CSH Surrey is committed to providing the highest standards of quality care – it’s at the heart of all that we do. To ensure that we meet the needs of our patients and those who care for them, CSH Surrey has made a commitment to listen and respond, continually improve, lead the way and maintain a motivated team.
Clinical Leadership and Commitment to Quality
CSH Surrey is proud to have clinicians leading its services - because they know what high quality services should look like. This commitment to clinical leadership starts at the CSH Board, with CSH Surrey's Chief Operating Officer, Director of Nursing & Quality, and one of its Non-Executives holding clinical qualifications.
This strong focus on clinical leadership allows CSH Surrey to gain front line assurance about the quality of its services.
However, the most important voice we listen to is the patients and carers we serve, and we do this through a number of means, including the national Friends and Family Test.
CSH Surrey’s Integrated Governance Committee (IGC) operates as a delegated Board Level Committee that examines and mitigates risk, ensures progress against strategic objectives and provides assurance to the Board.
The IGC meets on a monthly basis, with the remit to:
- Establish strategy and direction of travel
- Monitor quality standards, services and indicators
- Assess, stratify, mitigate or escalate risk
- Challenge assurance measures to ensure resilience prior to providing them to the Board.
In addition, CSH Surrey's IGC holds sub-committees to account, to ensure their functions are being carried out to a high standard.
CSH Surrey is a member of the Kent Surrey Sussex Patient Safety Collaborative, which is working to help all health and care providers in the region, as well as those who commission services, to deliver the safest care they can and to improve all the time. KSS PSC, as one of 15 PSCs in England, is part of the largest and most comprehensive safety programme of its kind in the world.
Regulation and Audit
It is the view of CSH Surrey that aiming just to achieve the minimum or essential standards is not sufficient, and that as a quality focused organisation it must strive to achieve the highest possible standards.
CSH Surrey has an ongoing inspection and audit programme focusing on regulatory and standards compliance and quality assurance measures. This activity is co-ordinated by the Quality and Governance Team, which is accountable to the Director of Quality and our Head of Quality and Nursing.
CSH Surrey measures compliance against the Care Quality Commission (England), NHS Information Governance Toolkit and other associated legislation.
Additionally announced and unannounced spot checks are made to clinical areas to ensure compliance with CSH Surrey standards.
All audits are routed via the IGC to form part of the assurance process, as well as specific Quality Indicators agreed with each clinical service.
CSH Surrey welcomes external reviews and inspections by external partners, as this offers the opportunity to demonstrate its commitment to quality as well as providing a forum for learning.
Listening and responding
By listening, responding and working together with partners and each other, CSH Surrey is confident it can continue to deliver ever better patient care and benefits to its wider community. Through listening and responding to patients via its innovative ‘Listening Project’ in 2013, CSH Surrey’s frontline nurses and therapists heard directly from service users about their experiences. This feedback has been used to define the behaviours most important to patients, which are now used to recruit, train and appraise co-owners – meaning the patient voice really is at the heart of service delivery.
Continuous improvement
Working together, CSH Surrey’s co-owners (employees) are able to focus on delivering exceptional care by improving their health services and clinical practices, systems and processes. Through service re-designs and efficiency work, its co-owners can focus on what really matters: the patients we care for.
A motivated team
CSH Surrey’s 1300+ co-owners continue to be among the most motivated and productive in the country as a result of its unique and proven co-ownership model. Its employee survey results outperform other NHS providers in areas including team work and manager support.
Quality Accounts
As a provider of NHS services, CSH Surrey is required to publish an annual Quality Account, which are published here:
https://www.cshsurrey.co.uk/about-us/governance/annual-reporting
Policy and Plan
Our Patient Safety Incident Response Plan sets out CSH's approach to the implementation of the Patient Safety Incident Response Framework (PSIRF). It’s contents combined with the PSIRF policy below, detail how we have developed, and plan to maintain, effective systems and processes for responding to patient safety incidents and provides information about our governance processes, training offer and ways we will make better use of learning to improve patient safety.
Patient Safety Incident Response Policy
Patient Safety Incident Response Plan