St Peter's Hospital, Chertsey

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 81

• Of these how many have an ensuite toilet: 52 6 with just a toilet, 46 with toilet and shower/bath

• Of these how many have an ensuite toilet and shower or bath: 46 46 have both shower/bath and toilet

• Does this hospital operate an accident and emergency unit:

• How many specialist palliative care beds are available at this hospital: 0

• Does this hospital have a named private unit/service:

Trust Questions

• Does the Trust treat private patients:

Patient Safety

Trust Questions

• Is there a system for recording operations that resulted in a foreign body being left post surgery:

• What is the reporting system for a foreign body being left post surgery: DATIX

• Is there a system for recording operations that were cancelled due to missing notes:

• What is the reporting system for operations that were cancelled due to missing notes: DATIX + LOCAL DATABASE THEATRES

• Is there a system for recording operations that resulted in wrong site surgery taking place:

• What is the reporting system for operations that resulted in wrong site surgery taking place: DATIX

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 0

• During the period 01 April 2010 - 31 March 2011, how many operations were cancelled due to missing notes: 8

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in wrong site surgery taking place: 0

• How many incident investigations using a full Root Cause Analysis did were carried out in 2010/11: 89

• What percentage of patient safety incidents resulting in severe harm or death had a full RCA initiated/completed: 100%

• What percentage of patients are risk assessed for venous thromboembolism on admission: 91-99%

• Compliant with all relevant NPSA safety alerts issues in 2010/11 (you can find a full list of alerts issued at http://www.nrls.npsa.nhs.uk/resources/?p=3). :

• Alerts where not expected to be compliant by 1st December 2011 and when expected to be compliant. : NPSA/2009/SPN002 still awaiting the release of version 4.3 from iSOFT to resolve this issue. iSOFT has confirmed that this version is currently in testing but no confirmed date has been provided for this version to become available on general release. Other Trusts with the same CliniCom PAS are in the same position. In the meantime, and to mitigate the risk, the patients' hospital number and usual demographics are used in accordance with the patient identification policy.

• Does the Trust have a policy for providing educational programmes on using and interpreting clinical indicators:

• Does the Trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support):

• Is safety and quality data available on a central platform and actively disseminated to users:

Infection Control

Trust Questions

• Does the Trust employ an antibiotic pharmacist:

• Does the Trust operate a pre-admission assessment clinic or equivalent system where patients are screened and results returned in advance of the day of admission:

• Elective patient groups screened at the pre-op assessment clinic: All elective surgical and medical All electives with some exceptions e.g. paediatrics, endoscopy

• Are all oncology patients screened at the pre-op assessment clinic: YES

• Are all chemotherapy patients screened at the pre-op assessment clinic: YES

• Are all elective neurosurgery patients screened at the pre-op assessment clinic: Not Applicable

• Are all patients with past history of MRSA screened at the pre-op assessment clinic:

• What method of MRSA screening is used when screening at admission: Culture based in 24-48hrs

• On admission, does topical suppression take place immediately: Not routinely, some groups only e.g. ITU

• Does the Trust have at least one accident and emergency unit:

• Are all patients admitted through A&E screened: Except Paediatrics or Maternity (unless complicated)

• Is screening done according to individual risk assessment:

• Does the Trust have a dedicated isolation ward:

• Protocol for isolating patients with infections: Isolated in side rooms according to priority. May need to cohort patients in ouotbreaks e.g. norovirus

• Does the Trust have an isolation policy:

• Where medically appropriate, are patients with C Diff isolated in single rooms as a matter of priority:

• Does the Trust have a policy to guide the use of metronidazole and vancomycin for C.difficile infected patients:

• Does the Trust routinely isolate all patients with diarrhoea: Unless an outbreak in large numbers e.g. norovirus when may have to cohort on a bay

Stroke Medicine

Hospital Questions

• Does the hsopital have a specialist stroke unit:

• What type of stroke unit does the hospital have: combined acute and rehabilitation stroke unit

• Number of beds in the unit: 56 6 acute and 50 step down

Trust Questions

• Does the Trust have a specialist stroke unit or units:

• Is the Trust part of a stroke care network:

• Details: Surrey Heart and Stroke Network

• How many emergency admissions with a primary diagnosis of stroke (ICD10 codes I60 - I64) did the Trust receive in the financial year (period 01 April 2010 - 31 March 2011): 491

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 476

• Is thrombolysis for stroke patients provided 24 hours per day and 7 days a week :

• Are there any formal arrangements with neighbouring hospitals for the emergency transfer of stroke patients who would benefit from thrombolytic treatment:

• These arrangements are with: We take patients from Epsom General Hospital (part of Epsom & St Helier University Hospitals)

Trauma & Orthopaedics

Trust Questions

• Does the Trust offer a trauma service:

• Does the Trust have a dedicated trauma list available 24 hours a day for the duration of the week, (Sunday to Sunday):

• Does the Trust offer an orthopaedics service:

• Do all the Trust's orthopaedic ward/team have a linked geriatric team with whom they have regular meetings at least once a week:

• Does the Trust run a pre-operative patient education session/class for patients to attend prior to Total Knee Replacement (TKR) and Total Hip Replacement (THR)? :

• Not able to put a figure on the percentage of all patients that attend the class prior to surgery: We have not audited this. However, in our Enhancing Recovery Programme all our Total Hip Replacement patients attend the class

• Does the Trust have a standardised anaesthetic protocol for Total Knee Replacement (TKR) and Total Hip Replacement (THR) patients:

• Not able to put a figure on the percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery:

• Does the Trust have a specialist orthopaedic physiotherapy service which is available 7 days a week:

• Not able to put a figure Patients' discharge delayed due to lack of physiotherapy services at weekends:

• Are patients for total knee replacement (TKR) and total hip replacement (THR) admitted prior to the day of surgery:

• Are patient records routinely recorded using a specific multi-disciplinary team THR/TKR pathway document:

• Is criteria-based discharge used:

• Are patients routinely phoned in the first 48 hours after discharge to check on their progress:

Paediatrics

Hospital Questions

• Does the hospital have a paediatrics service:

Trust Questions

• Is the Trust's elective paediatric surgery carried out only by designated surgeons with at least six months training in a specialist unit:

• Do the Trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week: Participation would be every other week

• Is a paediatrician on site (SpR or higher) 24 hours per day, 7 days per week:

• Are at least two registered children's nurses on duty 24hours per day in each children's ward:

• Is there a designated facility on site for parents or guardians to stay overnight:

Palliative Care

Trust Questions

• Does the Trust provide a palliative care service:

• How is specialist palliative care delivered at the hospital: Other (please specify) Monday to Friday 9 - 5 Specialist Palliative Care Nurses with support from palliative medicine consultants

• Does the hospital's specialist palliative team includes: A consultant in palliative medicine,A palliative care nurse,Other (please specify) Occupational Therapists

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week:

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital:

• Does the Trust routinely survey and evaluate the views of patients and bereaved relatives and carers regarding the delivery of care on the end of life programme:

Maternity Care

Maternity Sites

• St Peter's Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 4106

• How many babies were born in the unit during the year? (not including home births): 4169 live births

• How many women were booked for a home birth: 139

• How many women had a home birth? (not including births at home by accident): 72

• Number of antenatal rooms: 2

• Total antenatal beds: 10

• Number of assessment area rooms (for monitoring and / or induction): 3

• Total assessment area beds: 8 + 1 bariatric couch

• Number of delivery rooms: 10

• Total delivery beds: 16

• Number of postnatal rooms: 14

• Total postnatal beds: 40

• Number of rooms in obstetric high dependency unit: 1

• Total obstetric high dependency beds: 4

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0

• Amenity rooms; Are women able to book a single room in advance of their birth: 10

• If women can pay for a single room what is the average cost per night (GBP): 117

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby: Babies have ankle bands on both ankles

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: Security doors security doors

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Not available hand held massager

• Pain relief available - Aromatherapy: Not available

• Pain relief available - TENS: Provided by women Can rent

• Pain relief available - Epidural: Provided by unit available 24 hours

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 119

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On site

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: On site

Trust Questions

• Do all women have a choice about where they receive their antenatal appointments (i.e. at hospital or local health centre):

• Are NHS antenatal classes available (e.g. Parentcraft):

• Available during the daytime (until 5pm):

• Available in the evenings (after 5pm):

• Available at weekends (Saturday and/or Sunday):

• Available for women only groups:

• Available for other groups:

• Also available for: teenagers, multiple births

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: 12 weeks

• Scan 2 available between: 21 weeks

Trust Statistics

Trust Questions

• You can view various measures relating to the Trust's performance by clicking the following link: Ashford and St. Peter’s Hospitals NHS Foundation Trust