Annual Report Summary 2013-2014 Annual Report Summary 2013-2014

“I have been really Chairman and Chief Executive’s Report impressed by what I have seen. It feels to Last year was a remarkable year for our Trust. Our consistently high performance “Every day when I me like an absolutely against the national clinical standards walk into East Surrey excellent trust has cemented our position as one of the best performing district general Hospital I feel very with a really good trusts in the country. We are now recognised not only as a trust that has proud, but there atmosphere and turned itself around, but as a trust that has proven it can consistently deliver to have been many fantastically patient- the national standards. times this year centred. This hospital 2013/14 was a significant year for the NHS as well as for the Trust. A lot has changed in the health system when I have felt is a great example, the and we have played a significant part. Nationally the NHS focused on compassion and a duty of exceptionally proud.” candour following the recommendations in the 2 3 people I have spoken Francis reports. Also nationally, the spotlight was on Michael Wilson, CEO the newly established GP-led clinical commissioning to all say they are very groups (CCGs) that became responsible for deciding how most of the NHS budget is spent in their proud to work here.” areas. For us, this meant having a closer working Health Secretary, Jeremy Hunt relationship with our GP colleagues. We also developed our links with our catchment population through our public consultation as part of our NHS foundation trust application. Our focus is always patient safety, quality, clinical effectiveness and ensuring our patients have an excellent experience when they are in our care. This focus has, and will continue to remain our priority as we prepare to become a NHS foundation trust next year.

It has been a challenging year, with the NHS facing increasing numbers of patients visiting A&E departments across the country and the whole health economy having to work together to meet rising demands and expectations. Our year ended on a high though, with a visit from the Health Secretary, Jeremy Hunt. Annual Report Summary 2013-2014

There have been too many highlights from 2013/14 top 20 per cent of trusts in the country for 10 out Post Graduate Education Centre to help staff fulfill to mention, but a few things that stand out are: of the 28 positive indicators. A record breaking 68 their own personal goals and ambitions. It is through per cent of staff responded, which is one of the learning and sharing that we will continue on our The Care Quality Commission (CQC) ranked us in highest response rates in the country. journey of improvement. Band 6 (lowest risk) in its ‘Intelligent Monitoring’ ratings. This means our patients can expect the Our urology consultant Professor Abhay Rane It was clearly a year to be proud of, but we are safest care, and places us among the top 25 per became an OBE in recognition of his pioneering not complacent. Population growth, increasing cent of trusts. work here at East Surrey Hospital in developing age profile, technological advances and rising laparoscopic (keyhole) surgery. Abhay performed expectations coupled with constraints in public Our Endoscopy Unit achieved full and keyhole surgery through the belly button for the sector finances combine to present a huge challenge unconditional accreditation by the Joint Advisory very first time in Europe here in 2007 – and his to the health and care system. This will place huge Group (JAG), which defines the education, training patient was one of our nurses. pressure on the Trust to maintain, and where and quality standards for endoscopy in the UK. possible, improve our current performance. To do Other significant moments that have had a huge Our SHMI (standardised hospital mortality rate) is this we must play our full part in helping to develop impact on improving our patient’s experience in 0.95 placing us 40th nationally, which is in the top whole health system solutions. 2013/14 include: the opening of our new birthing 30% of all trusts - this is one of the most widely unit; our brand new Comet day unit at 2013/14 was a fantastic year for our Trust and we accepted quality measures. Hospital; a new state-of-the-art CT scanner; and made significant improvements in every aspect The Trust delivered to the national standard more recently the opening of our four brand new of the organisation. In order to become a NHS on ‘referral to treatment within 18 weeks’ for theatres, which have an ultra-clean air system. foundation trust, organisations must prove they the first time since the waiting time target was are both clinically and financially stable. In April We have won many awards over the year: Our introduced in 2000. 2013 our trust was granted permission to start the Infection Control team were the winners of the 4 application process to become a stand-alone NHS 5 2013 Schulke Hand Hygiene Champion Award; In June, 90 per cent of inpatients and 87 per cent foundation trust and we haven’t looked back. Being our breast cancer service was runner-up for its of patients were likely or a NHS foundation trust is a mark of quality and partnership with MediHome in the Health Service extremely likely to recommend our trust to their based on our performance over this past year, it is a Journal (HSJ) Care Integration Awards; our friends and family, and by December our Trust badge we deserve. was in the top 20 per cent of Trusts for being Respiratory team was short listed for a Nursing most likely to be recommended. Times Award for their joint work with Esydoc (19 GP Practices in east Surrey) to help asthma sufferers; During the heat wave in the summer we had the our After Breast Cancer (ABC) support group was best performing Emergency Department (ED) for awarded a Partnership Special Award at the Surrey three consecutive weeks out of all of the NHS Mirror Heart of the Community Awards; our Acute trusts in England. In quarter three, our ED was Stroke team won the Compassion award and Alan McCarthy Michael Wilson again the best; this time compared to the region Matron Denise Newman won runner-up in the Chairman Chief Executive “As part of an and was tenth best in the country. This was a Public’s Choice category at the regional Proud to remarkable achievement given that we had been Care Awards. anonymous staff the worst performing a few years ago. Within six months of the second Francis report Caring for patients with heart failure and patients being published we had launched our Nursing and survey we asked with community acquired pneumonia was the Midwifery strategy. Most of our patients tell us they focus of the Enhancing Quality (EQ) programme feel cared for and cared about, but the strategy what three words this year. In March we out-performed all other gives a clear direction of travel for developing our trusts in the Kent, Surrey and Sussex in both of nursing staff and to ensure we always put patients came to mind when these pathways. at the centre of all that we do. Strong leadership is a key recommendation in the Francis report. We have thinking about the The results from the 2013 inpatient survey focussed on how we develop our clinical leadership showed improvement over the year before with to take our Trust forward. As well as developing our us being on par with the majority (60 per cent) of Trust – top answers clinical leads, we have also launched our bespoke trusts – reflecting the continuous improvement of Ward Managers Leadership programme and the our services. were caring, Nursing Assistants (previously called Health Care The results from the 2013 national staff survey Assistants) development scheme. We are proud to improvement, and also showed improvement with us being in the be a learning organisation with a well-equipped patient-centred.” Annual Report Summary 2013-2014

ABOUT SURREY AND SUSSEX Our community

HEALTHCARE NHS TRUST The total population served by Surrey and Sussex Healthcare NHS Trust is around

Surrey and Sussex Healthcare NHS Trust was at Caterham Dene Hospital and Oxted Health 10 formed on 1st April 1998 following the merger Centre, in Surrey, and at Crawley and of Crawley, Horsham and East Surrey NHS Trusts. in . patients per day We sit at the heart of our community of over half arriving at our emergency department a million people, providing a comprehensive range The Trust is an associated university hospital of from . of emergency and non-emergency services to the Brighton and Sussex Medical School. + residents of east Surrey, north-east West Sussex, East Surrey Hospital has 642 beds, 10 operating and south Croydon, including the major towns of theatres, four of which are brand new and six that are Crawley, Horsham, Reigate and Redhill. currently being refurbished to the same high standard. We own East Surrey Hospital in Redhill, where we We have four additional theatres at Crawley Hospital in provide the more acute and complex services. East our recently refurbished Day Surgery Unit. Surrey Hospital is a Trauma Unit and the designated The Trust employs 3,500 substantive staff who hospital for Gatwick Airport and sections of the M25 are supported by the in-house Temporary Staffing and M23 motorways. Bureau and Agency staff. 535,000 6 7 We also reach out into the community to provide In 2013/14 we received £231m in income. Most a range of outpatient, diagnostic and less complex people of our activity has increased year on year, as 1 mile GREATER LONDON planned services closer to home. We provide services shown below:

CSH Surrey CROYDON

SURREY KENT 2011/12 2012/13 2013/14 Change REIGATE & Caterham BANSTEAD Dene Hospital A&E Attendances (All) 74128 80745 82338 2.0% First Community Health & Care Non Elective (Emergencies) 32773 35883 35722 -0.4% MOLE East Surrey Hospital Births 4485 4258 4444 4.4% VALLEY TANDRIDGE Outpatients 251782 252247 294779 16.9%

The catchment population is Crawley Hospital Elective (planned) care : CRAWLEY sprawling and covers many Horsham Hospital Daycases 24338 26412 27955 5.8% geographical miles. As well MID SUSSEX Elective Inpatients 5522 5031 5028 -0.1% as the major towns, there are a lot of rural communities HORSHAM Regular Day Attenders 4543 4752 5127 7.9% WEST too. The area is split over two EAST Total elective activity 34403 36195 38110 5.3% SUSSEX counties and covers a variety SUSSEX of demographics.

Sussex Community Trust Annual Report Summary 2013-2014

Working with our clinical commissioning groups Working with other healthcare providers

The Trust’s services are commissioned from five main CCGs: The Trust has developed partnerships with many facility at East Surrey Hospital, this building will be a other healthcare providers. step-down respiratory facility as part of their Lanes Fox Respiratory Unit. The Trust has worked with Royal Surrey County NHS East Surrey CCG NHS Surrey Downs CCG Foundation Trust to build a new Radiotherapy Unit on the East Surrey Hospital site. Working with local commissioners and providers, a partnership of a partnership of for the winter months (Nov to March) an additional British Oxygen Company (BOC) and Guys and St 58 community beds were commissioned to support 20 GP 33 GP Thomas’s NHS Foundation Trust are building a new winter pressures. practices practices in south East Surrey covering Caterham, Horley, Reigate, Redhill serving a population and Oxted 288,907 with a population of nearly with individual practices varying from Surrey and Sussex Healthcare 170,000 1,900 patients to over 31,000. NHS Trust’s objectives for 8 9 2013/14 were to: Crawley CCG - Horsham and North West Sussex Mid Sussex CCG • To deliver safe, high quality, Commissioning co-ordinated care Association a partnership of a partnership of • To ensure patients are cared 23 GP for and cared about 13 GP practices practices • To work in partnership with our community and a population of and a population of 123,900 223,200 • To become a sustainable, effective organisation

Croydon CCG serving a population of a partnership of 61 GP 350,000 practices 55% 12% aged 25 to 64 over 65 Annual Report Summary 2013-2014

Our Vision 2013/14 - THE YEAR IN FOCUS

Surrey and Sussex Healthcare NHS Trust is not only one of the most improved, now it is also one of the Safe, high quality healthcare that best performing trusts in England. In the past 12 months the quality of our services has gone from being puts its community first compliant to consistently being excellent. A&E 4 hour wait (Type 1) 1st Patient Opinion We consistently achieve this target and rank top A respected online forum - rates us as one of the of the local acute hospitals and 19th nationally most improved trusts for patient satisfaction and Our Values (w/c 12 January 2014) commends our ‘making things right’ responses Dignity & Respect: we value each person as an individual and will challenge disrespectful and Mortality inappropriate behaviour 0.95 2013 inpatient survey The Trust SHMI (standardised hospital mortality One Team: we work together and have a ‘can rate) is 0.95 placing it 40th nationally which is in The 2013 inpatient survey shows us ‘as do’ approach to all that we do recognising that the top 30% of all trusts expected’ for all of the categories, and shows we all add value with equal worth an overall shift from red (bottom 20% of trusts) two years ago to amber (national 10 11 Compassion: we respond with humanity and Care Quality Commission’s average) for all measures kindness and search for things we can do, Intelligent Monitoring Band 6 however small; we do not wait to be asked, We are rated Band 6, which means we are low because we care risk and rated as one of the safest hospitals Staff survey in the country Safety & Quality: we take responsibility for our 68% of staff responded to the 2013 staff survey actions, decisions and behaviours in delivering (data published March 2014), which is one of safe, high quality care Elective Length of Stay the highest response rates in England, with staff 8th saying they felt that what they do makes a real We rank 8th out of 22 acute trusts in southern difference to patients England and have performance better than both the peer group and national average

Staff motivation Outpatient follow up rates 5th For the second year running our staff are among We rank 5th out of 22 acute trusts in southern the most motivated NHS staff in the country and England and have performance better than they said they are proud to recommend our trust both the peer group and national average. as a place to work and be treated.

Friends and Family Test 5th Awards Friends and Family Test score has been the best in the region and with the 5th best response Over the year, staff at our Trust won six rate in England prestigious national and regional awards. Annual Report Summary 2013-2014

A Focus on Safety and Quality

This year we have continued to make One of the biggest challenges we’ve significant improvements in the quality of our faced over the past few years has been services. We have achieved all the required balancing bed capacity and demand. clinical standards – regularly exceeding While this had obvious knock on effects the standard in several indicators, but also for a number of access standards, it also needing to further improve in a couple of resulted in patients not being in the areas of performance. most appropriate bed for their condition and, therefore, not receiving the level of The Care Quality Commission (CQC) introduced its care we aspire to deliver. ‘Intelligent Monitoring’ system in October 2013. The CQC take the results of their ‘Intelligent Monitoring’ and group the 161 acute NHS trusts into six bands based on the risk that people might not be receiving safe, effective, high quality care - with band 1 being the highest risk and band 6 the lowest risk. CQC’s judgments take the results of their ‘intelligent monitoring’ and reports from other organisations into account. ‘Intelligent monitoring’ is based on 150 indicators that look at a range of information 12 including patient experience, staff experience and 13 statistical measures of performance.

The CQC reviews these ratings every three months and Surrey and Sussex Healthcare NHS Trust’s level of risk is detailed below: There are times when the emergency department is absolutely the right place to be, but for some people CQC Risk rating Band lowest it might not be the best place, particularly the very October to December 6 risk/safest sick elderly patients who might prefer to spend their (Quarter 3) hospitals last days in the familiar surroundings of their home CQC Risk rating Band lowest or care home. A national survey suggests that 70 per January to March 6 risk/safest cent of patients die in hospital but more than half “Patients and their relatives today expect a good (Quarter 4) hospitals would prefer to die at home. We are working with GPs in both Surrey and Sussex to develop new ways experience when they are admitted to hospital You can see the reports for each trust here: of supporting the elderly who are looked after in www.cqc.org.uk/media/hospital-imonitoring nursing and care homes and supporting their out of and they rightly demand a smooth transition hospital care for often very complex and challenging health needs. We have part funded 58 additional through the healthcare system. We have more beds in the community. Our newly appointed Community Geriatricians are taking their expertise to do, but more than ever before we have a from the department and out into the community to support GPs. Care planning helps relatives and workforce excited by the ask of delivering care doctors make decisions based on the wishes of the patient, and if patients are admitted to our care, we they would want for themselves.” try to give them an estimated date of discharge to help them and their family prepare for their on- Fiona Allsop, Chief Nurse going care and support. Annual Report Summary 2013-2014

A Focus on Care A Focus on Partnerships

Never before has patient experience carried The Secretary of State for Health visited the Through our NHS foundation trust application as much importance. In a world of instant Trust in March 2014 to see for himself the we have built a membership of over a 1,000 “The nurse who messaging and sharing, we recognise the improvements that we’d made. He was full of members and we continue to encourage importance of ensuring our patients and visitors praise for the Trust after his visit, saying: our patients and their relatives to become dealt with my son have a great experience from their very first “I have been really impressed by what I have members. The members come from all contact with the Trust, and right through to their seen. It feels to me like an absolutely excellent communities and represent our catchment in the Emergency discharge. Now that our services are performing Trust with a really good atmosphere and population. The membership forms a channel well we have been able to concentrate on fantastically patient centred.” for talking with, listening and hearing from our Department was improving our patient’s experiences and this is current and potential patients about how they starting to show through the positive feedback would like us to deliver our health services. wonderful! She was we have received. quick and efficient In the past 12 months, the number of as well as being consultants within our Care of the Elderly team has increased to 13 – all of whom are on the extremely kind and specialist register for geriatric medicine. This means that a specialist consultant is on hand caring and her manner 14 seven days a week at East Surrey Hospital. 15 There have also been changes in the number of junior doctors available on our Care of the was very reassuring.” Elderly wards (Abinger, Capel, Meadvale and Nutfield) during the twilight shifts. Now there are nine junior doctors at the hospital until 9pm and seven until midnight, with consultants on call. Specialist staff are also taking their services This year we introduced the ”Hello my out into Surrey and Sussex, with Community name is...” campaign across the Trust. This We’ve received more than 10,000 Geriatricians appointed to offer outreach care campaign was started by a doctor called responses since the ‘Your care matters’ and support GPs. Kate Granger at another trust who found initiative was launched last spring and many that when she became the patient, she of these have already triggered changes didn’t know the names of the people caring to improve our patients’ experiences. for her and that it made a huge difference Comments from patients about noise levels to her experience when one of the staff on wards at night have led to a number took a few seconds to introduce themselves. of changes including revising evening staff We are always looking for ways to improve rosters and clinical and cleaning work our patients’ experience, and were happy to patterns, moving staff closer but noisy staff support this campaign. Dr Andrew Allard, desks away from patient beds at night Junior Doctor, is regularly praised for his time and installing new soft close bins. excellent bedside manner and therefore he Feedback in the Endoscopy Department has became the face of our campaign. All staff led to extra seating and the introduction of are encouraged to introduce themselves by staggered appointment times. In Cardiology their name and job title with every patient the staff are providing more information interaction and the feedback we’ve had about medications and their side effects as from patients tells us it makes a difference well as more detailed contact information to them. We have also redesigned our for patients to take home with them. At name badges making them easier to read Crawley Hospital the Trust’s Day Surgery the name and job title – this has been Unit has introduced a ‘focused checking’ particularly useful for patients on our elderly initiative so patients are not asked the same care wards. questions by different members of staff. Annual Report Summary 2013-2014

A Focus on Sustainability We offer a range of staff development We are well on the way to becoming a NHS programs to help staff fulfill their own foundation trust. We have spent much of the ambition. Our Postgraduate Education Centre year preparing and progressing along the provides excellent facilities to our increasing application process. 2013/14 was a difficult year to manage financially, but the end result was good. number of medical students as a result of We continued last year’s balanced spend and ended the year with a small surplus becoming An Associated University Hospital We held our public and staff consultation on the membership and governance arrangements of £0.3m. We delivered our £11.1m savings programme and delivered our capital of Brighton and Sussex Medical School. The from November through to February. By March programme within the resource limit. simulation suite and brand new simulation dental lab make our hospital one of the most we had recruited over 1,000 members. We have desirable places to train. prepared all the necessary documentation, plans During the year we officially opened the Main came back to officially open the unit. Our four brand and strategies and our Board have taken part in Entrance at East Surrey Hospital. The entrance new theatres were built and opened in 2013/14. a ‘Readiness review’ with the Trust Development has a host of facilities and shops that helps set These new theatres form part of the £14million Authority – the organisation tasked with getting all the standard for our patients and visitors journey theatres project, and the next phase can start now non-foundation trusts through to the assessment through the hospital. Staff have welcomed the new stage with Monitor. Monitor is the regulator of the new theatres are in operation. The next phase shops too. We also opened our Birthing Unit. The NHS foundation trusts and is the organisation is to refurbish our existing six theatres to the same new unit has private rooms all with a pool, ensuite that makes the final assessment and grants NHS bathroom, mood lighting, plenty of space and a pull standard. We also developed an updated travel plan foundation trust status. down double bed. We were honored when the first and achieved planning permission to build more baby born (and her mum) at East Surrey Hospital parking spaces for visitors.

16 17

In 2013/14 the Trust strengthened the operational management of its services to help meet the 18 week referral to treatment target for elective patients. We did this by “My birth ended up allowing elective beds to be “ring-fenced” for elective use and using a better “bed- in an emergency model” (introduced during 2012/13) to plan ahead and manage peaks and troughs C-Section but even in emergency activity (the issue being that emergency admissions, being emergencies, in theatre I felt as take up the beds that would otherwise be used for elective patients). However, though staff were models and action plans only do part of the work, and other key changes are needed to doing their best to deliver the performance in real life. The Trust continues to make practical changes building keep me calm and on those implemented in 2012/13 so that it can reduce its length of stay and further well informed. I am improve the productivity of our elective work. currently pregnant with my second child and have no “The care and attention I have received on every hesitation having this occasion has been second to none.” one at East Surrey.” Annual Report Summary 2013-2014

Valuing patient feedback Valuing our staff

Surrey and Sussex Healthcare NHS Trust employed around Patient Opinion is an independent website that allows patients to tell their story about their experiences of UK health services, good or bad. We actively encourage patients to tell their stories and have a live-feed from Patient Opinion to the 3,500 = 3002.74 homepage of our website. In the past 12 months (excluding bank staff) 324 patients have told their story and these were full time equivalents viewed more than 83,770 times. 38% of stories were positive, 22% were mildly critical (typically detailing satisfaction with much of their care but wishing to draw attention to an often quite small area for improvement), 5% moderately critical and 2 people rated their experience strongly critical. 35% of the stories posted on Patient Opinion were Just under a quarter pulled from the NHS Choices website. 31% nurses and midwives of our workforce are The National Inpatient survey took place 30% from black and minority between September 2013 and January 2014. A administration, ethnic backgrounds. questionnaire was sent to 850 inpatients and 388 18 estates and 19 responses were received. Based on the responses, facilities staff Of course not all of our we receive a score out of 10 for each aspect of 5% allied health workforce are paid members care (the higher the score the better). We scored professionals of staff and we have a loyal ‘about the same’ for every measure. This means band of volunteers who our Trust is performing about the same for that provide a great service to our particular question as most other trusts that took 3% healthcare patients and the organisation part in the survey. scientists and as a whole. We hold a yearly technicians awards ceremony to pay Over the last 12 months we have continued to “The staff I met (including 17% other 13% doctors tribute to the hard work and develop and promote our bespoke Your Care pharmacists) clinical services or dentists commitment of our volunteers. Matters patient feedback programme. Patients were exemplary. are asked to complete a short questionnaire shortly after they have been discharged. As well With their as asking about a range of key measures, patients National staff survey are also given the opportunity to commend staff care my stay in for things they feel they did that went ‘above and We achieved a record response to the 2013 staff of Trust staff beyond’ their expectations. We also ask them for hospital was survey, with 68% of Trust staff completing the % completing any additional comments or suggestions about survey. The Trust was listed above the national the survey their experience. Both these types of comments made as good as average for the number of staff who returned 68 are sent directly to the ward or departmental their questionnaires. manager and relevant senior managers. This of staff feel that they allows them to both share positive comments it could be. From Results show that our staff are not only some of the most motivated NHS staff in England, but staff % make a difference and also learn from patients who tell us their the nurse in to patients experience could have been better. We ended the are also proud to recommend the Trust as a place 92 year with a Friends and Family Net Promoter Score to work and be treated. 92% of staff feel that they of +80 for our Inpatient wards and +76 for the charge down to make a difference to patients, whilst 87% of staff of staff have Emergency Department. have received relevant job training and development received relevant the tea lady, they in the last year. Overall, there has been improvement % in the quality of staff appraisals and in the support 87 job training and were all great.” and communication from managers. development in the last year Annual Report Summary 2013-2014

OUR PLANS FOR 2014/15 AND BEYOND SO2: Effective – Deliver effective and sustainable clinical services within the local health economy Strategic Objectives Delivery Plan 2014-19 Priority High level actions High Level Measures SO1: Safe – Deliver safe services and be in the top 20% against our peers Use monitoring and benchmarking of outcomes, by specialty, to maintain a quality Year 1: Baseline against CQC Priority High level actions High Level Measures Achieve the best focus across relevant services indicators established and incremental Consistently meet possible clinical improvement plan agreed Year 1 - 5: 100% compliance with progress reflected in the national patient outcomes for The safety of patients patient safety performance Quality Account Right patient, safety standards in our patients Years 2 – 5: Deliver incremental comes first in all we do standards benchmark Trust in right place, right time through all specialities and improvement plan the top 20% against peers ring fenced beds, fast tracking across divisions and ambulatory care programmes Years 1-4: Achieve a rating of In partnership with other Outcome of Chief Good or better with ongoing organisations identify Years 1 – 5: One new service per year Inspector of Hospitals Regular mock CQC Inspections improvements to ratings from new ways of working e.g. in line with the Clinical Strategy Inspection to be rated and speciality deep dives mock inspections and deep dives integrated care pathways as “Good” or better Year 5: Be in top rated category Timely review, assessment and Work in partnership with where relevant implementation Year 1-5: Compliance with Year 1: Establish process for review, 20 community partners to NICE guidance across Trust and 21 safety thermometer and as few outcomes monitored where assessment and implementation deliver a “safety first” and Deliver services as possible Never Events guidelines are not implemented personalising care culture differently to meet Years 2-5: Process embedded have clear, evidence based, need of patients, the Year 1: 100% of clinical staff reasons for the decision appraisals include safety goals local health economy Every member of staff has and the Trust Years 1 -5: Year on year relevant patient safety Year 2: 75% of non-clinical staff Effective working with partners improvement in partnership Avoid preventable harm goals included in their appraisals records include safety goals in the local health economy development and relationships across the local health economy annual objectives and can Year 3: 100% of all staff demonstrate how they achieve appraisals include safety goals Essential, mandatory and Year 1: Baseline established and organisational quality goals incremental improvement plan agreed Year 4&5: 100% of all staff speciality based on-going appraisals include safety goals training and development Years 2-5: Deliver incremental programmes for all staff improvement plan Actively participate in national Years 1-5: Agree and deliver Patient Safety Collaborative in standards as agreed Kent Surrey & Sussex area Share good practice; learn from incidents, complaints and poor Year 1: Baseline established practice. Triangulate themes using audit test approach and Develop a culture of openness and realistic improvement levels targets We are open and candour in handling & responding agreed for complaints and SIs transparent to complaints, serious incidents including communication with Years 2-5: Deliver agreed year on patients and their families in year incremental improvements harmony with the principles which are sustained of the NHS Constitution Annual Report Summary 2013-2014

SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive to people’s needs – Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex

Priority High level actions High Level Measurers Priority High level actions High Level Measurers Year 1: Audit programme and process Work in partnership with CCGs Regularly review and audit developed. Build on information from and ambulance services to working practices to ensure IP survey, Your Care Matters and FFT ensure referrals are appropriate Years 1-5: Compliance with through education workshops, Annual Plan objectives and patients feel cared about Implement programme with Years 2-5: patient profiling etc standards and NHSE standards evidence of year on year improvements Deliver access standards Work in partnership with CCGs Alternative providers for frail elderly Year 1: Nursing and Midwifery (N&M) and other providers to identify step-up and step-down facilities Strategy embedded within Trust. alternative healthcare provision Baseline established for each specialty Deliver high quality care for non acute emergencies around the individual Effective and competent and incremental improvement agreed multidisciplinary Take steps to ensure meaningful needs of each patient Year 2-5: Nursing review and working in all areas engagement with the local Years 1-5: Demonstrate that assessment reflects individual needs. community including minority services are shaped through Deliver incremental improvement groups ensuring that through its patient and member feedback in all specialities membership and the Council of Governors, the communities we Year 2: Macmillan cancer Year 1: Develop and implement a Use feedback to shape 22 Explore and establish new serve are able to influence the Information centre 23 scheme based on the concept of “You and improve the methods of gaining patient and future development of services. said… We did…” to demonstrate services patients receive carer input into care delivery responsiveness to patients’ views Year 1: Develop mechanism Active engagement of members, for engagement e.g. Quarterly Implementation of the SaSH patient/ member forums Plus values and behaviours Year 1: Embed N&M strategy within patients and carers in service across the whole organisation Trust and customer care training review and development Years 2-5: Programme of engagement delivering the Trust’s ambition developed and begin implementation, activities with patients and members to deliver excellent and Implement Workforce Strategy Support CCGs to repatriate compassionate patient care. Years 1-5: Repatriated services / Treat patients and their activity from out of area providers Engender a culture that activity to SaSH e.g. 80% of catchment families with dignity, With local partners increase expresses commitment and area (on campus and/community) respect and compassion community beds and capacity pride in the quality of care Year 2: Establish and undertake Develop local services Achieve bed occupancy of 95% of Hospital at Home provided, whilst monitoring programme of patient listening events as appropriate at East Surrey Hospital, and assessing performance to Years 2-5: Develop and embed Planned service developments Deliver planned service developments provide supportive challenge other Trust sites and values based recruitment Develop and implement and to learn from successes in the community Years 1- 5: Become the employer recruitment & retention strategy and when things go wrong of choice for the people of Surrey to attract and retain high & Sussex with achievement of Year 1: Develop and implement calibre staff which demonstrate incremental targets year on year Continually work with patient a scheme based on the concept and display Trust values of “You said… We did…” and Carers representatives Years 1-5: Quality assured appraisals or champions as part of the Listen to patients Years 2-5: Use scheme to listen Ensure staff are motivated and ongoing Patient Experience 90% of staff have a PDP and their families to and respond to patients’ views rewarded to innovate, shape Strategy. Involve families in Value staff 50% reduction in complaints and deliver high standards of Turnover rate 12% the care and planning of around communications, diagnosis care and professionalism patients where appropriate & treatment through greater Staff engagement in the understanding on both sides top 20% of trusts Annual Report Summary 2013-2014

SO 5: Well- led

Priority High level actions High Level Measurers Embed Leadership development Year 1: Ongoing implementation of by implementation of the SaSH Years 1–3: 100% compliance GE clinical leadership programme Deliver Non-elective/elective Plus values and behaviours with Annual Plan targets Minimal and Foresight Board development balance, increase productivity across the whole organisation cancellation or delays to timing of Programme Staffing review prepare 2 year CIP plan delivering the Trusts ambition to cycle and elements agreed and Live within our means planned operations in theatre due including efficiency gains deliver compassionate excellence undertaken. Ensure staff work to to remain financially to lack of beds/recovery space professional codes of conduct. Outline longer term areas for Implementation of National sustainable Years 4-5: Reduction in waste productivity gains for year 5; 3-5 Quality Board guidance e.g. opened theatre packs etc Promote and undertake for inclusion in next 2 year CIP; Have appropriately on nursing, midwifery and Standardisation of processes across staff listening events and repatriation/local referrals qualified and competent care staffing capacity and trust Agency bill reduced by 50% staff always working to capability along with similar Years 2–5: Deliver incremental Year 1: Establish Clinical lead roles, the highest standards guidance for medical staff improvement plan recruit to them and establish talent of professionalism Years 1–5: Ward refurbishment management and accountability process and ethics Embed a clinically led programmes divisional/service structure Year 2: Decision rights around Ensure IT and estate support/ New outpatients facility and develop an appropriate specified areas allocated to clinical optimise patient experience by framework of decision areas and agree implementation improving patient interface, Smart terminals in outpatients, making and accountability plan over next 3 years sharing and capture of ED and corridors 24 patient information and 25 Years 3-5: Implement patient communication Develop an East Surrey Hospital devolvement of decision rights app and where appropriate Year 1: Implement new patient tracking system. performance appraisal system In partnership with key that accounts for behaviours stakeholders in health, social care against agreed outputs below and others, respond positively We are an organisation and pro-actively to challenges Years 1–5: Achieve planned Clinical leads and agree metrics that is clinically led and Implement an effective and opportunities posed by Partnership Programme and targets for monitoring managerially enabled pro-active management the economic environment, and appraisal process Years 2-5: Effectively operate allowing rapid adoption of the appraisal system, delivering We are a well governed new ways of working metrics and standards organisation working in Audit review of governance partnership with others Year 1: Continuously improving and a learning provides strong assurance organisation which supports Trust values Ensure the right governance Year 2: Governance processes systems and internal control Year 1: Establish periodic (twice adapted to support clinical leadership mechanisms are in place and every 5 years) programme of 360 / model and remain effective working effectively at all levels multisource feedback for doctors Appraisals of all staff to Years 3-5: Steady state, and demonstrate compliance Year 2: Establish multisource feedback agile enough to adapt with Trust values programme for all other staff We will have a visible leadership team who Years 2-5: Multisource feedback for Year 1-5: Year on year improvements are engaged and play In partnership with other all staff used in staff appraisals to feedback from key stakeholders a valuable part in the stakeholders in the health and which is positive and in-line with local health and social social care system develop principles of good partnership working. care system to ensure and deliver flexible and Evidence of joint working to achieve the development and sustainable models of care. safe and sustainable services delivery of safe and sustainable services Annual Report Summary 2013-2014

Glossary How to contact us

Acute trust Commissioners Surrey and Sussex Healthcare NHS Trust A trust is an NHS organisation responsible for Commissioners are responsible for ensuring providing a group of healthcare services. An acute adequate services are available for their local Surrey and Sussex Healthcare NHS We also provide a number of Surrey and Sussex Healthcare trust provides hospital services (but not mental population by assessing needs and purchasing Trust provides emergency and services at four community sites: NHS Trust health hospital services, which are provided by a services. Clinical Commissioning Groups are the non-emergency services at: Trust Headquarters mental health trust). For example Surrey and Sussex key organisations responsible for commissioning Caterham Dene Hospital Canada Avenue Healthcare NHS Trust. healthcare services for their area. They commission East Surrey Hospital Church Road Redhill services (including acute care, primary care and Redhill Caterham Surrey Board (of trust) mental healthcare) for the whole of their population, Surrey Surrey RH1 5RH The role of the trust’s Board is to take corporate with a view to improving their population’s health. RH1 5RH CR3 5RA Telephone: 01737 768511 responsibility for the organisation’s strategies and Telephone: 01737 768511 Telephone: 01883 837500 Email: [email protected] actions. The chair and non-executive directors are lay Community services www.surreyandsussex.nhs.uk people drawn from the local community. The chief Health services provided in the community, for Surrey and Sussex Healthcare Horsham Hospital twitter: @sashnhs executive is responsible for ensuring that the Board example health visiting and podiatry (footcare). NHS Trust provides non- Hurst Road is empowered to govern the organisation and to emergency services at Crawley Horsham deliver its objectives. Department of Health Hospital which is managed by West Sussex The Department of Health is a department of the UK NHS Property Company. RH12 2DR Care Quality Commission government but with responsibility for government Telephone: 01403 227000 26 The Care Quality Commission (CQC) is the policy for England alone on health, social care and Crawley Hospital 27 independent regulator of health and social the NHS. Crawley Oxted Health Centre care in England. It regulates health and West Sussex 10 Gresham Road adult social care services, whether provided Foundation Trust RH11 7DH Oxted by the NHS, local authorities, private A type of NHS trust in England that has been created Telephone 01293 600300 RH8 0BQ companies or voluntary organisations. to devolve decision-making from central government Telephone: 01883 734000 control to local organisations and communities so Visit: www.cqc.org.uk they are more responsive to the needs and wishes of their local people. NHS Foundation Trusts provide Clinical Commissioning Group and develop healthcare according to core NHS Clinical commissioning groups are predominantly “Throughout my time principles – free care, based on need and not on GP-led groups of local healthcare professionals ability to pay. NHS Foundation Trusts have members that commission the local health services for at East Surrey I was drawn from patients, the public and staff, and their catchment population, based on patient are governed by a board of governors comprising impressed by the population’s needs. people elected from and by the membership base. professional attention NHS Choices which I received and The first port of call for the public for all information on the NHS. by the cheerful care Providers provided by all the Providers are the organisations that provide NHS services, for example Surrey and Sussex Healthcare nursing staff, day and NHS Trust. night. Thank you!” Need help or advice?

The Patient Advice and Liaison Service (PALS) focuses You can contact PALS by: on improving services for NHS patients. It aims to: • telephone: 01737 768511 Ext 6831 (for all sites) • advise and support patients, their families or 01737 231958. and carers • e-mail: [email protected] • provide information on NHS services • writing to: PALS, c/o East Surrey Hospital • listen to your concerns, suggestions or queries Redhill, Surrey, RH1 5RH

• help sort out problems quickly on your behalf. • You can ask a member of staff to contact PALS on your behalf.

This information is available in other languages and formats including audio tape, large print and Braille. For further information please contact PALS (Patient Advisory Liaison Service) on 01737 231958 or email: [email protected]