staff could not easily access important information such as handover lists, transfer letters and up to date guidelines.

• Some staff told us they would use other staff members to translate for parents or relatives. This was outside of best practice and trust policy.

Updated 29 January 2019

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately and learning was shared across the two sites. Staff could give us clear examples of when learning from incidents had resulted in changes to practice. This had improved since our last inspection.

• The service had sufficient nurses to ensure patients received safe care and treatment. The unit followed the Guidelines for Provision of Intensive Care Services (GPICS) for registered nurse to patient ratios in level two units.

• The service monitored the effectiveness of care and treatment and used the findings to improve them. The trust regularly participated in national clinical audits and managers demonstrated a good awareness and understanding of the patient outcomes of the unit.

• Mortality rates in the unit were within the expected range and unplanned readmission rates to the unit within 48 hours of discharge to a ward were better than the national average.

• Staff took the time to interact with people in a respectful and considerate way and were supportive to patients. During ward rounds and other interactions, staff answered patient concerns, explained symptoms and reassured patients.

• The service took account of the individual needs and choices of patients. Staff discussed patient needs and made reasonable adjustments to support patient requests where possible.

• Staff described service leaders as visible and approachable. Since the last inspection, the leadership had worked to improve links between the two sites, including joint working and staff rotation.

• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

• There was a clear drive from the clinical leadership to improve consistency and collaboration across the two sites; and learning and development between sites had improved since our last inspection.

However:

• The service did not have suitable premises and the design of facilities did not meet the needs of patients. At the last inspection, there were several concerns about the facilities not being suitable for the patients including the unit not having any isolation rooms for patients and excessive temperatures during summer months. During our inspection, we saw these concerns remained, although they were identified on the service's risk register.

• Some printed guidelines and policies we saw had passed their review date, or did not have a review date, which meant staff were at risk of not following the most up to date guidance.

• The service did not always maintain effective patient flow through the department. Delayed discharges remained consistently worse than the national average in the Intensive Care National Audit Research Centre (ICNARC) audit and this was graded as an extreme risk on the service’s risk register.

• The trust did not have a clear vision or strategy for the unit. While the service had defined plans to improve consistency of working between the two sites and had achieved some of these goals, the service lacked a defined longer-term strategy.

• The service had limited engagement with patients, staff, the public and local organisations to plan and manage appropriate services. Responses to the Friends and Family Test (FFT) were limited and there was limited active engagement of patients and relatives to provide feedback.

Updated 27 May 2016

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

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

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

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

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

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

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

Updated 14 February 2024

Updated 27 May 2016

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

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

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

Updated 27 May 2016

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

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

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

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

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

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

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

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

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

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

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

Updated 14 May 2018

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

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

However:

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

Updated 19 September 2019

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

• Although we found some improvements had been made since our previous inspection, particularly regarding the responsiveness of the service, there remained areas which required further improvements.
• Governance and risk management processes were not as strong or effective as would be expected. The department did not have an oversight of the work of the emergency nurse practitioners.

• The completion of mandatory safety training by staff was less than the trusts own target and was unlikely to be achieved within the current year.
• There were no competency assessments for most staff groups working in the department. New staff in the department were not provided with the required induction to the department and were not assigned mentors to work with.
• Emergency nurse practitioners felt they would benefit from clinical supervision and tuition from consultants and medical staff to increase their clinical knowledge.
• The emergency department had not achieved the Department of Health’s 95% performance target from October 2018 to February 2019 and there were sometimes delays for emergency medical staff being able to refer patients to specialty services in a timely manner.
• Patients waiting for X-rays were left unattended, unobserved, and left with no means of calling for help.
• Staffing in the department was always not sufficient to safely manage the numbers of patients. This was particularly evident during the periods of high attendance.

However:

• Guidelines were in place to support staff to provide effective treatment, and these were up-to-date with national guidance and standards and regularly reviewed and audited.
• Clinical staff ensured that patient treatment and care was delivered with kindness and compassion. Staff used professional guidance and best practices, including risk assessment tools and consent procedures to support the provision of safe and responsive care.
• Although nursing and medical staffing remained a challenging area, the day to day arrangements were focused on staffing the department to safe levels.
• There was excellent multidisciplinary team working both within the department and with teams outside the department, including external partners.
• The ED team included or had access to the full range of specialists required to meet the needs of patients in the ED. There was an onsite psychiatric liaison team. The team assessed patients aged 16 and over and provided advice to ED staff. Paediatric ED staff contacted the Children and Adolescent Mental Health team when they needed advice. The team were not based on site but would attend to visit paediatric patients who presented with mental health needs.
• Beds for mental health patients were obtained for those who were detained under the Mental Health Act through the bed management system of the hospital. Paediatric patients who presented with mental health problems were admitted to the paediatric ward routinely before being discharged or transferred to a mental health bed.

• Although much of the ED environment was not free from ligature points, staff assured us that, they had completed a risk assessment of the area for the appropriateness of its use by patients.
• ED staff had been trained on how to complete mental health risk assessment for patients presenting to the ED with mental health challenges.