Ashford and St Peter’s NHS Foundation Trust provides healthcare services across north-west Surrey to a population of 302,600. The trust provides district general hospital services and some specialist services such as neonatal intensive care and limb reconstruction surgery from sites at Ashford and St Peter’s Hospitals.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so, we rate the performance of services against each key question as outstanding, good, requires improvement or inadequate.

We also apply ratings to the trust’s overall performance. When we inspected the trust in December 2014 and published in 2015 we rated it as ‘good’ overall. We rated safety as ‘requires improvement’ ‘good’ for effective, caring, responsive and well led. We found that the trust was in breach of some regulations and we told the trust it must address this. We returned to the trust in February 2017 to review progress and found the trust had improved and was compliant with all regulations.

This unannounced responsive inspection was undertaken as we had received information of concern regarding standards of nursing care on medical wards at St Peter’s Hospital. We followed this up with the trust who provided us with further information. However, we needed to go and test this information to ensure patients were receiving safe care. We focussed the inspection on this issue and did not inspect other services or cover all of our key lines of enquiry. The results of this responsive inspection have not changed the ratings from the previous inspection report published in 2015.

We saw several areas of good practice including:

• The strategy and initiatives to prevent and monitor pressure ulcers

• The planning and delivery of nursing care

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

Importantly, the trust must:

• Ensure fire safety is regularly reviewed and enforced.

• Ensure the safe storage and security of medicines.

• Ensure safety checks and services on patient equipment are consistently completed.

In addition the trust should:

• Support and enable all staff to complete mandatory training.

• Continue its strategy to make safety thermometer information more accessible to staff and patients.

Professor Edward Baker

Chief Inspector of Hospitals

As this inspection was specifically focused on assessing required improvements of St Peter’s Hospital, it was not necessary to speak with people who had used the service on this occasion.

However, one person who was to be discharged on the day of our visit was keen to tell us their experience. We were told the nurses and doctors had been brilliant which had enabled this patient to make a speedy recovery. We were told that the hospital was “wonderful” and that they couldn’t be more complementary about the kindness that had been shown to them.

We spoke to people using the service or their representatives on Aspen ward, Falcon ward, Rowley Bristow ward, Swift ward and the Day Surgery Unit.

The majority of people using the service were happy and satisfied with their care and treatment and said it had been explained to them. One person said “they always tell you what they’re going to do before they do it” and people made positive comments including “they’ve treated me very well”, “staff are wonderful” and “the staff have all been excellent”. One person said they felt there was room for improvement although many individual staff were very caring.

People using the service gave mixed views about the food served with the majority of people speaking appreciatively of the food and a small number of others making less positive comments.

We received very positive comments about the standards of cleanliness and hygiene in the hospital. People using the service told us “I’ve got no complaints about the cleanliness - they clean in here every day”. Another person using the service told us they were “very impressed’ - cleaning is first class”.

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.

We spoke to many patients during our visit and received information from patients giving differing views about their experience of using the hospital services. Most of these were positive, although some negative comments were also received.

A number of patients told us that the majority of staff were helpful, patient and explained the care and treatment being provided.

Examples of comments we received from patients included that the staff always draw the curtains round the bed when necessary to ensure their privacy and dignity and that staff respected their dignity and were very discreet in their care.

We were also told that people thought their care was "absolutely excellent", that "staff

were very good" and "the staff on the ward were very nice" and that they (the patient) had been treated very well.

Other, less positive feedback included a patient who told us that they did not feel involved in their care or treatment and expressed concerns about some aspects of their care. One patient told us that one of their doctors had used medical language to explain their operation which they did not understand.

Another patient was due to be discharged the next day but did not know what

arrangements were in place regarding their discharge.

Our rating of services stayed the same. We rated it them as good because:

We rated effective, caring responsive and well-led as good. We rated safe requires improvement overall.

In urgent and emergency care we rated safe, responsive and well-led as requires improvement and caring and effective as good. We rated the service as requires improvement overall.

In critical care we rated safety, responsive and effective as good and caring and well-led as outstanding. We rated the service as good overall.

In medicine we rated safe as requires improvement and effective, caring, responsive and well led as good. We rated the service as good overall.

In children and young people’s services we rated safe, effective, caring, responsive and well-led as good, and the service as good overall.

We did not inspect all core services. The previous rating for those services we did not inspect were taken into account when working out the overall trust ratings for this inspection

The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately and could discuss the processes involved.

The service used safety monitoring results well and participated in the national safety thermometer scheme. Staff collected safety information and shared it with staff, patients and visitors. The trust used information to improve the service.

The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. Standards of hygiene and infection rates were monitored to identify any risks and infection rates were low.

Staff kept appropriate records of patients’ care and treatment. Multi-disciplinary, electronic records were clear, up-to-date and available to all staff providing care.

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. Specialist teams support ward staff and patients in vulnerable circumstances.

The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Recruitment, especially of nursing staff was a major challenge to the trust. However, there were systems, including the use of a flexible workforce that ensured there was a match between staff on duty and patients’ needs.

The services provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance through programmes of audit.

The trust made sure staff were competent for their roles. There was a programme of mandatory training and staff had opportunities to develop their skills and gain experience and qualifications to help them do their jobs effectively.

Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. Electronic records were used effectively and there were electronic systems to ensure patients’ conditions were monitored

Staff cared for patients with compassion. Feedback from patients and our observations confirmed that staff treated them well and with kindness and respected their privacy. In critical care there were examples of staff making exceptional efforts to deliver a caring service.

Staff involved patients and those close to them in decisions about their care and treatment. Patients said they were given sufficient information and support to make decisions about their care and treatment

Staff provided emotional support to patients to minimise their distress, and patients could access a member of a multi-faith chaplaincy team to discuss spiritual matters.

The trust planned and provided services in a way that met the needs of local people. They worked collaboratively with other healthcare organisations and patient groups to identify and meet local needs.

Generally, people could access the service when they needed it. Waiting times from referral to treatment met government standards and arrangements to admit, treat and discharge patients were in line with good practice. However, waiting times for assessment and treatment or admission in emergency care did not meet government and professional standards.

The service took account of patients’ individual needs. There were specialist teams to support those with additional needs, for example those living with dementia or those in vulnerable circumstances.

The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. However, the trust acknowledged there were issues with the timeliness of complaints responses and sometimes in the quality of the response. An action plan was in progress at the time of inspection to address these issues.

Generally, the trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care and promoted a positive culture focussed on the needs of patients. The organisational values were embedded and staff could give examples of how they guided them in their work.

The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. The trust had recently reset its overall strategy, mission and strategic objectives; these were well understood by staff.

Staff had been engaged in setting the trust’s recently revised vison, mission statement and strategic objectives. These and the existing trust values, were well understood and embedded in staff’s work.

The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. Staff were involved in quality improvement projects and research activity.

The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. Patients were involved in the production of pathways of care and other initiatives. There were arrangements for staff to register concerns or to highlight areas of exceptional practice or achievement.

However:

Medicines were not always stored in a way that ensured their effectiveness although patients were prescribed and given medicines well. Patients received the right medication at the right dose at the right time.

The service had suitable premises and equipment but did not always look after them well. We found issues relating to fire safety, waste management, storage of substances hazardous to health and emergency equipment being checked to ensure it was ready for immediate use.

Departmental managers did not always identify safety hazards and manage them.

The service provided mandatory training in key skills to all staff but completion rates were variable and often did not meet the trust own targets.