Quality 2020-21 Account Photo courtesy of Mark Norman, BBC South East Today, Health Correspondent 1 Contents Foreword 4 Overview 4 About us 7 Our vision and values 9 Clinically led 9 Achievements in quality Statement on quality from the Chief Executive 11 CQC Registration 14 Delivering high quality care during the pandemic 15 SASH+ impact on quality of care 18 Quality priorities for improvement in 2021-22 19 Our Priorities Safe Priority Overview 22 Incident reporting 22 Never Events 23 Falls 24 Healthcare Associated Infection 25 Pressure Ulcer prevention 30 Medicine safety 31 Safeguarding 31 Effective Priority: Overview 34 Clinical Audit 35 VTE (Venous Thromboelism) 38 Learning from Death 39 Research 42 Well-led Priority: Overview 46 Our people 46 National Staff Survey 46 Staff Friends and Family test 46 Developing our staff 49 Staff engagement 51 Equality and Diversity 51 Black, Asian, Minority Ethnic (BAME) staff 53 Freedom to Speak Up Guardian 56 Guardian for Safer Working 56 Information Governance 56 Payment by results 56 Data Quality 56 Income generated 57 Caring Priority: Overview 59 Patient Experience 59 COVID-19 60 Dementia 61 2 Personal needs 62 Responsive: Overview 65 Cancer waiting times 65 Referral to treatment standard 66 Cancer and Site Services Division Compliance with the mental health act 67 Statement of directors responsibilities Annexes Annex 1: Stakeholder review 70 Annex 2: Quality Account Indicator definitions 71 Conclusion pages Putting people first 75 Keep in touch 75 3 Foreword Photo courtesy of Mark Norman, BBC South East Today, Health Correspondent Welcome to the Surrey and Sussex Healthcare The impact on all aspects of our teams’ work NHS Trust Quality Account 2020/21, where has been immense. Words used to describe you can read details about our performance, what our community and our staff went through achievements and our plans for the coming year. do not really do them justice but we will try. We It is a pleasure to be able to share with you so quadrupled our critical care capacity, converting many examples of how our people are making a medical wards into spaces that could provide care positive difference for our patients. for some of our most critically unwell patients. We reorganised our estate and our services to create This has been a year like no other. The COVID-19 the best environment possible to provide the care pandemic has been the single greatest challenge our patients’ needed. At the same time, many staff to public health and the NHS in a generation. adapted their roles to work in unfamiliar areas. Our staff have responded with skill, dedication, courage and compassion in abundance. 4 quality, safe care. As part of our approach to this, we launched our response to the National Patient Safety Strategy in the form of our ‘Safe SASH’ campaign to coincide with World Patient Safety Day in 2020. Alongside our established Trust governance mechanisms, this encouraged every department to make safety pledges based on their safety and quality data. We were so pleased to see how this was met with enthusiasm and engagement from staff across all grades and departments. To take this work onto the next stage, we have now developed Trust-wide safety goals as we look to continue to provide the highest possible quality of care for our community, always asking ‘in what way can we do better?’ With visiting to our site greatly restricted during the pandemic, we have had to work in very different ways to ensure loved ones could keep in touch with relatives and carers. We rapidly set up a messaging service to make sure that people could send in correspondence for patients to read. We invested in new technology to support all our wards to provide video calls with loved ones. We were shortlisted for a prestigious Nursing Times award in the category of ‘care of older people’ for a process we introduced to ensure relatives were regularly updated on our patients’ conditions. Alongside this, we were proud to continue to offer visiting in exceptional circumstances wherever possible. During the year we were proud to have made major contributions to national and international research studies as part of our efforts to respond to the pandemic. We recruited over 300 patients Throughout this response we have taken pride in to the RECOVERY trial; the biggest global study continuing to place great importance on the quality to find treatments to help coronavirus patients. of care we have provided. We recruited the largest number of patients in the country to the COVID:HAREM study looking to On the one hand, this involved responding improve understanding of changes in treatment for rapidly to changing guidance and requirements appendicitis, cholecystitis, pancreatitis and cancer specifically related to the virus – medical and surgery. We were the third biggest contributor nursing teams, allied health professionals, to CHOLE:COVID cholecystitis audit, while also housekeeping, estates and facilities staff, contributing hundreds of data sets as part of procurement and administrative staff all played an international effort to characterise severe vital roles in this. emerging infections within the ISARIC study. SASH+, our established approach to Quality On the other hand, there was a very real need Improvement, has been invaluable throughout our to ensure focus remained on providing high response. 5 Richard Shaw Michael Wilson CBE Chair Chief executive We used our methods to support the supply We are very proud of our contribution to the of personal protective equipment (PPE), to pandemic response and are pleased to reflect decontaminate kit, to introduce twice-weekly many of our achievements within this account. lateral flow tests for our staff and latterly to design In reflecting on these achievements, we also and deliver our vaccination programme. remember those most affected by the last year. Our colleagues, relatives, friends and patients Alongside all of these efforts, we have placed a who lost their lives during the year remain at the great deal of importance on the wellbeing of our forefront of our minds. staff. Clearly the efforts of the last year have, and will continue to have, a profound impact on our teams. We have taken steps to provide them with as much support as possible. Our peer-to- peer Critical Incident Stress Management team has been invaluable, and we have supplemented this by investing in additional psychological support. We have created new wellbeing spaces Richard Shaw and created dedicated information about where Chair to seek help and support. Our chaplaincy and spiritual care team have provided immeasurable support to colleagues of all faiths and none, alongside the role they play in supporting relatives, patients and carers. We took a thorough approach to the ensuring every member of our staff received a personal Michael Wilson CBE COVID-19 risk assessment and we have put on Chief executive a number of listening events, both trust-wide and dedicated to different groups of colleagues. It is paramount that this work continues and increases June 2021 over the coming months as our colleagues continue to process the impact of our response. Portrait photos displayed on this page were taken prior to the pandemic 6 About us Population of 535,000Population of 535,000 5,000 • East Surrey Hospital, Redhill staff5,000 staff • EastCaterham Surrey DeneHospital, Hospital Redhill 800 • CaterhamEarlswood Dene Centre Hospital beds800 • Earlswood Centre beds • Crawley Hospital • Crawley Hospital 14 • HorshamHorsham Hospital Hospital operatingoperating 14 theatrestheatres CroydonCroydon M20 M20 Woking M25 Woking M25 Caterham Dene Hospital Caterham Dene Hospital Guilford Earlswood Guilford Earlswood East Surrey Hospital East Surrey HospitalTonbridge Tonbridge Crawley Hospital Tunbridge M23 Wells Crawley Hospital Horsham Hospital Tunbridge M23 Wells Horsham Hospital 7 Surrey and Sussex Healthcare NHS Trust (SASH) provides acute and complex services at East Surrey Hospital in Redhill alongside a range of outpatient, diagnostic and planned care at Caterham Dene Hospital, The Earlswood Centre in Surrey and at Crawley and Horsham Hospitals in West Sussex. Serving a growing population of over 535,000 we care for people living, working and visiting east Surrey, northeast West Sussex, and south Croydon, including the towns of Crawley; Horsham; Reigate and Redhill. East Surrey Hospital is the designated hospital for Gatwick Airport and sections of the M25 and M23 motorways. It has a trauma unit, which cares for seriously injured patients in partnership with the major trauma centres at St George’s University Hospitals NHS Foundation Trust, Tooting, and Royal Sussex County Hospital, Brighton. East Surrey Hospital has 800 beds and ten operating theatres, along with four more theatres at Crawley Hospital and a day surgery unit. We are a major local employer, with a diverse workforce of over 5,000 staff providing healthcare services to the communities we serve. The Trust is an Associated University Hospital of Brighton and Sussex Medical School and we are part of educating cohorts of final year medical students from the school each year under the supervision of our consultants. Our involvement supports the medical workforce of the future and the delivery of high-quality patient care. 8 Our vision Our values We will pursue perfection in the delivery Dignity and respect: we value each of safe, high quality healthcare that puts person as an individual and will challenge the people in our community first. disrespectful and inappropriate behaviour. One team: we work together and have a can-do approach to all that we do, recognising that we all add value with equal worth. Clinically led We are a clinically led organisation, Compassion: we respond with humanity focused on putting people first. Our and kindness and search for things we can services are led and managed through do, however small; we do not wait to be four divisions.