Epsomedical > Clinical Governance

Access Policy

The Access Policy sets out the rights and responsibilities of Epsomedical and its NHS patients. It derives from the NHS Constitution and the contract that we have entered into with the NHS through Surrey Heartlands Integrated Care Board. These documents give patients a number of rights and assurances, which are largely the same whichever provider a patient chooses to attend. However, the scope of our services is very different to that of most NHS hospitals and the Access Policy of all providers will be slightly different. Should a patient have a dispute with us over the administrative aspect of the service he receives, any complaint should be made by reference to the Access Policy. The Access Policy addresses among other issues:

Maximum waiting time targets, and how those are interpreted
Cancellations and failure to attend (DNA)
Discharge

Download Access Policy

Formulary

The hospital formulary lists drugs that we use and/ or prescribe in the treatments we provide. The formulary has been approved by our NHS Commissioner, Surrey Heartlands Integrated Care Board and the link can be found below:

FORMULARY

Quality Account

The Quality Account is an initiative of NHS England to provide information to the public and to the NHS about the quality of services delivered by hospitals across the country. It follows a format specified by NHS England and specifically requires providers to identify areas for improvement. The documents are also available via the NHS Choices website.

QUALITY ACCOUNT

Information Governance

We will acquire a lot of information about our patients in the course of a referral, all of which will be stored electronically. We have obligations to maintain the confidentiality of this information and we also have obligations to make it available to third parties in some circumstances. This short document outlines how we deal with these obligations.

How we use your data

Equality Monitoring

Epsomedical has a duty under the Equality Act of 2010 to promote equality in the workforce and to provide healthcare services that meet the needs of the population that we serve. We aim to ensure that no-one is placed at a disadvantage over others. The Public Sector Equality Duty (PSED) supports our aims by helping us to deliver policies and services which meet different peoples needs. We aim to meet these needs by:

Eliminating unlawful discrimination, harassment and victimisation and any other conduct prohibited by the Equality Act
Providing equality of opportunity between all people who work within and use our services

Please click the link below to download our latest WRES report.

WRES REPORT

CQC Ratings

Please find below our latest CQC ratings. To read the detailed report, simply click on the respective link. We implemented the points suggested by the CQC and look forward to an opportunity to improve our ratings at our next inspection.

STATEMENT OF PURPOSE

Clinical Governance Policy

Our Clinical Governance Policy is available to download using the link below.

CLINICAL GOVERNANCE POLICY

PSIRF Policy

The PSIRF Policy and Plan supports the requirements and implementation of the NHS England Patient Safety Incident Response Framework (PSIRF) within Epsomedical. The policy sets out Epsomedical’s approach to developing and embedding effective processes for responding to patient safety incidents and areas with the potential for learning. A patient safety incident or event is any unintended or unexpected incident or event which could have or did lead to harm for one or more patient’s receiving healthcare. Epsomedical’s Policy outlines how we will seek to learn from events to continually improve the quality and safety of the care that we provide as part of our systematic program of improvement. Please see the link below for a presentation that summarises Epsomedical’s PSIRF Plan. Please click on the links below to download our latest PSIRF Policy and Plan.

PSIRF PRESENTATION PDF

EPSOMEDICAL PSIRF POLICY

Infection Prevention & Control (IPC)

The purpose of the Epsomedical infection control programme is to facilitate effective infection control and limit the acquisition and spread of pathogenic micro-organisms. We support the principles that infections should be prevented wherever possible and that effective arrangements for the surveillance, prevention and control of infection are provided throughout the organisation.

It is our policy to encourage the individual responsibility of every member of staff to participate in the prevention and control of infection and to comply with legislation, policies and procedures applying to the safe provision of care.

To maintain standards and achieve these aims we continue to take the following measures:

Ensure that we have systems to manage and monitor the prevention and control of infection. This includes policies and procedures which assess and evaluate the risk to our patients, staff members and the care environment.
Identify patients who have or develop an infection, and provide relevant prompt treatment.
Identify staff who have or develop an infection which may affect their ability to attend the workplace.
Ensuring that the environment is maintained to a standard that prevents and controls the spread of infection.
Provide staff training and education.

Our policy has been formed on the principles and safe practice guidance recommended by our IPC advisors, which has been drawn up in line with national guidelines. Our COVID-19 and Local Safety Standards for Invasive Procedures (LocSSIPs) are additional policies and procedures which help guide and govern our staff in the delivery of safe care. An external audit of our IPC measures took place and the results were outstanding across all three sites. The inspectors recognised the efforts of all staff to secure the environment:

"…the facilities, infection prevention and control processes and practices in place throughout the Day Surgery Unit are of a very high quality with exceptionally high standards of cleanliness."

This continued external affirmation of the standards that we maintain is a testament to the hard work, collective responsibility and dedication of every member of staff who has helped us formulate and adhere to the organisations IPC principles.

Epsomedical Limited is committed to providing a clean and safe environment for its patient’s, staff and visitors, in line with the infection prevention and control guidelines outlined in the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections DH 2015. For infection control or cleaning queries, please contact our Infection Control Lead, Jayne Sharp, on 01932 588421

About Freedom to Speak Up

The Freedom to Speak Up (FTSU) is about encouraging a positive culture where people working in an organisation feel they can speak up and their voices heard, and their suggestions acted upon. Speaking up is about anything that gets in the way of providing good care. FTUS is for all workers including bank, agency and former workers.

Speaking up can be about anything which doesn’t feel right, for example, a way of working or a process that isn’t being followed, witnessing or experiencing discrimination or poor behaviours or actions. Speaking up captures a range of issues, some of which may be appropriate for other existing processes, for example, HR or patient safety or quality

Freedom to Speak Up (FTSU) guardians were recommended by Sir Robert Francis, following his review and subsequent report into the failings in Mid-Staffordshire.

FTSU guardians have a key role in helping our staff with concerns they might have with or within our organisation. The guardians help ensure our organisation is an open and transparent place to work, where everyone is encouraged to speak up safely to address any concerns or issues they might have.

Our Freedom to Speak up Guardians are there for our staff should they wish to raise concerns outside of our internal channels. Contact details for guardians are:

T: 01932 588400

E: freedomtospeakup@epsomedical.co.uk