The inspection team included an advisor with specialist knowledge of infection control, and five inspectors. During the inspection we spoke with 16 staff, in a range of roles, including matrons, maintenance engineers, healthcare support workers, housekeepers, nursing staff, consultants, doctors, directors and managers. We also observed care and spoke with 17 patients and visitors. We visited a sample of elderly care and rehabilitation wards, orthopaedic, surgical and maternity wards and the neurosciences department. We inspected operating theatres and the sterile services department where surgical equipment was decontaminated.

On the day of our inspection we found that the hospital was clean and procedures were in place to prevent and control the spread of infections. We spoke with many patients who were generally very positive about the standards of cleanliness. Most commented that they had observed staff wash their hands frequently, and made use of gloves and aprons when necessary. For example one patient told us," “I keep an eye on this kind of thing; they change their gloves patient to patient and job to job”.

We found some areas of the hospital where the fabric of the building had become compromised and although intermediate solutions had been instigated these were found to be unsuitable and inappropriate in a healthcare setting. We had concerns that security measures in some areas of the hospital were unsuitable and presented a risk to people’s safety. This included areas that housed electrical and computer communications equipment and for the safe storage for clinical waste.

During our visit we took the opportunity to speak with many women and found that they were generally very complementary about the care and dedication of the staff looking after them. We were told that communication was good, staff referred to individual birth plans and women felt supported and listened to. Whilst the women were clearly aware that there were staffing issues everyone that we spoke with said the care was “superb” and staff were committed and dedicated to “providing the highest standards”.

Staff were pleased to talk to us and told us “Our care of the women and babies is really good and we get lots of comments about how nice and helpful the staff are". “We get compliments from people on how well we look after the women despite staff shortages”.

Although staff told us they were supported by managers who were dedicated and approachable, there was genuine concern that current staffing levels impacted directly on the quality of care. Staff talked about not being able to take breaks and working longer hours than they were paid for. All felt they could not allow women to receive a lesser service due to staffing shortages. One member of staff we spoke with told us “staffing levels need to improve, there are not enough qualified staff on the ward. Staffing needs to be sorted out or something bad could happen”. Another member of staff told us “It is a lovely place to work, but we need more staffing support, we are so understaffed”.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records and spoke with staff. 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.

Our rating of services improved. We rated it them as good because:

• The service monitored safety and managed patient safety incidents well. Staff recognised incidents and reported them in line with policy. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
• When things went wrong, staff apologised and gave patients honest information and suitable support. Staff were aware of their responsibilities regarding duty of candour and we saw current examples of duty of candour being used in practice.
• 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.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean through the use of effective control measures such as daily and weekly checklists, to prevent the spread of infection. All staff had a good understanding of control of substances hazardous to health regulations.
• There was significant improvement in training compliance since our previous inspection. The service provided mandatory training in key skills to all staff and made sure everyone completed it across most of the core services we inspected.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• The trust had introduced several safety programmes to improve multidisciplinary working and monitor deteriorating patients to respond promptly. This included the sepsis bundle and NEWS2.
• Care and treatment provided was based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• The service monitored the effectiveness of care and treatment and used the findings to improve them. Information about the outcomes of people’s care and treatment were routinely collected and monitored.
• Managers made sure staff were competent for their roles and monitored the effectiveness of care and treatment. They usually compared local results with those of other services to learn from them.
• Staff at all levels worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• The service managed patients’ pain effectively and provided or offered pain relief regularly. Patients we spoke with told us staff offered pain relief quickly when they reported pain.
• Staff gave patients enough food and drink to meet their needs and improve their health. We saw staff prioritised mealtimes and there were enough staff to support patients that needed help eating and drinking. The service made adjustments for patients’ religious, cultural and other preferences.
• The service was working toward seven-day services in line with National Health Service Improvements (NHSI), Seven-day services in the NHS. We saw in the trust operational plan 2018-2019, that they plan to deliver the Seven Day Service standards for all admitting specialities by 2020.
• Staff understood their roles and responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Staff knew the processes for ensuring deprivation of liberty safeguards documentation was complete and up to date as well as how to support those who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion. All staff we spoke with were very passionate about their roles and were dedicated to making sure patients received the best patient-centred care possible. Feedback from patients was positive about the care they received.
• Staff provided emotional support to patients to minimise their distress.
• There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted dignity. Staff were caring and supportive of patients which was encouraged by management.
• Patients were active partners in their care. Staff were committed to working in partnership with patients and their families. Staff empowered patients to reach their potential and we found this in particular on Lindfield ward.
• The service took account of patients’ individual needs. The trust employed specialist nurses to support the ward staff. The service made reasonable adjustments and took action to remove barriers for patients who found it hard to use or access services. This included interpreting services, services for patients living with dementia, those with sensory loss or impairment and facilities for bariatric patients.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. There was a clear management structure at directorate and departmental levels.
• The trust had a strategy for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and patients. All staff we spoke with were very aware of the ‘Patient First’ strategy and had ‘bought in’ to the initiative.
• The trust used a systematic approach to continually improve the quality of its services, by creating an environment in which clinical care would flourish. The department had systems for identifying risks, planning to eliminate or reduce them.
• The trust engaged with patients, staff and the public to plan and manage services. We saw the staff encouraged patients to complete the family and friends test on their care and treatment.
• The trust was committed to improving services by learning when things go well and when they go wrong, promoting training, research and innovations.
• There was a culture of collective responsibility between teams and services. There were positive relationships between staff and leaders, where conflicts were resolved quickly and constructively, and responsibility was shared. The service proactively engaged and involved all staff ensuring that the voices of all staff were heard and acted on to shape services and culture.
• The board and other levels of governance in the organisation functioned effectively and interacted with each other appropriately.

However:

• Risks to self-presenting patients in the emergency department were not always assessed in line with guidance when they first arrived.
• There was a risk that there were not always enough nurses to ensure the safe care of the patients that attended the emergency department.
• Patients could not always access the service when they needed it. For example, overall waiting times from referral to treatment and for those patients referred on a 62-day cancer pathway were worse than the national average.
• Patient flow through the hospital remained an issue in some areas. For example, the percentage of critical care bed days occupied by patients with discharge delayed more than 8 hours was 12.0% compared to the national aggregate of 4.9%.
• In outpatients, the patient led assessment of the care environment audits for dementia and disability scored significantly worse than the national average across four outpatients areas that were assessed. The trust wide dementia strategy did not have any outpatient related actions.
• The outpatients core service did not collect, analyse and action data to improve waiting times. Waiting times for individual clinics were not recorded or collected by the services.
• The outpatients vision and strategy was not developed with involvement from key staff. Staff we spoke with in outpatients had no knowledge of, or involvement in developing these goals.
• A clinical pharmacist did not visit all wards daily; for example, Plumpton ward did not receive a regular pharmacy visit.