Epsom and St Helier University Hospitals NHS Trust

We carried out a comprehensive inspection of Epsom and St Helier University Hospitals NHS Trust (the trust) as part of our routine inspection programme. Epsom and St Helier University Hospitals NHS University Hospitals NHS Trust had been identified as having only two elevated and one risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system in May 2015 as such, had been placed in a low priority band for inspection (band 5 as of May 2015).

Epsom and St Helier University Hospitals NHS Trust has approximately 1,116 beds located across two acute locations; Epsom General Hospital which is located in Epsom and St Helier Hospital which is located in Sutton. The trust has a further four locations registered with the CQC: Kingston Satellite Dialysis Unit; Leatherhead; Mayday Satellite Unit and Sutton Hospital. In addition to these registered locations, Epsom and St Helier University Hospitals NHS Trust is the host for the South West London Elective Orthopaedic Centre (SWLEOC) which is located on the Epsom General Hospital campus. SWLEOC is run in partnership with a number of local trusts and is the largest hip and knee replacement centre in the United Kingdom and is one of the largest in Europe.

Additionally, St Helier Hospital is home to the Southwest Thames Renal and Transplantation Unit which provides acute renal care and dialysis and is integrated with the St George’s University Hospital NHS Foundation Trust renal transplantation programme. St Helier Hospital is also host to the Queen Marys Hospital for Children.

Epsom and St Helier University Hospitals NHS Trust provides district general hospital services to a population of approximately 420,000 people living across Southwest London and Northeast Surrey as well as more specialist services in particular renal and level two neonatal intensive care to a wider catchment area covering parts of Sussex and Hampshire.

We have focused our inspection on the acute services provided at Epsom and St Helier Hospital but have also included the renal service and the SWLEOC in the inspection due to the size of the services provided, in line with our published inspection methodology.

We have rated Epsom and St Helier University Hospitals NHS Trust overall as ‘requires improvement’. The key questions of safe, effective, caring, responsive and well-led were all rated as 'requires improvement'. Both Epsom General Hospital and St Helier Hospital were rated as ‘requires improvement’. However, the South West London Elective Orthopaedic Centre was rated as ‘Outstanding’ and the renal service was rated as ‘good’.

Our key findings were as follows:

• There was a significant shortfall of staff in a number of areas including critical care, medicine, surgery, and maternity services. At the time of the inspection, the trust had embarked on a large recruitment drive to increase the numbers of medical, nursing and allied health professional staff to help support clinical services. Inappropriate skill mix issues and staffing numbers had been identified as contributing factors in a marginal increase in the number of ward-based cardiac arrests identified by the trust between April and September 2015. Additionally, staff shortages were identified as impacting on the ability of staff to consistently provide individualised, evidence based and compassionate care.
• Community paediatricians were unable to meet all statutory requirements of attending child protection conferences because of demand, capacity and vacancies within the service. 
• The assessment and management of risks was not effective in several areas we inspected. In some instances, risks were either not identified, identified in various different meetings and documents, but not pulled together in a coherent risk register or remained on the risk register for several years with no timescale for resolution.
• The hospital was visibly clean. However data supplied by the trust indicated that wards repeatedly fell short of the infection prevention control compliance threshold. Staff reviewing patients on the critical care unit for example did not always comply with infection control practices such as being bare below the elbow and hand washing.
• The fabric of the St Helier building was reported as difficult to maintain due its age and the trust reported that this was likely to impact on the overall patient experience. This was due to the fact that staff reported difficulties in a range of areas including ensuring the building was hygienically clean; spacing between bed spaces was not in line with nationally recommended standards and a lack of appropriately equipped side rooms and isolation facilities for patients identified as being at risk of acquiring an infection, or whom had developed an healthcare acquired infection. The trust recognised that in relation to infection rates, they were performing worse when compared both nationally and to peer hospitals of a similar size. Again, reasons behind the poor infection rates were partly attributed to the fabric of the buildings. We were concerned that, in light of the fact the physical environment was not always fit for purpose, there had not been sufficient focus on staff consistently applying standard, evidence based practice such as decontaminating hands both before and after patient contact; staff not abiding by bare below the elbow policies; staff not applying isolation protocols in a timely way and staff wearing theatre clothing such as scrubs and theatre shoes in communal areas of the hospital such as the public coffee area located on the ground floor of St Helier hospital. Root cause analysis into incidents associated with patients acquiring healthcare-associated infections included a lack of isolation facilities (side rooms) as a contributing factor to the spread of MRSA in three additional patients during 2014/2015. The NHS estates and facilities dashboard placed the trust in the lower quartile for the percentage of side rooms available and in the lowest (worst) quartile for the amount of functional and suitable space available for the delivery of clinical care. 
• The estates critical maintenance backlog was such that, when considering the negative financial performance of the trust for 2015/2016 and the projected budgeted deficit reported for 2016/2017, it was unlikely the trust was going to be able to deliver any significant impact to the backlog which was reported as a risk adjusted backlog of circa £37 million; this placed the trust as having the 16th highest estates backlog nationally and in 3rd position when compared to peer groups across London of a similar size and activity. The trust was in the highest quartile (worst when compared nationally) for the total reported backlog for maintenance. 
• Patient outcomes including mortality rates were good across the majority of specialities; the trust performed well in national surgery audits in particular. In the SWLEOC, patient outcomes and patient satisfaction consistently exceeded national averages.
• Whilst patients were complimentary about the care they received and the attitude of staff, concerns were raised by relatives and staff alike regarding the ability of nursing staff to provide compassionate care due to them appearing rushed as a result of, or a perception that they were short of staff.
• In comparison to both local and national performance, the trust was consistently seeing, treating, admitting, discharging or transferring over 94% of patients who presented to the two emergency departments.
• We identified significant concerns with the culture and leadership of the critical care service. Due to the nature of the concerns, CQC were minded to consider whether it was appropriate to utilise its regulatory powers to encourage improvement within the service. We opted not to utilise our powers because, on raising the concerns with the executive team, we were satisfied with the swift action taken by the trust to introduce new leadership into the service, as well as to embark on a thorough review of critical care services across the organisation, which was supported by a local NHS trust.
• We also identified concerns with the management of patients on specific wards including ward B5 at St Helier Hospital. An increase in incidents involving patient harm and an increase in the number of patients who deteriorated on that ward had been identified by both the inspection team and also by the trust. The executive team had placed the ward into a programme of heightened monitoring and had introduced a range of initiatives and new leadership to help enhance the standards of care on that ward.
• As part of this inspection, CQC used Epsom and St Helier University Hospitals NHS Trust as a pilot site for testing a new methodology relating to Workforce Race Equality Standards; the findings of this specific piece of work has not contributed to our aggregation of judgements for any rating within this inspection process. We found that the trust was not fulfilling all its requirements for the WRES, failed to address areas of concern, and had not presented to issues the trust board. Six of nine WRES indicators were not adequately completed or actioned.

We saw several areas of outstanding practice including:

• The leadership of the outpatients and diagnostic imaging teams; staff were inspired to provide excellent services to patients with an ethos of the patient being at the centre of service provision.
• The diagnostic and imaging service was one of only a handful of services which had truly embraced ‘cross-site’ working. The service was working to reduce the doses of radiation patients received during diagnostic testing and this had been presented at both national and international conferences.
• Surgical outcomes and patient satisfaction results for patients receiving treatment in the South West London Elective Orthopaedic Centre was consistently better than the national average.
• The OPAL team were striving to enhance the care and overall experience for elderly patients and specifically for patients living with dementia who were admitted into hospital.
• The renal team had developed an acute kidney injury care bundle which was used throughout the trust and also at referring hospitals.
• Teams in the SWLEOC service had introduced a new patient pathway for patients suffering from chronic pain associated with musculoskeletal conditions.
• Innovative simulation training, supported with the use of mannequins and actors, was used to support the delivery of end of life care scenario training to a range of hospital staff. This training helped to embed the concept of end of life care across the trust.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure that there are sufficient numbers of suitably qualified staff both employed and deployed across the hospital at all times.
• Ensure child protection notifications are up to date and appropriate staff attend/produce reports for child protection conferences.
• Ensure that effective corporate governance and management arrangements are put in place.
• Ensure there are effective arrangements in place for the recognition, escalation and management of patients identified as being at risk of deterioration on the wards.
• Encourage collaborative working and sharing of clinical governance data between each of the core specialities, including critical care. The trust must ensure that there is a focus on cross-site working and sharing of information to aid in establishing an organisation-wide learning culture.
• Ensure that all patients who may lack capacity have a documented mental capacity assessment and, if appropriate, a deprivation of liberty safeguards (DoLS) assessment and application completed, and that patients consent is properly sought before treatment commences.
• Reaffirm and consistently apply the trust wide infection control policy, including the timely isolation of patients at risk of acquiring, or diagnosed with infectious diseases. Further, the trust must adopt a trust-wide culture whereby staff of all grades are empowered to challenge where non-compliance with the infection control policy is identified.
• Improve the care and compassion to shown to patients in the medicine, surgical and critical care areas on the St Helier Hospital site.
• Ensure that all emergency equipment is checked in line with the trust wide policy.
• Review the existing estate to ensure that it is fit for the purpose of delivering modern healthcare.
• Ensure that there are robust processes in place for the maintenance of medical equipment.
• Implement the required actions to ensure the requirements of the WRES are met.

Professor Sir Mike Richards

Chief Inspector of Hospitals