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.

Generally the people that we spoke with during our visit were very happy with the treatment and care that they received at this hospital. Many of them perceived it as being their local community hospital and told us that they preferred it there rather than other hospitals that they could have gone to. They said it was always very clean and we saw that there were good measures in place with regard to infection control, with hand washing facilities and antibacterial gel available. We noted that it was well signposted and there were several toilets for visitors use.

Most people considered that they were given the opportunity discuss their treatment options with the doctors and that they were kept informed about what was happening, although some highlighted the fact that it was more difficult at the weekends, when there were fewer staff around. They knew what their medication had been prescribed for, they received it on time and they were not ever left in pain.

Feedback that we received about the staff, especially the nurses, was very positive with people telling us how kind they were “even though they are sometimes rushed off their feet” and “they have such a good sense of humour”.

We asked people about the food that was served in the hospital; most of them said it was “good” or “quite good” although there were also some adverse comments. On the wards we visited we saw that the food was hot, looked appetising and portion sizes were appropriate. There were no problems experienced by those people who needed special diets or a vegetarian option.

We have highlighted the need to ensure that those people who are need of assistance, to ensure that their nutritional needs are met, are appropriately supported.

People that we spoke with said that they felt very safe in the hospital and had not witnessed anything of concern. However, we found that some of the staff lacked knowledge around adult protection issues and there appeared to e some shortfalls in training with regard to this. We have asked The Trust to provide us with information about how this will be addressed.

We also raised some concerns about patient confidentiality. Male and female patients were all being nursed in single sex wards or bays and had separate toilet facilities however, in several areas of the hospital; there is limited room available for staff to speak in private with patients and conversations, which may often be difficult, can be overheard.

This is a report on a focused inspection we undertook at Epsom General Hospital on 29 and 30 October 2018. The purpose of this inspection was two-fold. Firstly, to follow up on concerns raised by Her Majesty's Coroner, in relation to patients being treated for hyponatraemia (low sodium blood levels), and the internal communication of abnormal pathology results. We also followed up on received concerns about the safety of mental health patients in the emergency department, nurse staffing levels in medical care wards and the safeguarding of patients being discharged from hospital. The concerns raised related to both Epsom General Hospital and St Helier Hospital.

Secondly, we followed up on the outstanding requirements from critical care and services for children and young people at Epsom General Hospital. As we had not inspected these services for more than two years, we inspected and rated them in their entirety.

Our key findings were as follows:

• Staff in the emergency department (ED) provided care and treatment based on national guidance and evidenced of its effectiveness. We saw recently adapted guidance on quality standards for the treatment of patients with hyponatraemia and these were embedded in practice.

• Medical staff across the ED, acute medical unit (AMU) and medical wards, received training in the management of patients with hyponatraemia.

• There was a trust wide standardised approach to the detection of deteriorating patients using the National Early Warning Score (NEWS) scoring system and staff knew what action to take when the score was above 4.

• Pathology results needed to deliver safe care and treatment were available to staff in a timely and accessible way. There was a trust wide standard operating procedure for communicating abnormal blood results to appropriate staff.

• Staff received effective training in safety systems, processes and practices. The trust trained staff in the Mental Health Act (MHA) and Safeguarding Adults.

• The design, maintenance and use of facilities and premises were satisfactory. There was a designated room for interviewing patients with mental health needs in the ED at Epsom General Hospital. The room had an emergency panic alarm strip and two exit points and there were no ligature points.

• ED staff identified adults at risk of causing harm to themselves. Patients assessed as being at risk of suicide or self-harm, received early referrals to the mental health liaison team. Policies and procedures were in place for extra observation or supervision of patients with acute mental health needs.

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

• The trust 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.

• Staff we spoke with described service leaders as visible and approachable. In critical care, the leadership worked to improve links between the two sites, including joint working and staff rotation.

• Managers of the critical care 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 in critical care and learning and development between sites had improved since our last inspection

• Safeguarding processes had improved since our last inspection across children and young people services. 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 children and young people, including deteriorating health and wellbeing and medical emergencies. Staff were able to seek support from senior staff in these situations.

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

• The critical care 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 in critical care 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 risk register.

• The critical care service did not always maintain an 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.

• In the ED at Epsom General Hospital, people’s individual care records were not always written and managed in line with best practice. This meant timely and available information was not available to the multi-disciplinary (MDT) team.

• Some medical wards did not use a checklist when discharging patients and this could result in parts of the process being missed.

• 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.

• There was not a clear vision or strategy for critical care. While the service had defined plans to improve consistency of working between the two sites and had achieved some of these goals, it lacked a defined longer-term strategy.

• The critical care 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.

• In the children and young people service, 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.

• In the children and young people service, staff did not consistently record the temperature of the fridge in the clinical room in the neonatal unit, which was used to store breast milk. This meant that there was a risk that breast milk could be exposed to abnormal temperatures, which could cause the milk to deteriorate.

• 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's systems. This meant locum staff could not easily access important information such as handover lists, transfer letters and up to date guidelines.

Importantly, the trust must:

• Improve the environment and facilities on the critical care unit to reduce the infection control risks to patients.

• Improve systems and processes in critical care so that patients are not delayed from being discharged.

In addition, the trust should:

• Consider an outreach service to support patients whilst they are waiting to be admitted to the critical care unit.

• Consider ways to increase engagement and feedback from patients in critical care and those close to them to improve the quality of the service.

• Develop an agreed vision and strategy for the critical care service and that staff are involved in the process.

• Ensure that guidelines and processes have adequate version control and are regularly reviewed, so staff have access to the most up to date guidance.

Professor Ted Baker

Chief Inspector of Hospitals