Review of compliance. Surrey and Sussex Healthcare NHS Trust East Surrey Hospital. South East. Region: Canada Avenue Redhill Surrey RH1 5RH

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1 Review of compliance Surrey and Sussex Healthcare NHS Trust East Surrey Hospital Region: Location address: Type of service: South East Canada Avenue Redhill Surrey RH1 5RH Acute services with overnight beds Date of Publication: July 2012 Overview of the service: East Surrey Hospital is the major acute hospital for east Surrey and north-east West Sussex, providing a wide-range of services to the local community. The hospital has a full 24 hour/seven day emergency department and a walk-in centre for minor injuries. There are 28 wards and a number of outpatient clinics serving a local population of over 420,000 people. Page 1 of 12

2 Summary of our findings for the essential standards of quality and safety Our current overall judgement East Surrey Hospital was meeting all the essential standards of quality and safety inspected. The summary below describes why we carried out this review, what we found and any action required. Why we carried out this review We carried out this review to check whether East Surrey Hospital had taken action in relation to: Outcome 04 - Care and welfare of people who use services Outcome 08 - Cleanliness and infection control How we carried out this review We reviewed all the information we hold about this provider, carried out a visit on 29 June 2012, observed how people were being cared for, talked to staff, reviewed information from stakeholders and talked to people who use services. What people told us 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. Page 2 of 12

3 Another patient was concerned that some shared equipment was not always cleaned between patient use. An example given was the blood pressure cuff. What we found about the standards we reviewed and how well East Surrey Hospital was meeting them Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights The provider was meeting this standard. People experienced care, treatment and support that met their needs and protected their rights. Outcome 08: People should be cared for in a clean environment and protected from the risk of infection There were effective systems in place to reduce the risk and spread of infection. The provider was meeting this standard. Other information Please see previous reports for more information about previous reviews. Page 3 of 12

4 What we found for each essential standard of quality and safety we reviewed Page 4 of 12

5 The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. We will have reached one of the following judgements for each essential standard. Compliant means that people who use services are experiencing the outcomes relating to the essential standard. Where we judge that a provider is non-compliant with a standard, we make a judgement about whether the impact on people who use the service (or others) is minor, moderate or major: A minor impact means that people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. A moderate impact means that people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. A major impact means that people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary changes are made. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety Page 5 of 12

6 Outcome 04: Care and welfare of people who use services What the outcome says This is what people who use services should expect. People who use services: * Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. What we found Our judgement The provider is compliant with Outcome 04: Care and welfare of people who use services Our findings What people who use the service experienced and told us Patients spoken with were happy with the quality of personalised care they had received. They said that nursing staff were available when they needed them and that they responded promptly to any requests for help. One patient said that there were less staff at night and there had been occasions when they had to wait a bit longer for a response. Comments from patients and their carers included, "the staff have all been truly excellent" and, "I have been very pleased and pleasantly surprised after all the bad press this hospital receives, It's actually very good." Neither of the wards visited had any escalation beds in use. Patients asked about access to ward facilities which promoted their well being told us that toilets and showers were for single sex use, always kept clean and readily available. Facilities that allowed them to take care of their personal appearance were to hand. Other evidence We last visited East Surrey Hospital on 16 December 2011 in response to concerns raised with us by an anonymous whistleblower about the safety and functionality of an escalation area sited in the Pre operative/pre assessment area known as POPPA. POPPA would normally have been used to assess and prepare patients before they went into the operating theatre and to provide care post operatively. When there were not enough beds available for patients elsewhere in the hospital, POPPA was used as a small escalation ward of 5 beds to increase capacity. Page 6 of 12

7 During our visit of 16 December 2011 we also visited seven other areas in the hospital where patients were occupying escalation beds. They told us they were largely satisfied with the environment they were in and were as comfortable as their medical condition allowed. They told us that their nutritional needs were being met and that they were offered timely pain relief when necessary. Patients in the POPPA area however raised concerns with us about the lack of facilities available to them, which they believed impacted on their health and well being. It was clear that they were treated in an area which offered less favourable facilities than patients placed in escalation beds elsewhere in the hospital. The situation also had the potential to compromise their safety. On the basis of the evidence provided and the views of the people who used the service, we found there were areas of non compliance and we set a compliance action for the provider to address the issue of using POPPA as an escalation area. The provider sent us an action plan detailing how they would address this concern within an agreed timeframe. When the two new modular wards were opened in February 2012, increasing the hospitals bed capacity, the commission was informed that the escalation area in POPPA was no longer being used. We visited the Pre operative/pre assessment area on this visit to validate what the trust had told us and found that the area had been restored to its normal and intended function. Care and treatment was planned and delivered in a way that ensured peoples safety and welfare. Our judgement The provider was meeting this standard. People experienced care, treatment and support that met their needs and protected their rights. Page 7 of 12

8 Outcome 08: Cleanliness and infection control What the outcome says Providers of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. What we found Our judgement The provider is compliant with Outcome 08: Cleanliness and infection control Our findings What people who use the service experienced and told us We received very positive comments from patients about the high standards of cleanliness in the hospital and the hygiene control measures in place to protect them from unnecessary harm. Comments from patients included, "staff are always cleaning and I have found things to be spotless" and, "I have noticed housekeeping staff cleaning every day, including in difficult to reach places such as high up, behind equipment and under beds. We found this to be the case as we observed cleaning taking place on the wards during our visit. Another patient told us that staff took infection control measures seriously, wore aprons and gloves and washed their hands regularly. All staff working on the wards were required to be bare below the elbow to facilitate good hygiene practice. One patient was however concerned that staff who intermittently visited the ward, such as porters or ambulance staff didn't always use the hand sanitizers or wash their hands. The patient felt that could be a risk as these individuals were known to visit numerous other wards and departments during the course of their work. Staff spoken with were aware that door handles and handrails are 'hotspots' for infection transmission. Senior ward staff were observed to challenge individuals about missed opportunities to comply with the hospitals hand hygiene procedures. Another patient was concerned that some shared equipment was not cleaned between patient use. An example given was the blood pressure cuff. Issues of concern raised by patients were explained to the Chief Executive at our feedback session before we left. Page 8 of 12

9 Other evidence Prior to our last visit to East Surrey Hospital on 16 December 2011 we were made aware of information which suggested that antimicrobial hand rub containers were sometimes found to be empty and that the incidences of MRSA infections had increased. We therefore focused on cleanliness and the hospitals infection control measures, particularly the prevention, management and monitoring of Methicillin Resistant Staphylococcus Aureus (MRSA). When we visited on 16 December 2011 we found that the hospital maintained an appropriate standard of cleanliness and was taking reasonable steps to protect people from infection. We visited seven wards and some other departments and found there were antimicrobial hand rub gels available at all entry doors. We checked all the hand gel containers to make sure they were not empty. None were found to be empty, and we observed people using the hand gels as they went in and out of the wards. We saw evidence of the root-cause analysis of two MRSA infections which had occurred in November The root cause analysis concluded that both infections were preventable and that contributory factors included: lack of MRSA screening of eligible patients on admission and lack of communication between multi-disciplinary teams. The action plan for the two cases included relevant and appropriate actions, recommendations and timescales for dealing with the cause of the infections. Based on our findings we judged there to be indicators that suggested a lack of consistent diligence in the prevention, management and monitoring of MRSA in the hospital and we set a compliance action upon the provider to address this. The provider sent us an action plan detailing how it would address this area of concern and make the necessary improvements. On this visit we found that the hospital continued to provide, and to maintain a clean and appropriate environment that facilitated the prevention and control of infections. We were aware that the trust breached both MRSA and Clostridium difficile targets for 2011/12. The trusts 'Quality Account' for 2011/12 records that they had six MRSA infections against an expectation of four, and 56 C Diff infections against an expectation of 50. On this visit the hospital demonstrated that improved systems were in place to manage and monitor the prevention and control of infection. One further case of MRSA had been recently identified and declared a serious untoward incident. We looked at the work undertaken so far to establish the root cause of the infection and discussed the findings with the Lead Nurse for infection control and the hospitals Medical Director. There were indictors that this case was unpreventable. The hospital had an infection control task force in place, responsible for the prevention, monitoring and management of infections. We spoke with two of the trusts infection prevention and control leads and the lead Antimicrobial Pharmacist about the trusts new antimicrobial prescribing policy. We also reviewed the hospital's Infection Prevention Control and Antibiotic Stewardship (IPCAS) Annual programme for The main purpose of this programme of work is to ensure that a culture of continual Page 9 of 12

10 improvement is maintained to try to reduce infection risks that patients, staff and visitors are exposed to. The programme is based on good practice infection control objectives, CQC and NICE compliance requirements, and the recommendations made to the trust by the Strategic Health Authority. The infection control task force demonstrated an increased focus on good antimicrobial stewardship, driven primarily by the hospitals medical staff and pharmacists. The matrons and ward managers were aware of their responsibility for ensuring appropriate challenge as part of the ward drug rounds. The Trust had also developed a CDiff action plan and increased the frequency of the infection control taskforce monitoring visits to weekly. Actions for the infection control team included a review of the infection control key performance Indicators. This included adherence to MRSA screening protocols. The Infection Control Lead Nurse also carries out quality audits with all ward managers. These include cross audits of MRSA screening compliance, elements of the 'Good Antimicrobial Prescribing' audits, and intra venous line care and use of the urinary catheter monitoring record and daily care plan. An Antibiotic Stewardship Group had been established and antibiotic ward rounds with a dedicated lead pharmacist were taking place. Presentations were being arranged of all root cause analysis outcomes by clinical teams at infection control task force meetings. The purpose of this was to review lessons learnt and to look at actions plans to avoid reoccurrence. Staff we spoke with told us they had been trained in infection control. The agendas and notes from meetings at all levels and across all departments in the hospital demonstrated that infection control was a priority and a regular agenda item. There was information available to people using the service, and visitors, about the control of infection. Our judgement There were effective systems in place to reduce the risk and spread of infection. The provider was meeting this standard. Page 10 of 12

11 What is a review of compliance? By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. Where we judge that providers are not meeting essential standards, we may set compliance actions or take enforcement action: Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. We ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people. Page 11 of 12

12 Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public / Copyright (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Quality Commission Website Telephone address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 12 of 12