We carried out a comprehensive inspection of the East Surrey Hospital in May 2014. At that time we rated the outpatients department as requiring improvement because we found many clinic appointments were cancelled at short notice. Clinics were busy and were often running late and where medical records for clinics were often not complete, therefore clinics often saw patients with a temporary notes.

We judged the service was not fully compliant with Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 210, then in force. Consequently we issued a requirement notice, a form of enforcement action which demands providers make necessary improvements to meet the required standards.

The purpose of this inspection was to check improvements had been made, ensuring the terms of the requirement notice had been met. Therefore we did not rate this service.

Our key findings were as follows:

• The trust had met the conditions of the requirement notice.

• The trust had introduced systems to regularly assess and monitor the quality of outpatient services.  

• The trust had suitable arrangements for assessing and managing risks relating to the health, welfare and patients and others.

• This had been achieved through the establishment of a new management and governance structure and a strengthening of nursing leadership.

• Arrangements for the management of medical records had improved and more than 99% of full medical records were available at clinic appointments.

• Punctuality of clinics was much improved and 87% of patients were seen within 30 minutes of their appointment.

• Although there was an increase in the number of short notice clinics to meet increases in demands, there was now more stringent controls in place and better management of these.

• There were improved management controls to minimize the number of cancelled clinics.

• Thirteen additional consultants had been appointed, to assist in the provision of additional capacity to meet increasing demands.

However, there were areas of practice where the trust still needs to make improvements. The trust should:

• Ensure all staff are trained and able to use the electronic incident reporting system.

• Develop systems to ensure the consistent checking  of emergency equipment in the outpatients department.

• Ensure there are arrangements to ensure confidential patient notes are not left unattended in the outpatients department.

• Ensure all staff have received training regarding the Mental Capacity Act, and are clear about the practical application of this legislation in their work.

• Consider how the monitoring of actual versus scheduled appointment times could be used to inform further development and improvement.

• Review signage in the department to improve patient flow through the department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

During this follow up visit we spoke to patients or their representatives on Godstone and Copthorne wards. In addition, we visited and observed the Accident and Emergency department, the hospitals ‘walk in’ centre and the Pre operative/Pre assessment area (known as POPPA)

Patients indicated that they were treated as individuals and the majority were happy and very satisfied with the personalised care and treatment they received. One patient said, I have more confidence in the nursing staff here than in any other hospital I have been in....staff take a genuine interest in you” Numerous other patients spoken with made positive comments about their care including, "they've treated me very well", "staff are absolutely wonderful" and “I couldn’t have got better care if I had gone private.”

We also received very positive comments from patients about the standards of cleanliness in the hospital and the hygiene control measures in place to protect them from unnecessary harm. For example, a patient told us, "I've got no complaints about the cleanliness and I see staff washing their hands and using the hand sanitizers all the time. Another patient told us they were more than satisfied with hygiene levels on the ward. They said that staff took infection control measures seriously, wore aprons and gloves and washed their hands regularly. One patient was concerned however that some staff who visited the ward, such as porters, didn’t always use the hand sanitizers. The patient felt that was a risk as they visited numerous other wards during the course of their work. Another patient was concerned that some shared equipment was not always cleaned between patient use. An example given was the blood pressure cuff.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Prior to this visit, we had inspected the hospital twice in 2011. Our previous inspections assessed the quality of the care provided following concerns raised about poor care and issues relating to dignity and nutrition as part of a national programme of inspections.

We are aware of the challenges East Surrey Hospital is facing with regard to inadequate capacity in their Accident and Emergency (A&E) department and the impact it is having on patients. We know the hospital have secured funding and are now investing in improved facilities, care and safety. During our visit, we saw some evidence of the progress the hospital is making to improve capacity. We have discussed some of the evidence of progress under Outcome 4 ( Care & Welfare of People Who Use Services) of this report.

This report focuses mainly on the use of escalation areas in the hospital. We also assessed the management of infections. We will be inspecting other services in the hospital in the future to carry out checks on their compliance with standards.

We visited the hospital on 16 December 2011 to follow up on the concerns raised with us by an anonymous whistleblower about the safety and functionality of the Pre operative/ Pre assessment area (known as POPPA) and to validate the hospitals written response to those concerns. In addition, we had received concerns around the hospitals infection control measures, discharge planning and the management of serious untoward incidents.

We spoke to numerous patients who were occupying beds in various escalation areas sited around the hospital. Escalation beds are used when the hospital is under pressure and demand outstrips normal bed capacity. Some escalation beds were seen to have been added to the bed numbers ordinarily used in some of the hospitals main wards. These additional beds had been fitted into available empty spaces on wards. Other beds had been set up in areas whose primary function was not a ward, but a space usually afforded to other purposes, such as the discharge lounge or the POPPA area. This area is normally used to assess and prepare patients before they go into the operating theatre. When there are not enough available beds for inpatients, POPPA becomes a small ward area of 5 beds.

We spoke to nursing staff who were working in some of the escalation areas and to more senior nursing staff with responsibility for service outcomes in these areas. We also spoke to staff involved with the Patient Advice and Liaison Service (PALS). PALS supports patients and their carers who may wish to raise a complaint or concern about any aspect of their care and treatment while in hospital. In addition, we spoke with the hospitals infection control lead and the head of nursing who explained the hospitals risk assessments for escalation areas. We briefly fed back some our findings to the hospitals Chief Executive Officer and the Chief Nurse at the end of our inspection.

Patients told us they were largely understanding of the hospitals current bed pressures. One patient said they knew that the hospital trust was in the process of building more wards and said that the hospital had improved a great deal since they were last admitted two and a half years ago. One patient said as they had been so ill on admission that they were very glad to be receiving treatment, regardless of where their bed was actually located in the hospital.

Patients told us that they had been given specific information regarding their condition and staff had generally explained the care and treatment they were to receive during their stay. Some people were still awaiting results of diagnostic tests and decisions to be made about discharge arrangements, which was clearly making them anxious. They said that most staff however had been patient and understanding and had treated them with respect. Three patients said their individual care plans had been discussed with them, but other patients spoken with appeared unaware of any written care documentation and couldn’t remember if it had been shared with them or not. Patients told us that their nutritional needs, where appropriate, were being met and that they were offered timely pain relief.

Concerns were raised specifically by patients in the POPPA escalation area about the lack of facilities available to them. Comments included. “It is so hot and sticky in here. I can’t seem to get any air, and its making me feel worse”. Another patient who had been in the POPPA area for 3 days said, “There is no where to wash. Only one little sink and no mirror either”. Another patient commented about a lack of space between the beds, which left little opportunity for privacy, even with the bed curtains drawn. They said that private conversations, even when spoken in a low voice could clearly be overheard by other people. Another patient was confused as to whether they were allowed to have visitors in POPPA and said that there was very little information available and they didn’t want to bother the nurses. A patient was seen to be struggling to eat their lunch in comfort as there was no over bed tables available. The patient told us that they had a wound on their stomach which made it even more difficult to eat without suitable facilities.

Nursing staff working in the escalation areas who spoke to us said that they had received specific guidance about working in the escalation areas, were confident of their ability to manage the clinical area safely, and largely felt able to secure the care and welfare of patients during their stay. They said that they had sufficient operational support and direction from senior staff if they were unsure about anything, or needed to raise a patient safety concern. Some trained staff from adjacent wards commented that covering for colleagues who were taking their rest breaks in escalation areas was tiresome and annoying. It often meant leaving their own work area/ ward which could prove disruptive and often upset their work plans. However, they largely understood that this was a reasonable management request given the hospitals current circumstances and patient need.

Patients that were able to speak to us said they were very positive about their care and treatment. One patient said the staff were kind and caring and provided excellent care. Patients felt they were kept informed and either they or their family were involved in making decisions about their treatment. They felt they were given enough information to help with this process. The only area where people did not feel well informed or involved was in relation to their discharge planning, which concerned them. Staff were observed treating patients with respect. Patients confirmed that staff were responsive to their needs and they received care in a kind and respectful way. All patients said that when they called for assistance using the call bell, staff usually came quickly. One patient said, “Sometimes in the morning you might have to wait a bit longer as the staff are really busy then, but generally they are very good. One patient said that staff were discreet, obliging and understanding. All patients were accommodated in single sex bays or single rooms with en-suite facilities.

The majority of patients spoke very positively about their experiences of mealtimes. They said that housekeeping staff were very caring and discussed meal choices with them. They said they always suggested alternatives if there was something on the menu they disliked or were unable to eat. Patients felt they were well supported by staff if they needed help with eating or drinking. A patient on a specialist diet said that although the food was generally very good, it did “lack variety and imagination sometimes”. This lack of variety was particularly evident in the comments patients made to us about the tea time menu. A significant number said they were being offered too many sandwiches at tea time, which they felt limited their choice and became very repetitive.

Patients said that staff talked to them and explained the care or treatment they were about to provide and asked for their consent. Sometimes their consent to specific types of treatment would be asked for in writing by the doctors caring for them. They told us that they did not feel under pressure to give consent and felt that they had been given sufficient information to make decisions and could change their mind if they needed to.

Patients told us they were very pleased with the service and with the staff but that sometimes treatment was slow or delayed. Some patients told us that there were delays in getting diagnostic tests done. They said that diagnostic tests were scheduled and then rescheduled for a different day, sometimes more than once. Patients told us they were not always provided with an explanation for these delays. They praised nursing staff and doctors as being very knowledgeable and usually responsive. Patients told us they had opportunities to ask questions and were given explanations that reassured them. They felt staff were very approachable and kind. They told us they valued the opinions of the nurses and doctors and felt confident that they understood their care and welfare needs. None of the patients knew what a care plan was however and so did not think they had seen or agreed to one. Patients told us they had opportunities to ask questions and were given explanations that reassured them. They felt staff were very approachable and kind. Some of the patients said they were not provided with information about how long they might be in hospital. They also said they had no knowledge of their discharge arrangements.

Patients were positive about cleanliness and hand hygiene across both of the wards we visited. They felt the wards were kept clean and that the staff worked hard on this, especially in busy areas. A patient who had received treatment on Godstone ward on two separate occasions said they were accustomed to seeing the hospital matron come round to do her monitoring checks for cleanliness and safety of equipment, and were impressed with her thorough approach

People told us that they were happy with the way their medicines were being given to them in hospital. They told us that nurses and pharmacists had explained their medicines to them and they felt that they understood the changes that had been made during their stay. People being treated on the wards told us that they always had their pain relief when they needed it. We saw a pharmacist carefully explaining a new medicine to someone before they went home. We saw a nurse giving someone medicines, explaining to the person what they were doing and following a safe procedure. Someone told us that they were able to keep their inhalers with them so that they could use them when needed which was important to them. Some people had told us before we visited the hospital that there was a delay in them getting their medicines when they were ready to go home.

Our rating of services improved. We rated it them as outstanding because:

• There was a genuinely open culture in which all safety concerns raised by staff and people who use the service was highly valued as integral to learning and improvement.
• All staff were open and transparent, and fully committed to reporting incidents and near misses. The level and quality of incident reporting showed the levels of harm and near misses, which ensured a robust picture of quality. There was ongoing, consistent progress towards safety goals reflected in a zero-harm culture.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe. Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.
• There was an exceptional culture of data-driven continuous improvement and transformation at the trust, and this was supported by a comprehensive meeting structure and detailed performance reporting processes. All staff were actively engaged in activities to monitor and improve quality and outcomes.
• 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 due to a firmly-embedded and positive culture of openness and transparency, supported by a skilled, stable leadership and clear systems of control and governance.
• There was a strong, visible person-centered culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who use the service, those close to them and staff, was strong, caring and supportive.
• Staff at all levels clearly and passionately described how they met patients’ needs and demonstrated a good awareness of protected characteristics including race, sexuality, and disability. We saw a variety of resources made available to staff to help them support these population groups. We saw flexibility, choice and continuity of care reflected in the service delivered. Staff were well supported by the mental health liaison team and the frailty and interface team.
• People’s emotional and social needs was highly valued by staff and was embedded in their care and treatment.
• The trust overall score for the National NHS Staff Survey was in the top 20% for the three years preceding the inspection.  In some scores they ranked in the top 4 organisations nationally.
• Patients could access the service when they needed it, seven days a week. Services ran on time. Patients were kept informed of any disruption to their care or treatment.
• Trust performance for cancer waiting times was better than the operational standard and the national average in the most recent two quarters.
• There was an active review of complaints, how they were managed and responded to, and improvements were made as a result across the services.
• We saw comprehensive leadership strategies in place, such as the SASH+ programme, which helped promote and sustain the desired organisational culture. We found a skilled, stable and highly visible senior management team that possessed a deep understanding of issues, challenges and priorities affecting their service.
• The strategy and supporting objectives are stretching, challenging and innovative while remaining achievable. A systematic approach is taken to working with other organisations to improve care outcomes, tackle health inequalities and obtain best value for money.
• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.